Altered Bowel Function
Linda Barney, MD
Wright State University
Christopher Brandt, MD
Case Western Reserve University
Mr. Gunnerson.
Mr. Gunnerson is a 62-year-old male who is seen by his PCP in the office for abdominal distension and progressive constipation.
History
What other points of the history do you want to know?
History, Mr. Gunnerson Consider the following:
• Characterization of Symptoms:
• Temporal sequence• Alleviating /
Exacerbating factors:
• Associated signs/ symptoms:• Pertinent PMH• ROS• MEDS• Relevant Family Hx• Relevant Social Hx.
History Mr. Gunnerson
Characterization of Symptoms:
decreasing caliber and frequency of BM’s
Temporal sequence: 3months of abdominal
distension, Alleviating / Exacerbating
factors: No improvement with
laxatives
Associated signs/symptoms:
10lb wt. loss
No nausea/vomiting
PMH : HTN, Obesity Prostate CA treated with RT MEDS: Atenolol, ASA
Relevant Family Hx. Brother w/ polyps
What is your Differential Diagnosis?
Differential DiagnosisBased on History and Presentation
Constipation Colorectal neoplasm Diverticular disease Recurrent prostate cancer IBD Stricture
Physical Examination
What specifically would you look for?
Physical Examination, Mr. Gunnerson Vital Signs: Afeb, BP 180/85 Appearance: NAD
Relevant Exam findings for a problem focused assessment
HEENT: no adenopathy, no bruits
Genital-rectal: testicles symmetrical, firm prostate, no discrete mass, guaiac + brown stool,
Chest: CTA Skin/Soft Tissue: No inguinal adenopathy
CV: RRR without murmur Neuromuscular: no focal deficits
Abd: obese, distended, no appreciable organomegaly, Tympanic,mild lower abdominal tenderness, no mass
Remaining Exam findings non-contributory
Differential DiagnosisWould you like to update your differential?
What next?
1.Imaging?2.Labs ?3.Endoscopy?4.OR?5.Other?
Colonoscopy
GUNNERSON
Colonoscopy Findings
Colonoscopy is done and reveals a near obstructing lesion at 25cms. The proximal colon is surveyed to cecum without additional lesions.
Biopsy reveals adenocarcinoma
What further studies would you want at this time?
Studies Ordered Mr. Gunnerson
CT Scan: Abd/Pelvis CT Scan: Chest ?
PA/Lat Chest MRI ?
Bone Scan ? PET SCAN ?
Obstruction Series/Acute Abdominal Series etc. ?
OTHER:
Justify your additional evaluation
CT Scan Mr. Gunnerson
CT Scan Findings
Sigmoid lesion with some adjacent soft tissue change
CT otherwise negative/ No liver lesions identified
Chest X-Ray Mr. Gunnerson
Laboratory
What would you obtain?
Mr. Gunnerson
CBC: Hb/Hematocrit
WBC
Electrolytes
LFT’s Amylase /Lipase
PT/PTT/ Platelets Urinalysis
PSA Type and Crossmatch
CEA Type and Screen
List all labs ordered for your particular patient
Labs Mr. Gunnerson
CBC: Hb 11.0Hematocrit 34
WBC 8.0
CEA: 8.2
Electrolytes : Normal PSA: 4
LFT’s: Normal
PT/PTT: Normal
Lab Results Discussion
What labs are relevant at this particular point in his work-up?
How would you interpret the findings listed? Are there other tests that might contribute to his
peri-operative course?
Interventions at this point?
Interventions at this point?
Plan elective sigmoid colectomy Discuss surgical approach options Open Vs. Laparoscopic Discuss preoperative preparation Discuss treatment risks, potential
complications and alternatives
Intra-op Mr. Gunnerson
Liver inspection & US revealed no evidence of metastases
Post op Management
Discuss routine post op course Discuss most common complications
Pathology
4 cm circumferential Adenocarcinoma penetrating through muscularis propria
3 of 21 lymph nodes positive for metastatic adenocarcinoma
What Stage is Mr. Gunnerson’s Cancer?
Mr. Gunnerson’s Tumor Stage
Tumor = T3 Nodes= N1 Mets= Mo Stage III / Duke’s C
Colon Cancer Staging
Describe the staging systems for colorectal carcinoma and implications for treatment and prognosis
Outline further treatment options and follow-up care
Post-operative visit
When seen in follow-up Mr. Gunnerson notes that his older brother with a history of polyps alerted him that their father also had polyps before his accidental death at age 51.
Mr. Gunnerson has 3 healthy sons age ( 36, 34,& 31)
What would you advise him regarding their risk assessment and follow-up?
Alternative Scenarios
What if Mr. Gunnerson presented with:
Liver Metastases noted on original exploration
What if Mr. Gunnerson presented withAcute perforation ?
What if Mr. Gunnerson presented with:Complete Obstruction?
A large right sided cecal mass?
What if Mr. Gunnerson presented witha Rising CEA 2 years post-op?
How would you work this up?
What if Mr. Gunnerson was found on work-up to have: Liver Metastases?
Where else might colon CA spread and which studies might be utilized
to evaluate for metastases?
Chest X-Ray
CT Scan of Chest
OTHER?
Bone scan ? Pet Scan? CT scans?
What if Mr. Gunnerson presented withMultiple Synchronous Lesions ?
QUESTIONS ??????
Summary Colon CA can present with an array of symptoms or
as occult disease Colonoscopy is the most definitive diagnostic
modality Laparoscopic and open surgical options are
available Adjuvant treatment options may influence prognosis Screening and long-term follow-up guidelines are
important to disease management
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