1. Altered Bowel Function Linda Barney, MD Wright State University Christopher Brandt, MD Case Western Reserve University

2. 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.

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

4. 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.

5. 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

6. What is your Differential Diagnosis?

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

8. Physical Examination What specifically would you look for?

9. 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: CTASkin/Soft Tissue: No inguinal adenopathy CV: RRR without murmurNeuromuscular: no focal deficits Abd: obese, distended, no appreciable organomegaly, Tympanic,mild lower abdominal tenderness, no mass Remaining Exam findings non- contributory

10. Differential Diagnosis Would you like to update your differential?

11. What next? 1.Imaging? 2.Labs ? 3.Endoscopy? 4.OR? 5.Other?

12. Colonoscopy GUNNERSON

13. 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?

14. Studies Ordered Mr. Gunnerson CT Scan: Abd/PelvisCT Scan: Chest ? PA/Lat ChestMRI ? Bone Scan ?PET SCAN ? Obstruction Series/Acute Abdominal Series etc. ? OTHER: Justify your additional evaluation

15. CT Scan Mr. Gunnerson

16. CT Scan Findings  Sigmoid lesion with some adjacent soft tissue change  CT otherwise negative/ No liver lesions identified

17. Chest X-Ray Mr. Gunnerson

18. Laboratory What would you obtain?

19. Mr. Gunnerson CBC: Hb/Hematocrit WBC Electrolytes LFT’sAmylase /Lipase PT/PTT/ PlateletsUrinalysis PSAType and Crossmatch CEAType and Screen List all labs ordered for your particular patient

20. Labs Mr. Gunnerson CBC: Hb 11.0 Hematocrit34 WBC8.0 CEA: 8.2 Electrolytes: NormalPSA: 4 LFT’s: Normal PT/PTT: Normal

21. 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?

22. Interventions at this point?

23.  Plan elective sigmoid colectomy  Discuss surgical approach options  Open Vs. Laparoscopic  Discuss preoperative preparation  Discuss treatment risks, potential complications and alternatives

24. Intra-op Mr. Gunnerson Liver inspection & US revealed no evidence of metastases

25. Post op Management  Discuss routine post op course  Discuss most common complications

26. Pathology  4 cm circumferential Adenocarcinoma penetrating through muscularis propria  3 of 21 lymph nodes positive for metastatic adenocarcinoma

27. What Stage is Mr. Gunnerson’s Cancer?

28. Mr. Gunnerson’s Tumor Stage  Tumor = T3  Nodes= N1  Mets= Mo  Stage III / Duke’s C

29. Colon Cancer Staging  Describe the staging systems for colorectal carcinoma and implications for treatment and prognosis  Outline further treatment options and follow-up care

30. 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?

31. Alternative Scenarios What if Mr. Gunnerson presented with:

32. Liver Metastases noted on original exploration

33. What if Mr. Gunnerson presented with Acute perforation ?

34. What if Mr. Gunnerson presented with: Complete Obstruction?

35. A large right sided cecal mass?

36. What if Mr. Gunnerson presented with a Rising CEA 2 years post-op? How would you work this up?

37. What if Mr. Gunnerson was found on work-up to have: Liver Metastases?

38. Where else might colon CA spread and which studies might be utilized to evaluate for metastases?

39. Chest X-Ray

40. CT Scan of Chest

41. OTHER?  Bone scan ?  Pet Scan?  CT scans?

42. What if Mr. Gunnerson presented with Multiple Synchronous Lesions ?

43. QUESTIONS ??????

44. 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

45. Acknowledgment ASSOCIATION FOR SURGICAL EDUCATION The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials we welcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com