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McGraw-Hill Manual: Colorectal Surgery > Appendex II. Diagnostic Guides >
SELECTED COLORECTAL REFERENCE VALUES
Tumor Markers
Carcinoembryonic Antigen (CEA)
Normal
value:
< 5.0 ng/mL (smoker).
< 2.5 ng/mL (nonsmoker).
Comment: Elevation of CEA in colorectal cancer, but also in a variety of noncolonic cancers (eg, pancreatic, gastric, lung,
breast), as well as in benign conditions (eg, IBD, liver cirrhosis, chronic lung disease, pancreatitis). CEA > 20
highly suspicious for metastatic disease. After curative cancer resection, normalization of elevated values
expected within 1–2 months.
Prostate-Specific Antigen (PSA)
Normal value: 0–4 ng/mL.
Comment: Elevation of PSA in prostate cancer, prostatitis, after digital rectal exam.
IBD Markers
Perinuclear Antineutrophilic Cytoplasmic Antibody (pANCA)
Normal value: 1:8.
Comment: 60–80% positive in ulcerative colitis; 10–25% positive in Crohn colitis.
Anti-Saccharomyces Cerevisiae Antibody (ASCA)
Normal value: 20.0 units.
Comment: 5–15% positive in ulcerative colitis; 60–80% positive in Crohn colitis.
Celiac Disease Markers
Anti-Endomysial IgA
Normal value: < 1:5.
Comment: Sensitivity and specificity for celiac disease > 95% (ie, much better than anti-gliadin IgG).
Anti-Transglutaminase IgA
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Normal value: < 20 units.
Comment: Positive in celiac disease in > 90% of cases (ie, better than anti-gliadin IgG).
Infectious Diseases
CD4 Count
Normal
value:
500–1500 cells/ L.
Comment: HIV infection
assessment of activity and treatment response with CD4 cell counts and viral load. Critical: <
200 cells/
L.
Plasma HIV-1 RNA Monitoring
Normal value: No viral load detectable with appropriate HAART.
Comment: > 100,000 copies/mL sign of drug resistance or disease progression.
Complete Blood Count
White Blood Cells (WBC)
Normal value: 3.8–10.8 [ x 103 WBC/mL].
Comment: Marker for acute inflammation.
Hematocrit (Hct)
Normal value: 35–46 [%].
Comment: Assessment of blood levels.
Hemoglobin (Hgb)
Normal value: 12.0–16.0 [g/dL].
Comment: Assessment of blood levels.
Neutrophils Relative
Normal value: 42.0–75.0 [%].
Comment: Left-shift/bandemia is a marker for acute inflammation.
Lymphocytes, Relative
Normal value: 20.5–51.1 [%].
Comment: Marker for nutritional status.
Blood Chemistry
Creatinine (Cr)
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Normal
value:
0.5–1.2 mg/dL (SI units: 45–110 mol/L).
Comment: Serum value dependent on overall muscle volume and kidney function. Elevation does not occur before
glomerular filtration rate reduced to 25–40%. IV radiographic contrast to be avoided if creatinine > 2.0 mg/dL.
Albumin
Normal
value:
3.2–5.0 g/dL (SI units: 32–50 g/L).
Comment: Marker for nutritional status and synthetic liver function, < 3.0
increased risk of postoperative
complications.
Prealbumin
Normal value: 20–40 mg/dL (SI units: 200–400 mg/L).
Comment: Marker for nutritional status.
Transferrin
Normal value: 200–300 mg/dL (SI units: 2–3 g/L).
Comment: Marker for nutritional status.
Lactate
Normal value: 4.5–19.8 mg/dL (SI units: 0.5–2.2 mmol/L).
Comment: Elevation suspicious for underperfused/ischemic tissues, false normal possible.
Coagulation
D-Dimer (D-Dimer)
Normal
value:
0.6–1.5 mg/100 mL (SI units: 50–130 M/L).
Comment: Elevation unspecific through numerous processes (surgery, DVT, etc); high negative predictive value: normal
D-
dimer DVT/PE highly unlikely.
INR
Normal value: 0.5–1.4.
Comment: Anticoagulation with warfarin target range of 2–3.
Bleeding Time
Normal value: < 6 minutes.
Comment: Increased with platelet dysfunction (aspirin, von Willebrand disease).
Stool Analysis
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Fecal Fat
Normal value: 2–6 g/day on 100 g/day fat in diet.
Comment: Increased in pancreatic insufficiency, cystic fibrosis, lipase inhibitor medication.
FOBT (Fecal Occult Blood Test)
Normal value: Negative.
Comment: Sensitivity: 5 mg hemoglobin in 1 g of stool, false positive and false negative results (eg, vitamin C).
Anophysiology Testing
Pudendal Nerve Terminal Motor Latency (PNTML)
Normal
value:
< 2.5 ms.
Comment: Pudendal neuropathy: true elevation (proper test setup), true absence. False pathologic: proper stimulation not
achieved. False normal: direct muscle stimulation.
Anal Manometry—Mean Resting Pressure
Normal value: 50–100 mm Hg.
Comment: Relatively reliable as no patient cooperation needed.
Anal Manometry—Maximal Mean Squeeze Pressure
Normal
value:
100–350 mm Hg.
Comment: Rule of thumb: doubled resting pressure. False low values; patient not cooperating. False normal values:
pressure generated by contraction of puborectalis and gluteus muscles.
Anal Manometry—High Pressure Zone (Anal Canal Length)
Normal value: 2–4 cm.
Comment: Females generally have shorter length of anal canal than males.
Rectoanal Inhibitory Reflex (RAIR)
Normal
value:
Present at 30–60 cc.
Comment: Absent in Hirschsprung and Chagas disease, megarectum/rectocele, post coloanal or ileoanal (50%); absent for
anatomic or technical reasons.
Anorectal Sensation—Volume at First Sensation
Normal value: 10–50 mL.
Comment: Little value of lower limit as some patients sense the insertion of the probe as such.
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Anorectal Sensation—Volume at First Urge
Normal value: 50–150 mL.
Comment: Particularly of relevance if no urge felt.
Anorectal Sensation—Maximum Tolerable Volume
Normal
value:
140–320 mL (females).
170–440 mL (males).
Comment: Reduced tolerance: typical finding in IBS. Increased tolerance: rectocele, megarectum, neurological sensory
deficiency.
Rectal Compliance
Normal
value:
2–6 mL/mm Hg.
Comment: Formula: compliance =
volume/ pressure. Reduced compliance: typical finding in IBS. Increased tolerance:
rectocele, megarectum, neurologic sensory deficiency.
Balloon Expulsion Test
Normal value: Ability to expel balloon filled with 60–200 mL.
Comment: If not expelled in left lateral position, recheck when patient sits on toilet.
Balloon Retention Test
Normal value: Ability to retain a 100-mL balloon against (minimal to significant) external axial traction of > 0.5 kg.
Comment: False normal values: pressure generated by contraction of puborectalis and gluteus muscles.
Colonic Transit Time (Sitzmark Study)
Intestinal Transit Time (Baseline Reference)
Normal value: Overall 36–48 hours, stomach 0.5–2 hours, small intestine 1–4 hours, large intestine 30–46 hours.
Comment: Distinction between upper GI dysfunction and lower GI dysfunction.
Simplified Colonic Transit Test (1-Day Method)
Normal value: > 80% of all markers eliminated on day 5.
Comment: Three distribution patterns:
(1) < 6 markers left: grossly normal.
(2) diffuse distribution of > 5 markers throughout colon: colonic inertia.
(3) distal accumulation > 5 markers: functional outlet obstruction.
Sequential Colonic Transit Test (3-Day Method)
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Normal
value:
Segmental transit time: ascending colon: 11.3 hours; descending colon: 11.3 hours; rectosigmoid: 12.4
hours.
Total colonic transit time = 35 hours.
Comment: Pathologic: > 50 markers on day 4, > 70 hours total transit time, > 30 hours segmental transit time.
Defecating Proctogram (Defecography)
Anorectal Angle (Baseline Reference)
Normal
value:
90–110 degrees at rest.
Comment: The anorectal angle is the proctographic angle between the midaxial longitudinal axis of the rectum and the
anal canal.
AMSTERDAM II CRITERIA FOR HNPCC
Amsterdam II Criteria
A family should be classified as having HNPCC if there is/are:
One cancer related to colorectal cancer (CRC) or HNPCC in patient 50 years.
Two or more generations.
Three or more relatives with CRC or HNPCC-related cancers with one = first-degree relative of the other two.
Familial adenomatous polyposis to be excluded!
HNPCC cancers: colorectal, endometrial, gastric, ovarian, ureter or renal, pelvic, biliary tract, small bowel, pancreatic,
brain (gliomas), skin cancers (sebaceous adenomas).
Cross-Reference
Carcinogenesis (Ch. 3)
Hereditary nonpolyposis colon cancer (HNPCC, 153.8, V84.09) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Bethesda criteria for MSI testing (App. 2)
BETHESDA CRITERIA FOR MSI TESTING
Bethesda Criteria (Revised 2003, Bethesda II)
Tumors should be tested for microsatellite instability (MSI) in the following situations:
Colorectal cancer (CRC) in patient < 50 years.
Presence of synchronous, metachronous colorectal, or other HNPCC-associated tumors, regardless of patient's age.
CRC in patient < 60 years with histologic features of microsatellite instability (MSI):
– Crohn-like lymphocytic reaction.
– Mucinous/signet-ring differentiation.
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– Medullary growth pattern.
CRC or HNPCC-associated tumor in 1 first-degree relative, with one cancer at < 50 years of age.
CRC or HNPCC-associated tumor at any age in 2 first-degree or second-degree relatives.
HNPCC cancers: colorectal, endometrial, gastric, ovarian, ureter or renal, pelvic, biliary tract, small bowel, pancreatic, brain
(gliomas), skin cancers (sebaceous adenomas).
Cross-Reference
Carcinogenesis (Ch. 3)
Hereditary nonpolyposis colon cancer (HNPCC, 153.8, V84.09) (Ch. 4)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Amsterdam II criteria for HNPCC (App. 2)
TUMOR STAGING IN TNM SYSTEM
Overview
Most commonly TNM system (other systems abandoned: Dukes, Astler-Coller, etc):
T = primary tumor, N = lymph node involvement, M = distant metastases
Colorectal Cancer
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through muscularis propria into subserosa or into nonperitonealized pericolic or perirectal tissues
T4 Tumor perforates visceral peritoneum or directly invades other organs/structures
Regional Lymph Nodes (N)
NX Regional lymph nodes could not be assessed
N0 No regional lymph node metastases
N1 Metastasis in 1–3 regional lymph nodes
N2 Metastasis in 4 regional lymph nodes
Distant Metastasis (M)
MX Distant metastasis could not be assessed
M0 No distant metastasis
M1 Distant metastasis
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Extent of Resection
RX Presence of residual tumor cannot be assessed
R0 No residual tumor
R1 Microscopic residual tumor
R2 Macroscopic residual tumor
Modifiers
p Pathologic assessment
c Clinical assessment
u Ultrasonographic assessment
y Assessment after chemoradiation
Clinical Stage Based on Most Advanced TNM Component (Bold)
Stage I: M0 + N0 T1 or T2
Stage II: M0 + N0 T3 or T4 IIA T3 N0 M0
IIB T4 N0 M0
Stage III: M0 N+, any T IIIA T1–T2 N1 M0
IIIB T3–T4 N1 M0
IIIC Any T N2 M0
Stage IV: M1, any T, any N
Anal Cancer
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm in greatest dimension
T2 Tumor > 2 cm, but < 5 cm in greatest dimension
T3 Tumor > 5 cm in greatest dimension
T4 Tumor of any size invades adjacent organ(s), eg, vagina, bladder, urethra
Regional Lymph Nodes (N)
NX Regional lymph nodes could not be assessed
N0 No regional lymph node metastases
N1 Metastasis in perirectal lymph node(s)
N2 Metastasis in unilateral internal iliac and/or inguinal lymph nodes
N3 Metastasis in perirectal and inguinal lymph nodes and/or bilateral internal iliac and/or inguinal lymph nodes
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Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Extent of Resection
RX Presence of residual tumor cannot be assessed
R0 No residual tumor
R1 Microscopic residual tumor
R2 Macroscopic residual tumor
Modifiers
p Pathologic assessment
c Clinical assessment
u Ultrasonographic assessment
y Assessment after chemoradiation
Clinical Stage Based on Most Advanced TNM Component (Bold)
Stage 0: M0 + N0 TIS
Stage I: M0 + N0 T1
Stage II: M0 + N0 T2 or T3
Stage IIIA: M0 T1 - T3 + N1
M0 + N0 T4
Stage IIIB: M0 T1 - T3 + N2-3
M0 T4 + N1
Stage IV: M1, any T, any N
Cross-Reference
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
FECAL INCONTINENCE SCORING SYSTEMS
(1) Cleveland Clinic Florida Incontinence Score ("Wexner" Score)
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Interpretation
Sum of all parameters: CCFIS 0 = perfect control, CCFIS 20 = absolute incontinence.
Advantage
Simplicity and practicality: easy to use and interpret. Most commonly used comparability.
Disadvantage
System only based on subjective data input, lack of objective parameters.
Does not take coping mechanisms into consideration, eg, no accidents if patient always close to bathroom, or "no
pad" but change of underwear several times, etc.
(2) Fecal Incontinence Quality of Life Score (FIQL)