History

Fact Explanation
Introduction Colorectal cancer is the third most common cancer worldwide and one third of the colorectal cancers are rectal cancers. Most are adenocarcinomas. 5-year survival rates have been improved with the improved surgery and radiotherapy methods. [7]
Bleeding per rectum Rectal bleeding will be ifresh and may either mixed with stools or pass with stools. [13] Bleding may be atributed to haemorrhoids on certain occasions.
Pain Colorectal carcinoma commonly causes painless bleeding. [11]
Tenesmus [2] and sense incomplete evacuation of the rectum [1] Tenesmus is painful desire to defecate without passage of stools. Sense of incomplete evacuation is found in lower GI neoplasms. These symptoms are usually occurred in lower rectal neoplasms.
A period of altering bowel habits Alternating constipation and diarrhoea is a feature of lower GI malignancies. [2,11]. Lower GI malignancy will lead to obstruction and period of constipation may results.Then due to obstruction inflammatory reaction is taking place over the time and that will cause mucus production and will lead to diarrhoea.
Anorexia and weight loss Anorexia and weight loss are systemic manifestation of a malignancy. [9]
Shortness of breath on exertion, lethargy Intermittent chronic blood loss may cause amaemia. [4] Low oxygen to the tissues due to the anaemia, causes lack of energy.
Hepatic and pulmonary symptoms, neurological defecit such as confusion, headache, somnolance Distant metastases are found in 10%–15% of patients even after complete resection of the colorectal tumour. [12] Liver metastases are found in 20%–30% of patients, and to lung, in 10%–20%. Brain metastases are quite rare. [12]
Family history or personal history of colorectal carcinoma/ adenomatous polyposis Family history of rectal carcinoma and adenomatous polyposis syndrome in any first-degree relative younger than age 60; or a history of colorectal cancer or adenomatous polyps in two or more first-degree relatives at any age increase the risk of rectal carcinoma. [14] The most common inherited conditions are familial adenomatous polyposis (FAP) & hereditary nonpolyposis colorectal cancer (HNPCC), also called Lynch syndrome. HNPCC is due to the mutations in genes MLH1 and MSH2, involved in the DNA repair pathway, and FAP is caused by mutations in the tumor suppressor gene APC. [14]
Diet Increased fat in diet, high intake of red and processed meats, highly refined grains and starches, and reduced fibre are known to increase the risk of colorectal carcinoma. Fiber [6] dilutes or adsorbs fecal carcinogens, modulates colonic transit time, alter bile acid metabolism, reduce colonic pH, or increase the production of short-chain fatty acids, by which it reduces the risk of colorectal cancers. [5]
Usage of Alcohol and Smoking [14,16] Increases the risk of colorectal carcinoma. [14,16]
Age and sex Colorectal carcinoma [1] are known to be more common in elderly people. More than 90% of colorectal cancer cases occur inthe age group above 50 years. [14] Rectal carcinoma is more common in males compared to females. [8]
History of inflammatory bowel disease There is increased risk for colorectal cancer in patients with inflammatory bowel disease, particularly in long-standing ulcerative colitis. Risk of colorectal cancer in Crohn’s disease is 20 times greater than a control population. [17]
History of gallstones or cholecystectomy Abnormal bile acid metabolism may facilitate the development of gallstones and may also increase the risk of colon cancer. [15]
References
  1. STEBBING JF, NASH AG. Avoidable delay in the management of carcinoma of the right colon. Ann R Coll Surg Engl [online] 1995 Jan, 77(1):21-23 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502499
  2. STRINGER MD, RANDALL T, RUTTER DP, PICTON SV, PUNTIS JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med [online] 1998 Nov, 91(11):589-591 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296954
  3. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  4. HANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  5. CHAN AT, GIOVANNUCCI EL. Primary Prevention of Colorectal Cancer Gastroenterology [online] 2010 Jun, 138(6):2029-2043.e10 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2010.01.057
  6. PERICLEOUS M, MANDAIR D, CAPLIN ME. Diet and supplements and their impact on colorectal cancer J Gastrointest Oncol [online] 2013 Dec, 4(4):409-423 [viewed 12 September 2014] Available from: doi:10.3978/j.issn.2078-6891.2013.003
  7. GLIMELIUS B. Neo-adjuvant radiotherapy in rectal cancer World J Gastroenterol [online] 2013 Dec 14, 19(46):8489-8501 [viewed 06 October 2014] Available from: doi:10.3748/wjg.v19.i46.8489
  8. DEL GIUDICE ME, VELLA ET, HEY A, SIMUNOVIC M, HARRIS W, LEVITT C. Systematic review of clinical features of suspected colorectal cancer in primary care Can Fam Physician [online] 2014 Aug, 60(8):e405-e415 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131977
  9. CURLESS R, FRENCH J, WILLIAMS GV, JAMES OF. Comparison of gastrointestinal symptoms in colorectal carcinoma patients and community controls with respect to age. Gut [online] 1994 Sep, 35(9):1267-1270 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1375705
  10. DAMIENS K, AYOUB JP, LEMIEUX B, AUBIN F, SALIBA W, CAMPEAU MP, TEHFE M. Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution Curr Oncol [online] 2012 Oct, 19(5):254-258 [viewed 06 October 2014] Available from: doi:10.3747/co.19.1048
  11. DEL GIUDICE ME, VELLA ET, HEY A, SIMUNOVIC M, HARRIS W, LEVITT C. Systematic review of clinical features of suspected colorectal cancer in primary care Can Fam Physician [online] 2014 Aug, 60(8):e405-e415 [viewed 08 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131977
  12. DAMIENS K, AYOUB JP, LEMIEUX B, AUBIN F, SALIBA W, CAMPEAU MP, TEHFE M. Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution Curr Oncol [online] 2012 Oct, 19(5):254-258 [viewed 08 October 2014] Available from: doi:10.3747/co.19.1048
  13. HAMILTON W, ROUND A, SHARP D, PETERS TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study Br J Cancer [online] 2005 Aug 22, 93(4):399-405 [viewed 08 October 2014] Available from: doi:10.1038/sj.bjc.6602714
  14. HAGGAR FA, BOUSHEY RP. Colorectal Cancer Epidemiology: Incidence, Mortality, Survival, and Risk Factors Clin Colon Rectal Surg [online] 2009 Nov, 22(4):191-197 [viewed 08 October 2014] Available from: doi:10.1055/s-0029-1242458
  15. SCHERNHAMMER ES, LEITZMANN MF, MICHAUD DS, SPEIZER FE, GIOVANNUCCI E, COLDITZ GA, FUCHS CS. Cholecystectomy and the risk for developing colorectal cancer and distal colorectal adenomas Br J Cancer [online] 2003 Jan 13, 88(1):79-83 [viewed 09 October 2014] Available from: doi:10.1038/sj.bjc.6600661
  16. WU AH, PAGANINI-HILL A, ROSS RK, HENDERSON BE. Alcohol, physical activity and other risk factors for colorectal cancer: a prospective study. Br J Cancer [online] 1987 Jun, 55(6):687-694 [viewed 09 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002031
  17. FREEMAN HJ. Colorectal cancer risk in Crohn's disease World J Gastroenterol [online] 2008 Mar 28, 14(12):1810-1811 [viewed 09 October 2014] Available from: doi:10.3748/wjg.14.1810

Examination

Fact Explanation
Pallor Anaemia is due to intermittent chronic blood loss [2], or malignancy induced inflammation. [4]
Rectal or abdominal mass Mass raises the suspicion of an malignancy particularly when accompanied by weight loss. [2]
Digital rectal examination [3] Finger can reach around 8 cm above the dentate line. Size, ulceration, fixation of the tumor to structures which are surrounding (eg, sphincters, vagina, prostate, coccyx and sacrum) and presence of any pararectal lymph nodes can be assessed using the digital rectal examination. DRE will reveal any polyps, growths, haemorrhoids and ulcers [3] in the anorectal region.
Wasting [2] Cachexia and anorexia will lead to weight loss and lead to generalized wasting. [2]
Jaundice, hepatomegaly Liver is a common site of metastases. [5]
Respiratory system:dyspnea Liver and lungs are the common sites of metastases as mentioed above. [5]
Focal neurological sign Brain is rarely involvedwith the metastatic disease. Most lesions of the brain are supratentorial. [5]
Obesity Higher body weight and physical inactivity increases the risk of getting colorectal carcinoma. [6]
References
  1. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  2. DEL GIUDICE ME, VELLA ET, HEY A, SIMUNOVIC M, HARRIS W, LEVITT C. Systematic review of clinical features of suspected colorectal cancer in primary care Can Fam Physician [online] 2014 Aug, 60(8):e405-e415 [viewed 08 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131977
  3. YAGNIK VD. Massive Rectal Bleeding: Rare Presentation of Circumferential Solitary Rectal Ulcer Syndrome Saudi J Gastroenterol [online] 2011, 17(4):298 [viewed 12 September 2014] Available from: doi:10.4103/1319-3767.82592
  4. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  5. DAMIENS K, AYOUB JP, LEMIEUX B, AUBIN F, SALIBA W, CAMPEAU MP, TEHFE M. Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution Curr Oncol [online] 2012 Oct, 19(5):254-258 [viewed 08 October 2014] Available from: doi:10.3747/co.19.1048
  6. HAGGAR FA, BOUSHEY RP. Colorectal Cancer Epidemiology: Incidence, Mortality, Survival, and Risk Factors Clin Colon Rectal Surg [online] 2009 Nov, 22(4):191-197 [viewed 08 October 2014] Available from: doi:10.1055/s-0029-1242458

Differential Diagnoses

Fact Explanation
Colonic polyps [11] Polyps are colonic mucosa overgrowths that carry < 1% risk of becoming malignant. Bleeding per rectum [11] which is persistent or intermittent is a common symptom in polyps. Inflammatory, juvenile, peutz-Jeghers, are the various types of polyps. Colonoscopy allow both diagnosis and the immediate therapeutic polypectomy. [4] Adenomatous and Peutz-Jeghers polyps need follow up with fibre optic colonoscopy for the recurrence and malignant changes. [5]
Haemorrhoids [9] This usually presents with painless rectal bleeding [9] with passage of mucous which is usually noticed during defecation. Person may notice a lump at anus which is manually or spontaneously reducible at the early stages and not reducible at later stages( stage 3) In advanced cases such as complicated with fibrosis, gangrene formation, necrosis and infections, it may cause pain. [9]
Colonic malignancies [7] Right-sided colonic bleeding [7] present with bright red blood in the case of massive bleeding is brisk. Otherwise it presents with dark altered blood or malena. Left-sided bleeding may be bright red. Intestinal obstruction can occur in colonic malignancies. Presentation would be abdominal pain, constipation, vomiting and abdominal distension. Loss of appetite and loss of weight and other features of dissemination of the malignancy may be present. [7] Right sided bleeding may be present with iron-deficiency anemia. [8]
Angiodysplasia [10] Angiodysplasia commonly affects the caecum and ascending colon less commonly located in the jejunum and/or ileum and the remainder are throughout the alimentary tract. [1] It is a significant cause of bleeding in the elderly people. [1] Degenerative pathology with aging is known to be associated. Lesions occur due to the intermittent partial chronic obstruction of the submucosal veins at the points where they penetrate the muscle layers of the colon. [2] Usually it will be altered blood with a maroon-colored stool.
Diverticular disease [3] Acute painless bleeding, with mild abdominal cramping due to the intraluminal blood and increased pressure [11] may be the presenting symptoms. Majority will have pain in the left lower quadrant, Fever may also present. May be recurrent. Sometimes bleeding may be massive causing hypotension and shock. Pneumaturia is a significant finding in colovesical fistula. [1] Perforated disease may have features of generalized peritonitis like tenderness, rebound tenderness, rigidity in the abdomen. Water-soluble contrast enema, CT scan, and ultrasound are the investigations done during the acute phase of diverticular disease. [11]
References
  1. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  2. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  3. GALLAGHER HW. Diverticulitis and Rectal Bleeding Ulster Med J [online] 1954 Nov, 23(2):142 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC248019
  4. LATT TT, NICHOLL R, DOMIZIO P, WALKER-SMITH JA, WILLIAMS CB. Rectal bleeding and polyps. Arch Dis Child [online] 1993 Jul, 69(1):144-147 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029431
  5. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474
  6. RAWLS GH. Treatment of Colorectal Cancer J Natl Med Assoc [online] 1982 Aug, 74(8):809-812 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552969
  7. STEBBING JF, NASH AG. Avoidable delay in the management of carcinoma of the right colon. Ann R Coll Surg Engl [online] 1995 Jan, 77(1):21-23 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502499
  8. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  9. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 12 September 2014] Available from: doi:10.1055/s-0031-1272818
  10. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  11. Diverticular disease of the colon. West J Med [online] 1981 Jun, 134(6):515-523 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272839
  12. WAUGH JM, HARP RA, SPENCER RJ. The Surgical Management of Multiple Polyposis Ann Surg [online] 1964 Jan, 159(1):149-154 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1408485

Investigations - for Diagnosis

Fact Explanation
Sigmoidoscopy This is the first line investigation in lower GI bleeding. [3] It usually examine upto splenic flexure of the colon. Intestinal growths, ulcers, polyps etc may be found on sigmoidoscopy. [3]
Colonoscopy This is an important diagnostic tools to evaluate acute lower gastrointestinal bleeding. Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosis. These may be operator dependent. Active bleeding will limit the use of the investigation. It is important to exclude the synchronous lesions in the colon. [2]
Stool occult blood test Stool for occult blood is positive even in asymptomatic people. [2]
Carcinoembryonic antigen (CEA) Plasma level of carcinoembryonic antigen (CEA) is elevated in a suspected case of colorectal malignancy. [4]
CA 19.9 level Carbohydrate antigen 19.9 is elevated in coloretal carcinoma. [5] Carbohydrate antigen 19.9 sensitivity was related to tumor stage.
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  3. STRINGER MD, RANDALL T, RUTTER DP, PICTON SV, PUNTIS JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med [online] 1998 Nov, 91(11):589-591 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296954
  4. NEVILLE AM, NERY R, HALL RR, TURBERVILLE C, LAURENCE DJ. Aspects of the structure and clinical role of the carcinoembryonic antigen (CEA) and related macromolecules with particular reference to urothelial carcinoma. Br J Cancer Suppl [online] 1973 Aug:198-207 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2149056
  5. FILELLA X, MOLINA R, GRAU JJ, PIQUé JM, GARCIA-VALDECASAS JC, ASTUDILLO E, BIETE A, BORDAS JM, NOVELL A, CAMPO E. Prognostic value of CA 19.9 levels in colorectal cancer. Ann Surg [online] 1992 Jul, 216(1):55-59 [viewed 09 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242546

Investigations - Fitness for Management

Fact Explanation
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, [1] which will manifest as low haemoglobin, reduced mean corpuscular volume [3] and mean corpuscular haemoglobin with microcytic anaemia and increased red cell distribution width. [1]
Electrocardiogram and electrocardiogram Indicated prior to surgery particularly in patients who have a high risk for the cardiovascular morbidities. [2]
Serum electrolytes and Creatinine These are particularly important in patients with co-morbities like diabetes mellitus or hypertension. [2] Renal functions may be altered i9n metastatic ureteric invasion.
Random blood sugar If patient is diabetic, blood sugar should be repeated on the day of surgery. [2]
Prothrombin time and International normalized ratio To detect any bleeding diathesis before surgery. [2]
Liver function tests Liver is a common site of metastatic disease. [3] It is also important to have a base line value in the management of these patients.
References
  1. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  2. ZAMBOURI A. Preoperative evaluation and preparation for anesthesia and surgery Hippokratia [online] 2007, 11(1):13-21 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464262
  3. DAMIENS K, AYOUB JP, LEMIEUX B, AUBIN F, SALIBA W, CAMPEAU MP, TEHFE M. Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution Curr Oncol [online] 2012 Oct, 19(5):254-258 [viewed 08 October 2014] Available from: doi:10.3747/co.19.1048

Investigations - Followup

Fact Explanation
Colonoscopy Syndromes like heredetery non polyposis colorectal carcinoma (HNPCC) has a high risk of malignant transformation [5] and need regular follow up. It is recommended to screen every 2 yearly from the age of 25, and5 years younger than the earliest affected case in the family up to 75 years. [2]
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin. [1]
Carbohydrate antigen 19.9 Main use of 19.9 in locoregional cancer is for the prognosis. [3]
References
  1. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474
  2. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  3. FILELLA X, MOLINA R, GRAU JJ, PIQUé JM, GARCIA-VALDECASAS JC, ASTUDILLO E, BIETE A, BORDAS JM, NOVELL A, CAMPO E. Prognostic value of CA 19.9 levels in colorectal cancer. Ann Surg [online] 1992 Jul, 216(1):55-59 [viewed 09 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242546

Investigations - Screening/Staging

Fact Explanation
Duke's staging This grading is one of the important prognostic factor in rectal carcinoma. [4] Modified Dukes Classification System involves 4 stages as follows: stage A, limited to the bowel wall, stage B, extension to pericolic fat with no involvement of the lymph nodes, stage C regional lymph node metastases, stage D ditant metastases (liver, lung, bone). It can be further subdivided into stage C1 and C2: positive lymph nodes with no involvement of the apical node as C1 and involvement of the apical nodes as C2. [5]
CT scan, MRI scan To stage the disease in colorectal carcinoma. [1]
Carcinoembryonic antigen (CEA) [3] Plasma level of carcinoembryonic antigen (CEA) is measured preoperatively in a suspected case of colorectal malignancy. [3] It may also be elevated in other conditions like gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease. [2]
Screening for rectal carcinoma Many colorectal carcinomas are asymptomatic until a late stage where they cause symptoms due to partial obstruction. Therefore screening for rectal cancer is important in identifying the lesions at an early stage. [6] Average Risk Screening, rigid proctoscopy, sigmoidoscopy, fecal occult blood testing, CT Colonography, stool DNA screening (SDNA), fecal immunochemical test (FIT) etc are some availabla tools of screening for colorectal carcinoma. Fecal occult blood testing is recomended annually for screening with the guaiac-based test with dietary restriction or an immunochemical test without dietary restriction. Screening with flexible sigmoidoscopy/ colonoscopy is done every 5 years where needed. Computed tomography colonography is a novel technique used for colorectal examination. As carcinoma can occur due to the genetic mutations , those can be detected using fecal DNA testing. [6]
References
  1. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  2. HOLYOKE D, REYNOSO G, CHU TM. Carcinoembryonic antigen (CEA) in patients with carcinoma of the digestive tract. Ann Surg [online] 1972 Oct, 176(4):559-564 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1355453
  3. NEVILLE AM, NERY R, HALL RR, TURBERVILLE C, LAURENCE DJ. Aspects of the structure and clinical role of the carcinoembryonic antigen (CEA) and related macromolecules with particular reference to urothelial carcinoma. Br J Cancer Suppl [online] 1973 Aug:198-207 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2149056
  4. DEANS GT, PATTERSON CC, PARKS TG, SPENCE RA, HEATLEY M, MOOREHEAD RJ, ROWLANDS BJ. Colorectal carcinoma: importance of clinical and pathological factors in survival. Ann R Coll Surg Engl [online] 1994 Jan, 76(1):59-64 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502188
  5. RARATY MG, WINSTANLEY JH. Variation in the staging of colorectal carcinomas: a survey of current practice. Ann R Coll Surg Engl [online] 1998 May, 80(3):188-191 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503027
  6. GORDON PH. Screening for colorectal carcinoma Curr Oncol [online] 2010 Apr, 17(2):34-39 [viewed 10 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854634

Management - General Measures

Fact Explanation
Patient education and psychological support Educating the patient about the nature of the problem, available treatment options and its side effects, complications including the side effects of radiotherapy and chemotherapy will improve the treatment compliance. Possibility of metastases [2] and recurrences may also need to be told. Particularly stoma care advice has to be given to prevent complications related to the stoma. [5]
Management of anaemia [1] Anaemia can be due to chronic intermittent blood loss from gastrointestinal tract, malignancy induced inflammation and underlying comorbidities. [1] If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion. [1]
Reducing the risk of colorectal carcinoma Clinical trials have shown that aspirin in doses as low as 325 mg per day reduces risk of colorectal carcinoma. [3] Reduction of fat in diet is also an important measure. Avoidance of smoking and heavy alcohol use, prevention of weight gain, and the maintenance of a reasonable level of physical activity are known to lower the risks of colorectal cancer. [4] Simple measures like maintaining adequate fluid intake, eating fresh vegetables, fruits and green leaves, adequate fibre intake and maintaining proper toilet habits are important tp prevent constipation. [4]
Preparing for surgery Preoperative bowel preparation with polyethylene glycol electrolyte solution is given the day before surgery. Counseling on the stoma is given and the site for proximal diversion is marked before surgery. Prophylactic intravenous antibiotics were given at the induction of anesthesia. [5]
References
  1. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  2. DEANS GT, PATTERSON CC, PARKS TG, SPENCE RA, HEATLEY M, MOOREHEAD RJ, ROWLANDS BJ. Colorectal carcinoma: importance of clinical and pathological factors in survival. Ann R Coll Surg Engl [online] 1994 Jan, 76(1):59-64 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502188
  3. GARCIA-ALBENIZ X, CHAN AT. Aspirin for the prevention of colorectal cancer Best Pract Res Clin Gastroenterol [online] 2011 Aug, 25(0):461-472 [viewed 28 August 2014] Available from: doi:10.1016/j.bpg.2011.10.015
  4. LLOYD M. Consensus on prevention and treatment of colorectal cancer: implications for general practice. Br J Gen Pract [online] 1990 Dec, 40(341):483-484 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371441
  5. RARATY MG, WINSTANLEY JH. Variation in the staging of colorectal carcinomas: a survey of current practice. Ann R Coll Surg Engl [online] 1998 May, 80(3):188-191 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503027

Management - Specific Treatments

Fact Explanation
Surgery Surgery is the most important part in the treatment of rectal cancer. [4] Stage T1 and T2 local excision is possible. Local excision combine with pre- or postoperative radio-chemotherapy gives the good the outcome. Transanal endoscopic microsurgery (TEM), is a new technique that provides a locally curative operation. [2] High ligation of the interior mesenteric artery, will be beneficial. Minimum margin of mesorectum should be 5 cm. There are main 2 types of surgical options available: Abdominoperineal resection (APR) and anterior resection. [1]
Anterior resection Anterior resection is a sphincter-sparing operation that gaining the popularity. Anterior resection with mesorectal excision is a safe option that can be done for rectal carcinoma. [6] Some studies have shown that the complete removal of the lymphovascular tissue surrounding the rectum and a free circumferential margin reduces the local recurrence rates in patients with rectal cancer. [6] Peritoneum is incised 1 to 2 cm above the rectouterine or rectovesical pouch. Loop ileostomy is used for the proximal diversion. [6]
Abdominoperineal resection (APR) Abdominoperineal resection (APR) does not preserve the sphincters. There is no difference in the improvement in the survival and reduction in the local recurrences with APR when compared too AR. [5] APR is better in patients who have poorly differentiated Duke's C tumour with a high risk of distal intramural spread. [5]
Transanal Resection & Transanal endoscopic microsurgery (TEM) Transanal excision is done with the conventional technique using traditional equipmentand it provides an easy operative access to most distal rectal lesions. But the disadvantages of the procedure includes, difficulty in conducting on mid-rectal tumors and in large patients with a deep buttock cleft. These can be overcome with the transanal endoscopic microsurgery (TEM) that can be used to treat the early stage rectal cancerand for palliation in advanced rectal cancer in who refuse radical excision/ unfit for surgery. [10] Perforation into the peritoneal cavity and post op haemorrhage are the potential adverse effects of treatment.
Chemotherapy Intravenous Fluorouracil, oral fluoropyrimidines, angiogenesis Inhibitors, epidermal Growth Factor Receptor Inhibitors in isolation [3] or as combined treatment is used for the systemic therapy in colorectal cancers. [3]
Radiotherapy Peripoerative radiotherapy with dosage > 40 Gy in 3-4 weeks reduces the local recurrence rate. [7] Late complications of the radiotherapy includes increased risks of poor anal and sexual function, small bowel toxicity with obstruction and secondary malignancies. [8]
Treatment of the recurrances Occasional local recurrences can be managed by chemoradiotherapy [8] and secondary surgery.
Treatment of metastases Most of our patients had supratentorial brain lesions. Other common sites of extracerebral metastase are lung and liver. Patients with metastatic brain lesions are treated with surgery and radiation therapy with addition of corticosteroid treatment on certain occasions. Incorporation of monoclonal antibodies (bevacizumab, cetuximab, panitumumab) into chemotherapeutic regimens have improved the patient survival in colorectal carcinoma. [9]
References
  1. PERRY WB, CONNAUGHTON JC. Abdominoperineal Resection: How Is It Done and What Are the Results? Clin Colon Rectal Surg [online] 2007 Aug, 20(3):213-220 [viewed 28 August 2014] Available from: doi:10.1055/s-2007-984865
  2. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474
  3. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  4. RAWLS GH. Treatment of Colorectal Cancer J Natl Med Assoc [online] 1982 Aug, 74(8):809-812 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552969
  5. CHRISTIANSEN J. Place of abdominoperineal excision in rectal cancer. J R Soc Med [online] 1988 Mar, 81(3):143-145 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291506
  6. RARATY MG, WINSTANLEY JH. Variation in the staging of colorectal carcinomas: a survey of current practice. Ann R Coll Surg Engl [online] 1998 May, 80(3):188-191 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503027
  7. åHLMAN L, GLIMELIUS B. Pre- or postoperative radiotherapy in rectal and Prectosigmoid carcinoma. Report from a randomized multicenter trial. Ann Surg [online] 1990 Feb, 211(2):187-195 [viewed 06 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357963
  8. GLIMELIUS B. Neo-adjuvant radiotherapy in rectal cancer World J Gastroenterol [online] 2013 Dec 14, 19(46):8489-8501 [viewed 06 October 2014] Available from: doi:10.3748/wjg.v19.i46.8489
  9. DAMIENS K, AYOUB JP, LEMIEUX B, AUBIN F, SALIBA W, CAMPEAU MP, TEHFE M. Clinical features and course of brain metastases in colorectal cancer: an experience from a single institution Curr Oncol [online] 2012 Oct, 19(5):254-258 [viewed 08 October 2014] Available from: doi:10.3747/co.19.1048
  10. KUNITAKE H, ABBAS MA. Transanal Endoscopic Microsurgery for Rectal Tumors: A Review Perm J [online] 2012, 16(2):45-50 [viewed 10 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383161