General and Colorectal
CASE 11: a reCtal maSS
history
A 70-year-old man was seen in the surgical outpatient clinic complaining of a 3-month history of loose stools. He normally opens his bowels once a day, but has recently been passing loose motions up to four times a day. The motions have been associated with the passage of blood clots and fresh blood mixed within the stools. His appetite has been normal, but he reports a 2-stone weight loss. The past history was otherwise unremarkable. His father died from cancer at the age of 45 years, but he is unsure of the origin.
examination
No pallor or lymphadenopathy is present. The abdomen is soft and non-tender with no palpable masses. Digital rectal examination is normal.
INVESTIGATIONS
rigid sigmoidoscopy reveals a mass located approximately 11 cm from the anal verge (Figure 11.1).
Figure 11.1 lesion on sigmoidoscopy.
Questions
•What is the likely diagnosis?
•How should the patient be investigated?
•What are the options for treatment?
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100 Cases in Surgery
ANSWER 11
A sessile mass is seen occupying approximately half of the bowel wall circumference. A biopsy of the lesion should be taken at the time of sigmoidoscopy to confirm the diagnosis of rectal cancer.
Blood tests including full blood count, liver function tests and tumour markers (e.g. carcinoembryonic antigen [CEA]) should be arranged. An urgent colonoscopy is required to determine whether there are any synchronous cancers (5 per cent) or synchronous polyps (75 per cent) in the rest of the large bowel.
The patient should be staged using computerized tomography (CT) of the chest and abdomen to check for chest, mediastinal and intra-abdominal metastases. Magnetic resonance imaging (MRI) of the pelvis is used to ascertain the depth of tumour invasion through the rectal wall and any regional nodal metastases. For tumours located above approximately 5 cm from the anal verge, an anterior resection is carried out with or without a temporary defunctioning stoma. If the tumour is less than 5 cm from the anal verge, then abdomino-perineal resection of the anus and rectum maybe required with a permanent end colostomy.
For tumours penetrating the rectal wall, preoperative radiotherapy is beneficial, and more recently a combination of chemotherapy and radiotherapy has been advocated for some tumours.
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General and Colorectal
CASE 12: inveStigation oF anaemia
history
A 68-year-old man is referred by his general practitioner (GP) with a 6-week history of lethargy and breathlessness on walking. He is off his food and has lost 2 stone in weight over the previous 2 months. He reports no rectal bleeding or change in bowel habit. His father died at the age of 58 years from a colonic tumour. He is otherwise well and not on any regular medication. His GP referred him to the colorectal clinic, as he was concerned about his blood results and his strong family history of colorectal cancer. An OGD had been previously requested by the GP and was normal.
examination
On examination, his conjunctivae are pale and he looks cachectic. There is no jaundice or palpable lymphadenopathy. The chest is clear and the heart sounds are normal. Examination of the abdomen reveals a fullness in the right iliac fossa. There is no associated hepatomegaly. Digital rectal examination and sigmoidoscopy to 18 cm are normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
7.4 g/dl |
11.5–16.0 g/dl |
mean cell volume |
68 fl |
76–96 fl |
White cell count |
6 × 109/l |
4.0–11.0 × 109/l |
platelets |
250 × 109/l |
150–400 × 109/l |
Sodium |
132 mmol/l |
135–145 mmol/l |
potassium |
3.8 mmol/l |
3.5–5.0 mmol/l |
urea |
16 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
6.2 μmol/l |
44–80 μmol/l |
a Ct scan of the abdomen and pelvis (Figure 12.1) is organized.
Figure 12.1 Computerized tomography of the abdomen.
Questions
•How should microcytic anaemia be investigated?
•What is the diagnosis shown on the CT scan?
•What further investigations are required for this patient?
•What treatment is appropriate?
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100 Cases in Surgery
ANSWER 12
Iron-deficiency anaemia should be firstly confirmed by a low serum ferritin, red cell microcytosis or hypochromia. The patient should then have their urine checked for haematuria, a rectal examination, and should be screened for coeliac disease. OGD and colonoscopy should be performed to exclude malignancy. One of the most common causes of iron-deficiency anaemia is from medications such as aspirin or other non-steroidal anti-inflammatory drugs.
The CT scan in this patient shows a caecal tumour. These can present insidiously and may only present with iron-deficiency anaemia. Further investigations should include liver function tests and a CEA tumour marker level. A CT scan of the chest, abdomen and pelvis will delineate the nature of the mass and any metastatic disease. A colonoscopy provides a tissue diagnosis and will rule out any synchronous tumours in the large bowel.
In the absence of metastatic disease, the patient should undergo right hemicolectomy. Adjuvant chemotherapy may be required, depending on the depth of the resected tumour and involvement of the local lymph nodes. If metastatic disease is present, then a palliative resection should be considered in patients with anaemia or obstruction.
KEY POINT
• Serum ferritin should be checked in patients with microcytic anaemia.
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