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.

What other points of the history do you want to know?

History, Mr. Gunnerson Consider the following: Associated signs/ symptoms: Pertinent PMH ROS MEDS Relevant Family Hx Relevant Social Hx. Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors:

History Mr. Gunnerson 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 Characterization of Symptoms: decreasing caliber and frequency of BM’s Temporal sequence: 3months of abdominal distension, Alleviating / Exacerbating factors: No improvement with laxatives

What is your Differential Diagnosis?

Differential Diagnosis Based on History and Presentation Constipation Colorectal neoplasm Diverticular disease Recurrent prostate cancer IBD Stricture

What specifically would you look for? 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 Diagnosis Would you like to update your differential?

What next? Imaging? Labs ? Endoscopy? OR? Other?

Colonoscopy GUNNERSON

Colonoscopy Findings What further studies would you want at this time? 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?

List all labs ordered for your particular patient Mr. Gunnerson List all labs ordered for your particular patient CBC: Hb/Hematocrit WBC Electrolytes LFT’s Amylase /Lipase PT/PTT/ Platelets Urinalysis PSA Type and Crossmatch CEA Type and Screen

Labs Mr. Gunnerson CBC: Hb 11.0 Hematocrit 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 with Acute perforation ?

What if Mr. Gunnerson presented with: Complete Obstruction?

A large right sided cecal mass?

What if Mr. Gunnerson presented with a 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 with Multiple 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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