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Altered Bowel Function

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Title: Slide 1 Author: php Last modified by: KUMC Created Date: 10/4/2004 1:50:14 PM Document presentation format: On-screen Show Company: php Other titles – PowerPoint PPT presentation

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Title: Altered Bowel Function


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
  • Associated signs/ symptoms
  • Pertinent PMH
  • ROS
  • MEDS
  • Relevant Family Hx
  • Relevant Social Hx.
  • Characterization of Symptoms
  • Temporal sequence
  • Alleviating / Exacerbating factors

5
History Mr. Gunnerson
  • 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
  • Characterization of Symptoms
  • decreasing caliber and frequency of BMs
  • Temporal sequence
  • 3months of abdominal distension,
  • Alleviating / Exacerbating factors
  • No improvement with laxatives

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 CTA Skin/Soft Tissue No inguinal adenopathy
CV RRR without murmur Neuromuscular 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?
  • Imaging?
  • Labs ?
  • Endoscopy?
  • OR?
  • 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/Pelvis CT Scan Chest ?
PA/Lat Chest MRI ?
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
List all labs ordered for your particular patient
CBC Hb/Hematocrit WBC Electrolytes
LFTs Amylase /Lipase
PT/PTT/ Platelets Urinalysis
PSA Type and Crossmatch
CEA Type and Screen
20
Labs Mr. Gunnerson
CBC Hb 11.0 Hematocrit 34 WBC 8.0 CEA 8.2
Electrolytes Normal PSA 4
LFTs 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
Interventions at this point?
  • 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. Gunnersons Cancer?
28
Mr. Gunnersons Tumor Stage
  • Tumor T3
  • Nodes N1
  • Mets Mo
  • Stage III / Dukes 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
  • 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_at_surgicaleducation.com
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