approach to a patient who presented to us with bleeding per rectum and her follow up

1. Clinical Case Presentation
Rectal mass with bleeding PR
Dr. Vaibhav (JR)
Dr.Revathi (JR)
Dr. Ankita (SR)
AIIMS Delhi

2. Patient’s history
Mrs. X, 58 yr F
● Delhi
● Occupation ?
● Admitted on 11th August, 2019
● Presenting complaints:
1. Bleeding PR X 5 months
on & off, fresh red blood, mixed with stools, Passage of clots/mucus/mass? preceding/following
defecation?, associated pain? a/w any particular consistency of stools?
2. Altered bowel habit X 5months
passed stool once every 2-3 days consistency? a/w any loose stools/mucus? Any relation with
meals?feeling of incomplete evacuation
● H/o ??significant unintentional weight loss & decreased apetite - loosening of
clothes in prior 4 months

3. History contd...
● No h/o any mass protruding from the anal opening
● No pain during defecation
● No h/o fever
● No h/o bleeding PR other than this period??
● No urinary complaints?
● No h/o chronic cramping abdominal or pelvic pain
● No h/o jaundice
● No h/o cough, blood in sputum or difficulty breathing
● No h/o recurrent blood transfusions.
● ??

4. History contd..
Past medical history:
● Had pulmonary TB 15 yrs back - took ATT for 6 months and declared cured.
● Had suffered chest pain 8 yrs back - stenting in LAD done i/v/o significant
stenosis.
● On low dose aspirin since then
● No other comorbidities
Personal & family history:
● (veg/nonveg)
● h/o altered bowel habit, decresed appetite
● No h/o alcohol intake/smoking or any other substance abuse
● No family history h/o cancer??

5. Menstrual & obstetric history:
● Menarche?
● menopause at 48 yrs of age
● No h/o abnormal bleeding PV
● GPLA? (Describe)
● Had undergone (open/lap)tubectomy 32 yrs back
Previous treatment history (for bleeding pr??):

6. Time to Unmute!
● Differential diagnosis please?
● What is hematochezia & how is it different from malena?
● Causes?
● Tenesmus?
● Anything significant in medical history?
● Did we miss anything?
● How to approach a patient with massive lower GI bleed in casualty?

7. Causes of
lower GI
bleed
Small intestinal sources
● Vascular ectasias
● Neoplasms (stromal tumor, adenocarcinoma etc)
● Ulcers
● IBD
● Infection, ischemia, vasculitis
● Intussusception, aortoenteric fistulas
● Meckel’s
Colonic sources
● Hemorrhoids, anal fissures
● Diverticulosis
● Neoplasms, vascular ectasias
● Radiation induced
● polyps , SRUS

8. Hematochezia
& tenesmus
add malena
● Hematochezia is the passage
of fresh blood through the
anus, usually in or with stools
● Tenesmus is a feeling of
incomplete defecation.

10. Examination
General physical examination:
● Decubitus, orientation, bluilt, nutrition, PICCLE??(may not right, but say it)
● Pallor present
● BMI: 22 kg/m2 KP/ECOG??
Systemic examination:
CNS/Respiratory/Cardiovascular system: WNL

11. Examination contd...
P/A examination:
● Abdomen scaphoid
● Visible infraumbilical scar (describe verbaly)
● No visible fullness or lump
● No dilated/engorged veins
● All quadrants moving well with
Respiration
● All hernial sites normal
Umbilicus central
and inverted
Infraumbilical
tubectomy scar
(semilunar)

12. ● No tenderness (superficil/deep say only)
● No palpable organomegaly/ lump
● Tympanic note on percussion (no e/o free fluid say)
● Bowel sounds

13. ???
● Differential diagnosis please?
● Did we miss anything?
● How DRE is done?
● Any difference in DRE with respect to gender?
● Can this be haemorrhoids?
● Role of proctoscopy?
● Quadrants of abdomen?

14. PR exam
● No perianal excoriations, fissure
● normal anal tone
● Mucosa normal
● Fecal and blood staining on gloves present
● No mass felt

15. Proctoscopy
● No evidence of hemorrhoids, ulcer, mass or active bleeding seen.
PV exam
● Uterus anteverted
● Fornices are free
● No cervical motion tenderness
● No adnexal mass
Provisional diagnosis: ? PR bleed under evaluation
Ddx: Colorectal malignancy with no clinical evidence of metastasis

16. Investigations:
Hemogram
● TLC - 9k
● Hb - 9.6
● Hct - 30.3
● Plt - 1.84
Serum CEA levels: 102.8 ng/ml
KFT/LFT
● Urea - 15 mg/dl
● Cr - 0.6
● Na+ - 137
● K+ - 4.6
● T. Bil - 0.5
● Albumin - 4.2 g/dl
● AST/ALT - 22/22

17. Sigmoidoscopy
● Rectum seen till 15 cm from anal verge
● Circumferential growth at 15 cm in rectum. Scope non negotiable beyond.
Biopsy
● Features of moderately differentiated adenocarcinoma.

18. Imaging:
CXRay:
CECT Abdomen and Pelvis:
• Concentric mural thickening and enhancement (10 mm thickening) in sigmoid colon 12.5
cm from anal verge with surrounding fat stranding and nodularity on serosal surface
• Few subcentimetric LN (4-5 mm) seen along mesenteric vessels
• Liver:
• small hypodense lesion measuring 11.5 x 10.7 mm in segment VIII of liver with
homogeneous enhancement in portal venous phase.
• 2 Small non enhancing hypodense lesion 3.5 x 5 x 3.5 mm and 5 x 5 x 5 mm in
subcapsular location of segment VII and IVA respectively.
• Left adrenal gland is slightly bulky (9 mm thickness) with surface nodularity.

19. CECT Chest:
● Ground glass opacities in posterior
segments in bilateral lower lobe lung
● 2 calcified nodules in apicoposterior
segment of left upper lobe. ? Calcified
granuloma
● Small non calcified nodule 3 mm in
medial basal segment of left lower lobe.
● Multiple oval non calcified non necrotic
LN in mediastinum. ?
Infective/inflammatory etiology.
● No pleural effusion.

20. Circumferential
mural thickening
in rectum

22. ● Please add relevant pictures of imaging (if possible as relatives to click/ take
from net whatever findings this pt had on ct)
● Add cxray of this pt with film if possible
● Put a picture of adenocarcinoma microscopic view if possible

23. Brainstorming time!!
● Sequence of investigations required & its significance?
● What was missed here? Was it delebrate?
● Comments on: Primary disease vs systemic disease. Sites of metastsis?
● Common histopathogy found in rectal carcinoma
● High risk features and its significance?
● Known risk factors for rectal carcinoma?

24. Evaluation of patient with suspected rectal
malignancy
● Rigid sigmoidoscopy (and biopsy) (flexible not used)
● Colonoscopy in all patients - rule out synchronous tumours
● CECT Chest, Abdomen and Pelvis in all patients - principal sites of mets
● ERUS/Ec MRI for T staging
● PET not routinely recommended.
● CEA levels to monitor response to treatment, prognosis (>5 ng/ml) and
recurrence.
● (streamline into heading: to confirm diagnosis, to stage, fitness for sx/t/t)

25. Principal sites of mets in colorectal cancer
● Liver: 34%
● Lung: 22%
● Adrenal: 11%

27. MRI

30. Gross

31. Histopath
Signet ring histology associated with poor prognosis.

33. Pathogenesis

35. Management

36. Case summary
• 58 yr lady, ECOG 2
• Painless fresh irredular bleeding PR with constipation,
decreased appetite & unintensional weight loss X 5months
• Pallor, palpable growth on DRE/proctoscopy (describe)
• Anemia,CEA 102.8 ng/ml
• Concentric mural thickening in the rectosigmoid junction
12.5cm from the anal verge with surrounding fat stranding
and nodularity over serosal surface, lymph nodes 4-5mm
along mesenteric vessels
• Moderately differentiated adenocarcinoma rectum (HPE)

37. • How was our pt managed a summary in
points here
• And a follow up of herin another slide

38. NOT true about staging of carcinoma rectum:
1) Dukes classification has 3 stages
2) MRI has high diagnostic accuracy in T staging
3) TNM staging is the optimum staging classification
4) ERUS is superior to MRI for pelvic node assessment
5) TNM staging is T3N1bM0

39. Dukes and Modified Astler coller staging

40. TNM staging

41. Radiological findings in staging
• Circumferential resection margin (CRM) that provides information on the
margin resection status for TME and influences local recurrence and therapy
plan.
• Extramural venous invasion (EMV), a feature that influences prognosis
• Sphincter complex status to decide sphincter-sparing surgery as well as the
need for preoperative RT
• Extramesorectal nodes that can impact therapy planning, particularly RT
• MDCT cannot replace HR-MRI for local staging
Indian Journal of Radiology and Imaging / May 2015 / Vol 25 / Issue 2

42. What would be your preferred management?
1) Supportive care
2) Local therapy
3) Low anterior resection
4) APR with colostomy
5) Neoadjuvant CT

43. Principles of treatment
• Surgery is the mainstay of curative therapy
• Early rectal cancers (T1 and good prognosis T2) may be
amenable to local transanal excision
• The primary resection consists of rectal resection performed
by total mesorectal excision
• Most cases can be treated by anterior resection, with the
colorectal anastomosis being achieved with a circular stapling
gun

44. • Low, extensive tumours require an abdominoperineal
excision with a permanent colostomy
• Adjuvant chemotherapy can improve survival in node-positive
disease
• Liver resection in carefully selected patients offers the best
chance of cure for single or well-localised liver metastases.

45. Neoadjuvant therapy
• Clinical stage 2 & 3 mid and lower rectal cancer
• CRT / SCRT ( 5 wks/ 5 days); 5-FU and oxaliplatin
• SCRT in resectable synchronous metastases/ tumours in the
colon
• Reduces local recurrence, downstages tumour, enables
sphincter preservation for very low rectal tumours.
• Rectal cancers located in the upper third of the rectum are
typically treated like rectosigmoid tumors and are exempt
from neoadjuvant treatment.

46. Case:
• cT3N1bM0
• Upper rectal tumour
• Undergone laparoscopic LOW ANTERIOR RESECTION with
DIVERSION LOOP ILEOSTOMY
• Postoperative chemotherapy and radiotherapy

48. Preoperative preparation
• Counselling and siting of stomas
• Correction of anaemia and electrolyte disturbance
• Group and save of blood
• Bowel preparation
• Deep vein thrombosis prophylaxis
• Prophylactic antibiotics

49. Low anterior resection
• Lloyd Davis position with the legs carefully padded in stirrups
• Open LAR is performed through a vertical midline laparotomy
incision- followed by
• Abdominal exploration (to rule out peritoneal disease and
liver metastasis)
• Vascular mobilization
• Mesenteric dissection
• TME
• Rectal transection, colon resection, and colorectal or coloanal
reconstruction.

50. Coloanal anastomosis

51. Lap LAR

52. Lap LAR
video

53. Benefits and limitations
• Open versus Lap LAR
• CLASICC, COLOR II, and COREAN are laparoscopic versus open
TME RCTs
• Demonstrated superiority of the laparoscopic approach
• Short-term postoperative outcomes
• Noninferiority of short- and long-term oncologic outcomes
• Less intraoperative blood loss

54. • Morbidity rates for laparoscopic and open TME are similar
(30% to 50%)
• 5% to 12% urinary dysfunction
• 10% to 35% sexual dysfunction
• 20% to 30% incidence of fecal incontinence
• LapLAR- Abdominal extraction site with wound-related
complications such incisional pain, superficial and deep
wound infection, incisional hernia and prolonged recovery.

55. COMPLICATIONS
Most effective way to prevent intraoperative and postoperative
complications is by anticipating them during each step of the
procedure.

56. Intraoperative complications
• Hemorrhage – presacral , periprostatic bleeding
• Rectal perforation
• Small bowel, colon perforation, vaginal and bladder
perforation, vascular injury such as injury to the iliac vessels,
and ureteral injury.

57. Urethral injury
• Urethral injury - specific to taTME.
• APR- incidence of 1% to 2%
• In early Surgeon’s learning curve
• During difficult anterior dissection for very low rectal tumors
• Patients with bulky anterior rectal tumors or an enlarged
prostate.
• Urethral repair is performed using a perineal approach, or a
transabdominal open, laparoscopic, or robotic approach.

58. Postoperative complications
• Anastomotic leak with pelvic sepsis
• Anastomotic strictures
• Transient urinary dysfunction, including urinary retention and
urinary incontinence- 0% to 27%
• Sexual dysfunction
• Fecal incontinence, tenesmus, and fecal urgency
• LAR syndrome

59. LAR syndrome
• LARS score or Wexner Score
• Multifactorial
• Colonic dysmotility
• Decreased rectal sensibility
• Disappearance of the anorectal reflex
• Reduction of rectal tone
• Damage to the pelvic nerves or internal sphincter.
• Rx- Dietary recommendations, antimotility agents, and fiber
supplements. pelvic floor strengthening exercises and biofeedback,
sacral nerve stimulation

60. Symptoms of LARS may include some or all of:
Increased frequency of stool
Urgency with or without incontinence of stool
Feeling of incomplete emptying
Fragmentation of stool (passing small amounts little and often)
Difficulty in differentiating between gas and stool

61. Transanal Total Mesorectal excision

63. APR
• Ernest Miles
• Indications:
• Tumour involving anal sphincters
• Tumour too close to sphincters for adequate margins
• Sphincter preserving surgery not possible – unfavourable
body habitus or poor preoperative sphincter control.

64. • Rectum and sigmoid colon are mobilized through an
abdominal incision
• The pelvic dissection is carried to the level of the levator ani
muscles
• Perineal portion of the operation excises the anus, anal
sphincters, and distal rectum.

66. Surgical anatomy

67. Transanal Approaches to Early Rectal
Cancer
INDICATIONS
• T1N0 tumors located in the lower rectum (<10 cm from the
anal verge)
• Mobile and polypoid lesions
• Tumors involving less than 1/3 of rectal circumference
• Tumors less than 3 cm in diameter
• G1-2 tumors
• No evidence of lymphovascular invasion (even though the
preoperative evaluation of this parameter is challenging)

68. Surgical technique
• Placed in high lithotomy position
• Anterior lesion – Prone jacknife position
• Lone star retractor placed to evert the anus
• Mucosa is scored circumferentially by using conventional
monopolar electrocautery to adequately define the resection
margin (at least 0.5 cm).
• Full-thickness excision of the tumor is performed down to the
perirectal fatty tissue
• Procedure ends with closure of the rectal wall defect using
interrupted resorbable sutures.

69. POSTOPERATIVE COMPLICATIONS
• Rectal bleeding
• Perirectal infection
• Pain in case of resection reaching the dentate line
• Anorectal stenosis
• Prostate or vagina injury in case of anterior rectal tumors

71. Post operative course
Case:
Postoperative period patient had lower mild abdominal pain * 3
days
No rectal bleeding/ urinary complaints
No evidence of abdominal distension, difficulty in evacuation of
stools or tenesmus
Patient was discharged on POD 6

72. HPE and adjuvant therapy
• Final staging IIIB
• Adjuvant chemoradiotherapy is planned
• Received 2 cycles of CAPEOX f/b 4 cycles of FOLFOX regimen till date
• No long term complications like fecal incontinence, tenesmus/urinary
difficulties

73. Factors Associated With a High Risk of Relapse for Colorectal
Cancer
TUMOR FACTORS
• Disease stage
• High-grade tumor (poorly differentiated)
• Tumor location (more distal)
• Obstruction/perforation
• Lymphovascular invasion
• Perineural invasion
• Mucin production
• Diminished stromal immune reaction
• Low microsatellite instability
TECHNICAL FACTORS
• Inadequate resection margins (circumferential radial, distal,
• mesorectal)
• Implantation of exfoliated cells
• Anastomotic leak
• Tumor location (tumors in pelvis and splenic flexure are anatomically and technically more difficult)

74. Adjuvant therapy
For people with stage III colon cancer (pT1-4, pN1-2, M0) or
stage III rectal cancer (pT1-4, pN1-2, M0) treated with short
course radiotherapy or no preoperative treatment, offer:
• Capecitabine in combination with oxaliplatin (CAPOX or
XELOX) for three months, or if this is not suitable
• Oxaliplatin in combination with 5-fluorouracil and folinic acid
(FOLFOX) for three to six months

76. Follow up
Colonoscopy should be performed within 12 months.
If that study is normal, colonoscopy should be repeated every 3
to 5 years thereafter.
Local resection of rectal tumors should be followed with
frequent endoscopic examinations (every 3–6 months for 3
years, then every 6 months for 2 years).
CEA is often followed every 3 to 6 months for 2 years. CT scans
are often performed annually for 5 years,

77. Management of colorectal hemorrhage

78. Screening

80. Overview

81. BUZZ