Tasleem Akhtar, a 50-year old female, presented with post-prandial vomiting, abdominal pain, and constipation. Imaging showed signs of intestinal obstruction. She underwent exploratory laparotomy, which found a stricture in the sigmoid colon due to a hard mass. A segment of the sigmoid colon was resected along with the mass. Histopathology revealed colorectal cancer. She was diagnosed with colorectal cancer affecting the sigmoid colon.

1. Dr. Danish Sagheer

2. HISTORY

3.  Tasleem Akhtar 50 y/o married female
resident of sargodha, presnted to E.R on 9th
jan 2022 with c/o:
 Post-prandial vomitting for last 7-8 days
 Severe pain in abdomen for last 4 days
 Absolute constipation for last 3 days

4.  Pt. was in USOH 8-10 days back when she
started experiencing vomitting episodes after
taking meals. Vomitting was sudden,
projectile, containing food particles,
aggravated upon taking meals and relieved
upon taking anti-emetics
 Vomitting was later associated with pain
abdomen and constipation

5.  Patient started experiencing generalized
abdominal pain 4 days back which started
from epigastric reigon and spread throughout
the abdomen.
 Pain was severe, colicky in nature, aggravated
upon taking meals and relieved upon
vomitting and on taking analgesics.

6.  Patient also complained of Obstipation for
last 3 days.
 She gave history of a similar episode of
Obstipation one week back which was
relieved by enema at a local hospital

7.  CVS: HTN -ve, IHD -ve
 RESP: Asthma -ve, COPD -ve, TB -ve
 CNS: CVA -ve , No other senile illnes
 RENAL: CKD -ve
 GIT: Hepatitis -ve, CLD -ve, NAFLD -ve

8.  Medical: Insignificant
 Surgical: Hx of Appendectomy 20 years ago

9.  Patient belong to a lower middle class family
 She lives in her own house having 6 rooms
with 12 people among which 2 are bread
earners
 Uses drinking water from a well and has no
pets
Allergies:
 No hx of any known allergies

10.  HTN, DM both parents
 No other hx of any familial disease
Personal history:
Normal sleep and appetite
No Addictions

11.  Upon GPE, a middle aged ladyof medium
hieght, moderately obese, lying in bed in
obvious discomcomfort, well oriented in time,
place and person
 Her vitals were
 B.P: 150/90, Pulse: 102/min
 Temp: 99F , R.R 16/min

12.  Jaundice –ve
 Anaemia –ve
 Cyanosis –ve
 Koilonychia –ve
 Palpable Lymph nodes –ve
 Edema -ve

13.  GIT:
Abdomen – Tender, Distended with sluggish
bowel sounds
Hernial orificies were normal
Upon DRE:
No impacted stool, hemmorhoids or fissure
seen. Normal mucosa

14.  CVS: S1+S2+0
 CNS: GCS: 15/15. No sensorimotor
neurological deficit
 RESP: Normal vesicular breathing. No added
sounds

15. Intestinal Obstruction??

16. CBC:
Hb: 14.7, TLC : 10700, PLT: 380000
LFTs:
Bilirubin: 0.9 , ALP: 234 U/L, ALT: 37U/L
RFTs and S/E:
Urea: 27, Creatinine: 0.7
Serum Na+ : 140, Serum K+: 3.9

17.  BSR : 94 mg/dl
 HbsAg: -ve
 Anti HCV: -ve
 HIV: -ve

18. >X-RAY Abdomen:
Multiple air fluids levels with dilated Gut
loops
 USG Abdomen:
Excessive gas shadows and Dilated gut loops
noted. Mild interloopal fluid was noted

19.  Done on 9th Jan
 Diffuse
circumferential wall
thickness of sigmoid
colon with segment
of strictural
narrowing.
 Retrogradely marked
dilatation of small
and large gut seen

20.  Admit
 NPO
 NG Intubation
 Foley’s cathertization
 Inf. 5% D/W 1000ml B.D
 Inf. R/L 1000ml O.D
 Inj. Metronidazole 500mg/100ml i/v TDS
 Inj. Tramal+ Gravinate

21.  On 13th jan, her exploratory laparotomy was
performed. Her per-op findings were:
 An Omental band near ileocecal junction
 Sigmoid stricuture and a hard fixed mass
involving sigmoid colon
 Enlarged mesenteric lymph nodes

22.  Omental band was released
 Tumor identified and 8-10cm of sigmoid colon was
resected along with it and sample was sent for
histopathology
 Proximal end was brought out as end colostomy and
dital stump was closed using silk suture (Hartman’s
Procedure)
 1 pelvic drain was placed
 Haemostasis secured and patient was sent back to
ward

24.  The large intestine
is approximately
1.5 mlong
 The large intestine
begins at the
ileocaecal valve and
extends to the
anus.

25. Cancer effecting:
 Caecum
 Colon
 Rectum
 Anal canal and appendix are not considered
in the definition, and are treated as separate
entities

26.  Epidemiology
 Colorectal cancer is the second leading cause
of cancer-related deaths after lung cancer
 5-year survival rate : 55%.
 The most lethal GI malignant diseases in the
Western world.
 Is preventable and is highly curable if
detected early

28.  Early stages of colorectal cancer may have NO
signs or symptoms.
 If signs and symptoms are present, they may
include:
 Bleeding from the rectum or blood in the
stool
 Marked change in bowel habits
 Abdominal mass
 Abdominal cramps or pain
 Iron deficiency anemia that is not due to
other conditions

33. Lab INVESTIGATIONS:
CBC,
RFTS,
LFTS,
BSR,
Serum electrolytes
Stool R/E

34. Tumor markers:
Carcinoembryonic antigen (CEA)
CA 19-9
Can also be raised in
Not used to diagnose or screen colorectal
carcinoma. They’re rather used in pre-
diagnosed pts along with other investigations
Can also be used to monitor response to
treatment

35.  Double-contrast
barium enema
 described as
APPLE-CORE filling
defect

37.  If there is a
suspiscion of
colorectal carcinoma,
Biospy is taken
during colonoscopy
or flexible
simoidoscopy and
specimen is sent for
histopathalogy

38.  Chest X-ray: Mets in lungs
 Ultrasonography
 Contrast enhaced CT-Scan and MRI Scan
These investigations are helpful to identify
if tumor has spread into surrounding
structures and into distant abdominal visceras

41.  Dukes’ staging for colorectal cancer
 ●● A: invasion of but not breaching the muscularis
propria
 ●● B: breaching the muscularis propria but not
involving lymph nodes
 ●● C: lymph nodes involved.
D: Distant mets

42. Surgery is mainstay treatment of both palliative
and curative management of ca colon
It is necessary that tumor and 2 cm tumor free
margins should be resected
Following are various types of resections
depending upon the location of tumor:

43.  For carcinoma of
cecum and ascending
colon
 Cecum, ascending
colon, hepatic
flexure, proximal 3rd
of transverse colon is
resected
 Anastomosis is made
between ileum and
transverse colon

44.  Done for Ca of
hepatic flexure and
transverse colon
 Rt. Hemicolectomy+
whole of transverse
colon and splenic
flexure
 Anastomosis is made
between ileum and
descending colon

45.  Splenic flexure,
Descending colon and
sigmoid colon
 Distal 2/3rd of
transverse colon,
descending colon and
sigmoid colon are
removed and colorectal
anastomosis is created

46.  Tumor of upper 2/3rd is treated with Anterior
resection
 Tumor of distal 3rd is treated with
Abdominoperineal resection
 HARTMAN’S PROCEDURE: In this procedure
rectum is excised, distal stump is closed and
proximal stump is brought out as End
colostomy

47.  Advanced carcinoma of rectum which is fixed
and un-resectable is managed by palliative
procedures such as Colostomy to relieve the
obstruction and chemo/radiotherapy to
shrink the tumor

48.  Given in stage III and IV patients
 It has no survival benefits in stage 1 and II
 5-Fluorouracil in combination with Folinic
acid is most frequently used
 Neo adjuvant chemo is sometimes used in
non-operable cases to shrink the size of
tumor and make them operable

49.  Limited role in colorectal carcinoma
 Can be given pre-operatively or post op. to
reduce risk of local recurrence
Has also some role in combination therapy
with chemo as neo-adjuvant. Used to shrink
size of tumor preoperatively