Case Presentation

Group IVSurgery Unit I

Ward no 24

Particulars of the patient:

Name : Mr. Abul Bashar

Age : 50 years

Sex :Male

Father’s name : Late Sultan Ahmad

Mother’s name : Late Aleya Khatun

Present address : Bogarbil, Rangunia,

Chittagong

Contact number : 01676847914

Occupation : Farmer

Religion : Islam

Marital status : Married

Date & time of admission : 26.10.13 at 3.30pm

Date & time of examination : 27.10.13 at 9.30 am

Bed number : 04

Ward number : 24 ( surgery unit- I)

Under whom he was admitted : Professor Dr. Omar Faruque Yousuf

The presenting complaints:

• Passage of blood streaked stool for

1.5 months.

• Alteration of bowel habit for 1.5

months.

• Sense of incomplete defecation for 1.5

months.

• Pain in the middle of the lower

abdomen for the last 7 days.

According to patient’s statement, he was relatively well 1.5 months

back, then he noticed streaks of blood on stool, admixed with

mucus. The blood was slight in amount and defecation was not

associated with pain. He also complained of increased frequency of

passage of stool for the last one month (10 times/ day). For about

1.5 months he had been experiencing alteration of bowel habit with

early morning diarrhea. Occasionally, he felt sense of incomplete

defecation. Sometimes, he would strain for emptying the bowel

without resultant evacuation. For the last 7 days, he developed mild

pain in the lower abdomen which was stretching in nature,

aggravated by filling of bladder and relieved by micturition. He also

had anorexia and gave history of weight loss, the loss being 50% of

his previous body weight.

He gave no history of jaundice, ascites, hematuria, hematemesis,

bone pain, hemoptysis or chest pain.

The history of present illness:

The history of past illness:

He was not diabetic, not hypertensive and

gave no history of tuberculosis, asthma.

He gave no history of previous hospitalization

and blood transfusion.

Personal history:

He was a chain smoker; pack-year was

50.

He was non alcoholic.

His diet was normal.

Personal hygiene was not satisfactory.

Family history:

No member of his family was suffering from such disease.

Drug history:

He used to take homeopathic medicine to relieve his problems.

Socio-economic history:He came from a lower socio-economic status.

General examination

Appearance : Ill looking

Body built : Normal

Nutrition :

Malnourished

Co-operation : Co-

operative

Decubitus : On choice

Anemia : Present

Jaundice : Absent

Edema: Absent

Dehydration : Present

Pulse : 80 bpm

Blood pressure : 110/70 mm

Hg

Temperature : 98◦F

Respiratory rate : 20

breaths/min

Neck vein : Not

engorged

Lymph node : Not palpable

Hernial orifice : Intact

Abdomen Examination:Inspection:

Abdomen was scaphoid in shape

Umbilicus was centrally placed and

inverted

Abdomen was not distended

No engorged vein, no visible peristalsis,

no scar mark were presentPalpation: Mild tenderness present

Temperature was normal, no mass was

palpable

Liver, spleen were not palpable, kidney

was not ballotable.

Percussion:

Percussion note was tympanitic

Shifting dullness and fluid thrill

absentAuscultation:

Bowel sound was present and normal

Digital rectal examination:Inspection:

Skin around the anus was normal

No excoriation,no faecal soiling

No fistula, fissure or hemorrhoids was

presentPalpation: Anal tone was normal A circumferential mass was found in

rectum; 5 cm above the anal verge

Surface was irregular

Consistency was hard

The mass was fixed with the surrounding

structures.

Upper limit of the mass could not be

reached

On withdrawal, the finger was blood

stained

Salient Feature

Mr. Abul Bashar, 50 years old, farmer, son of late Mr. Sultan

Ahmad hailing from Bogarbil, Rangunia, Chittagong presented

with the complaints of passage of blood streaked stool for 1.5

months, altered bowel habit and sense of incomplete defecation

for the same duration.

According to patient’s statement, his presenting complaints

started 1.5 months back. Then he noticed streaks of blood on

stool admixed with mucus. He also complained of alteration of

bowel habit with early morning diarrhea and increased

frequency of defecation (10times/day). He had been experiencing

sense of incomplete defecation for the last 1.5 months. He

developed pain on the central lower abdomen for the last 7 days

which was stretching in nature and was aggravated by filling of

urinary bladder and relieved by micturition. The patient was

anorexic and lost 50% of his previous body weight. He gave no

history of jaundice, ascites, hematuria, hemoptysis, melena.

The patient was not diabetic, normotensive. He was a chain

smoker, smoking 25 sticks per day for 40 years. He came from

low socio-economic status and none of the member of his family

suffered from such disease.

On general examination, the patient was ill looking, of average

body built, malnourished, co-operative and decubitus on choice.

He was anemic, dehydrated, not icteric, not edematous. His

pulse, blood pressure, temperature and respiratory rate were

within the normal limits. Neck vein was not engorged, neck gland

was not enlarged, peripheral lymph nodes were not palpable,

hernial orifices were intact. On abdominal examination, mild

tenderness was found in lower abdomen. No organomegaly was

found.

On digital rectal examination, there was no visible excoriation,

fecal soiling, hemorrhoids, fissure or fistula. On palpation, anal

tone was normal. There was a circumferential mass, located 5

cm above the anal verge. It was hard in consistency, surface

was irregular and fixed with surrounding structures. Upper

limit of the mass could not be reached. On withdrawal , the

finger was blood stained. Other systemic examination revealed

no abnormality.

Provisional diagnosis:

Carcinoma rectum

Differential diagnosis:

i. Intestinal tuberculosisii. Hemorrhoids

Investigation:

• For diagnosis:

Proctoscopy with biopsy.

• To see extension:

Colonoscopy (to exclude synchronous tumour)

• To see metastasis:

Chest X-ray P/A view

USG whole abdomen

Liver function test

CT scan of chest and abdomen

• For pre-operative staging:

Endoluminal USG of rectum (to assess local

spread)

MRI (for local staging)

Colonoscopic findings of rectal carcinoma

Endoluminal USG of rectum

MRI showing rectal carcinoma

• G/A fitness:

CBC

Urine R/M/E

Random blood glucose

Serum creatinine

Chest X-ray P/A view

ECG

Confirmatory diagnosis:

Carcinoma rectum.

Management:

A. Preoperative preparation:

• Counseling and siting of stomas

• Correction of anemia and electrolyte disturbance

• Cross matching of blood

• Bowel preparation

• Prophylactic antibiotics

• Insertion of urinary catheter

B. Surgery:

• Curative treatment: Anterior resection

CARCINOMA RECTUM

Carcinoma Rectum

Definition:

Carcinoma located within 12cm of the

anal verge by rigid proctoscopy is called

carcinoma rectum.[National Comprehensive Cancer Network Guideline (UK)]

Risk Factors:

Age above 50years

Male gender

High intake of fat

Alcoholism & smoking

High intake of red meat

Obesity

Person with family history of 2 or

more 1st degree relative has 2 to

3 fold greater risk factor.

Origin

Accumulation of genetic abnormalities

Increase in dysplasia in adenoma

Adenocarcinoma [adenoma-carcinoma sequence]

• Well differentiated• Prognosis is good

Low grade

• Moderately differentiated• Prognosis is fair

Average grade

• Undifferentiated• Prognosis is poor

High grade

Histological Grading

H & E stain: Rectal carcinoma

Limited to rectal wall

Extension to extra rectal tissue

C1: Pararectal lymph nodes involvedC2: Lymph nodes accompanying vessels involved

Widespread metastasis

A

B

C

D

Dukes’ Staging

TNM Staging

• T1 : Tumor invasion through muscularis mucosa.• T2 : Tumor invasion into muscularis propria• T3 : Tumor invasion through the muscularis propria but

not through the serosa• T4 : Tumor invasion through the serosa or esorectal

fascia

• N0 : No lymph node involvement• N1 : Between 1 and 3 involved lymph nodes• N2 : 4 or more involved lymph nodes

• M0 : No distant metastasis• M1 : Distant metastasis

Types of rectal carcinoma spread1. Local spread:

Circumferential spread rather than in a

longitudinal direction.

2. Lymphatic spread:

It occurs almost exclusively in an upward

direction.

3. Venous spread: Principal sites of metastasis are,

Liver (34%)

Lungs(22%)

Adrenal gland (11%)

Other organs (33%)

4. Peritoneal dissemination:

It occurs in case of high lying rectal carcinoma.

Epidemiology

•More common in developed countries.•Higher rates in Australia New Zealand Europe USA.•Lower rate in South Central Asia , Africa.•More common in men.

Principles of surgical treatment:

• Curative treatment

• Palliative treatment

Curative treatment: Even in the presence of widespread

metastasis a rectal excision should be considered.

• Tumor whose lower margin is ≥2 cm above the anal canal:

Anterior resection (sphincter saving operation):

Temporary colostomy is done.

• Tumor in upper 1/3rd of rectum or rectosigmoid tumor:

High Anterior Resection

• Tumor involving the lower 1/3rd of the rectum:

SCAPR (Synchronized Combined Abdominoperineal

Resection): Permanent sigmoid end colostomy is done.

• Tumor involving middle & lower 1/3rd :

TME (Total mesorectal excision)

• Others:

TEM (Trans anal Endoscopic Microsurgery): In case

of unfit patients & small low grade T1 tumor.

Hartmann’s operation: for old and frail patient.

Palliative treatment:

• Radiotherapy:

Preoperative radiotherapy can be given for inoperable

primary tumor or local recurrence, especially when painful.

• Chemotherapy:

Adjuvant chemotherapy can improve survival in node

positive diseases.

• Combined radiotherapy & chemotherapy can be given to

shrink an extensive tumor prior to surgical excision.

• Palliative colostomy

When there is intestinal obstruction.

When there is gross infiltration of neoplasm.