A 59-year-old female presented with severe rectal bleeding for 3 days. She has a history of hypertension, diabetes, and hemorrhoid surgery. On examination, she was dehydrated and in pain. Investigation showed possible colorectal cancer. She received IV fluids, pain medication, and antibiotics for acute management and may require surgery, chemotherapy, or radiotherapy. Colorectal cancer can be several types and screening is recommended for those with risk factors or family history. Staging helps determine treatment and prognosis.

1. The weekly online grand round
Department of internal medicine
Hawler teaching hospital
Date: 28th march 2021
Time: 10:45
Duration: 1 hour
CASE PRESENTER SUPERVISOR
59 year old female
presented with sever rectal
bleeding
Maryam Abdulwahid
Internal medicine trainee
Dr. Hussein Sinjari

2. Sever Bleeding per rectum for 3
days duration

3. History of presenting illness
 59 year old female a known case of hypertension and DM,
presented with sever bleeding per rectum for 3 days duration, Her
condition started before 2 months as constipation and slight
bleeding per rectum which was relieved by taking laxatives. But in
the past three days the bleeding became profuse, fresh red in
color not mixed with stool and contained large clot and mucus,
associated with tenesmus and abdominal pain which was diffuse
and relieved by passing stool. Also associated with nausea,
anorexia, fever, sweating and weight lose.

4.  PMH/ Hypertension, DM, IBS
 PSH/ hemorrhoid surgery
 DH/ - metformin tab 500mg 1*2
 - Antihypertensive
 - bisacodyl tab on need
 -she has allergy to ceftriaxone and other unknown drug??
 FH/ no any hx of cancer in first degree relatives
 Systemic review/ not significant

5. Examination
 General examination
 Conscious, alert, dehydrated, tired, in pain
 Vital sign:
 BP/ 120/70 mmhg
 PR/ 93b/min.
 Spo2/ 98%
 Temperature /37.2 c

6. Abdominal examination
 On inspection: not distended, no any skin pimentation and colour change, no any
epigastric pulsation, no visible viens
 On palpation/ soft abdomen, no tenderness, no any palpable organomegally,
 On auscultation/ positive bowel sound, no added sound

7. Investigation:
 CBC
 CRP
 ABDOMINAL ULTRASOUND
 COLONOSCOPY
 CT ABDOMEN

12. MANAGEMENT
 Acute treatment in emergency:
 FLUID : N/S 500CC
 Pain killers: paracetamol bottle
 Antibiotics: amoxiclave vial 1*2 1gm
 flagyl bottle 1*3

13. MANAGEMENT
 SURGERY
 CHEMOTHERAPY
 RADIOTHERAPY

15. TYPES OF COLORECTAL CANCER
 Adenocarcinoma
 Carcinoid Tumors
 Gastrointestinal Stromal Tumors
 Lymphoma
 Hereditary Colon Cancer ( FAP, Lynch syndrome (hereditary
nonpolyposis colorectal cancer).

16. RISK FACTORS
 a diet high in red, processed, or charred meats
 a lack of exercise
 obesity, particularly extra fat around the waist
 smoking
 drinking too much alcohol

17. INDICATION OF SCREANING
 A personal history of colorectal cancer or adenomatous
polyps
 A strong family history of colorectal cancer or polyps, such as
cancer or polyps in a first-degree relative younger than 60.
 A history of chronic IBD
 A family history of any hereditary colorectal cancer.

18. SCREENING TEST
 Fecal testing/ every 1-2 year
 Guaiac-based fecal occult blood test (gFOBT)
 Fecal immunochemical test (FIT)

19. SCREENING CONT….
 Flexible sigmoidoscopy, every 5 years or every 10 years with FIT or FOBT
every year
 Colonoscopy, every 10 years
 Double contrast barium enema (DCBE)/ every 5 years
 CT colonography
 Stool DNA test

20. Stages of rectal cancer.
 Stage 0 (carcinoma in situ)/ Only the innermost layer of the rectum wall
contains abnormal cells.
 Stage 1/ Cancer cells have spread past the innermost layer of the rectum wall, but
not to lymph nodes.
 Stage 2/ Cancer cells have spread into or through the outer muscle layer of the
rectum wall, but not to lymph nodes.
 Stage 3/ Cancer cells have spread through the outermost muscle layer of the
rectum and to one or more lymph nodes. Stage 3 is often broken up into sub stages
3A, 3B, and 3C based on the amount of lymph tissue affected.
 Stage 4/ Cancer cells have spread to distant sites, like the liver or lungs.