Colorectal cancer

Question 1

symptoms of colorectal cancer

Answer 1

Change in bowel habit (usually to more loose and frequent stools)
Weight loss
PR bleeding
Tenesmus (feeling of full rectum even after opening bowels)
Iron Deficiency Anaemia (microcytic anaemia with low ferritin)
Bowel obstruction

Question 2

iron deficiency without explanation

Answer 2

indication for 2 week wait cancer referral for colonoscopy and OGD for GI malignancy (microscopic bleeding)

Question 3

investigation for colorectal cancer:

Answer 3

1. Colonoscopy. Endoscopy to visualize full colon. Gold standard investigation. Can include biopsy or tattooing. (to mark for surgery) of suspicious lesions
2. CT colonography. CT with bowel prep and contrast to visualize the colon. Consider in patient less fit for colonoscopy. Staging CT scan. CT Thorax Abdomen and Pelvis. To look for metastasis or other cancers. Consider in patients with weight loss in addition to colonoscopy as initial investigation to exclude other cancers
3. Carcinomembryonic Antigen (CEA). Tumour marker blood test for bowel cancer. Not useful in screening. Useful in predicting relapse of previously treated bowel cancer

Question 4

Dukes classification

Answer 4

Dukes A – confined to mucosa and part of the muscle of the bowel wall
Dukes B – extending through the muscle of the bowel wall
Dukes C – lymph node involvement
Dukes D – metastatic disease

Question 5

TNM classification

Answer 5

Dukes A – confined to mucosa and part of the muscle of the bowel wall
Dukes B – extending through the muscle of the bowel wall
Dukes C – lymph node involvement
Dukes D – metastatic disease

Question 6

colorectal cancer treatment

Answer 6

Decision taken by MDT
Based on clinical condition, general health, staging radiography, histology and patient wishes
Options are surgical resection, chemotherapy, radiotherapy and palliation in any combination

bowel resection:
colectomy can be palliate/curative
laproscopic gives better recovery, less complications
remove tumour and create an end to end anastomosis

Question 7

covering loop ileostomy

Answer 7

A temporary ileostomy created to protect a distal anastomosis
Typically left for 6-8 weeks to allow healing of the anastomosis, after which is it reversed
“Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto skin
Proximal end (the productive side) has turned inside out to form a spout to protect the surrounding skin
Usually located lower right side of abdomen

Question 8

bowel resection complications

Answer 8

Bleeding / infection / pain
Damage to nerves, bladder, ureter or bowel
Post op ileus
Anaesthetic risks
Conversion to open
Anastomotic leak / failure
Requirement for a stoma
Failure to remove the tumour
DVT/PE
Hernias
Adhesions

Question 9

operations for colorectal cancer

Answer 9

right hemicolectomy: remove tumours of the caecum (ascending, proximal and transverse colon)

left hemicolectomy (distal transverse and descending colon)

sigmoid colectomy (Remove sigmoid)

anterior resection (remove tumours of the low sigmoid colon or higher rectum)

abdominoperineal resection (ARP) remove the tumour of the lower rectum. remove rectum and anus, suture over the anus, permanent colostomy

Question 10

follow up to curative resections

Answer 10

CT T.A.P. at 1 and 2 or 3 years
Colonoscopy at 1 and 5 years
CEA 6 monthly for 3 years
Thereafter based on local policy