Post on 04-Jan-2016
Case Presentation
Group IVSurgery Unit I
Ward no 24
Particulars of the patient:
Name : Mr. Abul Bashar
Age : 50 years
Sex :Male
Father’s name : Late Sultan Ahmad
Mother’s name : Late Aleya Khatun
Present address : Bogarbil, Rangunia,
Chittagong
Contact number : 01676847914
Occupation : Farmer
Religion : Islam
Marital status : Married
Date & time of admission : 26.10.13 at 3.30pm
Date & time of examination : 27.10.13 at 9.30 am
Bed number : 04
Ward number : 24 ( surgery unit- I)
Under whom he was admitted : Professor Dr. Omar Faruque Yousuf
The presenting complaints:
• Passage of blood streaked stool for
1.5 months.
• Alteration of bowel habit for 1.5
months.
• Sense of incomplete defecation for 1.5
months.
• Pain in the middle of the lower
abdomen for the last 7 days.
According to patient’s statement, he was relatively well 1.5 months
back, then he noticed streaks of blood on stool, admixed with
mucus. The blood was slight in amount and defecation was not
associated with pain. He also complained of increased frequency of
passage of stool for the last one month (10 times/ day). For about
1.5 months he had been experiencing alteration of bowel habit with
early morning diarrhea. Occasionally, he felt sense of incomplete
defecation. Sometimes, he would strain for emptying the bowel
without resultant evacuation. For the last 7 days, he developed mild
pain in the lower abdomen which was stretching in nature,
aggravated by filling of bladder and relieved by micturition. He also
had anorexia and gave history of weight loss, the loss being 50% of
his previous body weight.
He gave no history of jaundice, ascites, hematuria, hematemesis,
bone pain, hemoptysis or chest pain.
The history of present illness:
The history of past illness:
He was not diabetic, not hypertensive and
gave no history of tuberculosis, asthma.
He gave no history of previous hospitalization
and blood transfusion.
Personal history:
He was a chain smoker; pack-year was
50.
He was non alcoholic.
His diet was normal.
Personal hygiene was not satisfactory.
Family history:
No member of his family was suffering from such disease.
Drug history:
He used to take homeopathic medicine to relieve his problems.
Socio-economic history:He came from a lower socio-economic status.
General examination
Appearance : Ill looking
Body built : Normal
Nutrition :
Malnourished
Co-operation : Co-
operative
Decubitus : On choice
Anemia : Present
Jaundice : Absent
Edema: Absent
Dehydration : Present
Pulse : 80 bpm
Blood pressure : 110/70 mm
Hg
Temperature : 98◦F
Respiratory rate : 20
breaths/min
Neck vein : Not
engorged
Lymph node : Not palpable
Hernial orifice : Intact
Abdomen Examination:Inspection:
Abdomen was scaphoid in shape
Umbilicus was centrally placed and
inverted
Abdomen was not distended
No engorged vein, no visible peristalsis,
no scar mark were presentPalpation: Mild tenderness present
Temperature was normal, no mass was
palpable
Liver, spleen were not palpable, kidney
was not ballotable.
Percussion:
Percussion note was tympanitic
Shifting dullness and fluid thrill
absentAuscultation:
Bowel sound was present and normal
Digital rectal examination:Inspection:
Skin around the anus was normal
No excoriation,no faecal soiling
No fistula, fissure or hemorrhoids was
presentPalpation: Anal tone was normal A circumferential mass was found in
rectum; 5 cm above the anal verge
Surface was irregular
Consistency was hard
The mass was fixed with the surrounding
structures.
Upper limit of the mass could not be
reached
On withdrawal, the finger was blood
stained
Salient Feature
Mr. Abul Bashar, 50 years old, farmer, son of late Mr. Sultan
Ahmad hailing from Bogarbil, Rangunia, Chittagong presented
with the complaints of passage of blood streaked stool for 1.5
months, altered bowel habit and sense of incomplete defecation
for the same duration.
According to patient’s statement, his presenting complaints
started 1.5 months back. Then he noticed streaks of blood on
stool admixed with mucus. He also complained of alteration of
bowel habit with early morning diarrhea and increased
frequency of defecation (10times/day). He had been experiencing
sense of incomplete defecation for the last 1.5 months. He
developed pain on the central lower abdomen for the last 7 days
which was stretching in nature and was aggravated by filling of
urinary bladder and relieved by micturition. The patient was
anorexic and lost 50% of his previous body weight. He gave no
history of jaundice, ascites, hematuria, hemoptysis, melena.
The patient was not diabetic, normotensive. He was a chain
smoker, smoking 25 sticks per day for 40 years. He came from
low socio-economic status and none of the member of his family
suffered from such disease.
On general examination, the patient was ill looking, of average
body built, malnourished, co-operative and decubitus on choice.
He was anemic, dehydrated, not icteric, not edematous. His
pulse, blood pressure, temperature and respiratory rate were
within the normal limits. Neck vein was not engorged, neck gland
was not enlarged, peripheral lymph nodes were not palpable,
hernial orifices were intact. On abdominal examination, mild
tenderness was found in lower abdomen. No organomegaly was
found.
On digital rectal examination, there was no visible excoriation,
fecal soiling, hemorrhoids, fissure or fistula. On palpation, anal
tone was normal. There was a circumferential mass, located 5
cm above the anal verge. It was hard in consistency, surface
was irregular and fixed with surrounding structures. Upper
limit of the mass could not be reached. On withdrawal , the
finger was blood stained. Other systemic examination revealed
no abnormality.
Provisional diagnosis:
Carcinoma rectum
Differential diagnosis:
i. Intestinal tuberculosisii. Hemorrhoids
Investigation:
• For diagnosis:
Proctoscopy with biopsy.
• To see extension:
Colonoscopy (to exclude synchronous tumour)
• To see metastasis:
Chest X-ray P/A view
USG whole abdomen
Liver function test
CT scan of chest and abdomen
• For pre-operative staging:
Endoluminal USG of rectum (to assess local
spread)
MRI (for local staging)
Colonoscopic findings of rectal carcinoma
Endoluminal USG of rectum
MRI showing rectal carcinoma
• G/A fitness:
CBC
Urine R/M/E
Random blood glucose
Serum creatinine
Chest X-ray P/A view
ECG
Confirmatory diagnosis:
Carcinoma rectum.
Management:
A. Preoperative preparation:
• Counseling and siting of stomas
• Correction of anemia and electrolyte disturbance
• Cross matching of blood
• Bowel preparation
• Prophylactic antibiotics
• Insertion of urinary catheter
B. Surgery:
• Curative treatment: Anterior resection
CARCINOMA RECTUM
Carcinoma Rectum
Definition:
Carcinoma located within 12cm of the
anal verge by rigid proctoscopy is called
carcinoma rectum.[National Comprehensive Cancer Network Guideline (UK)]
Risk Factors:
Age above 50years
Male gender
High intake of fat
Alcoholism & smoking
High intake of red meat
Obesity
Person with family history of 2 or
more 1st degree relative has 2 to
3 fold greater risk factor.
Origin
Accumulation of genetic abnormalities
Increase in dysplasia in adenoma
Adenocarcinoma [adenoma-carcinoma sequence]
• Well differentiated• Prognosis is good
Low grade
• Moderately differentiated• Prognosis is fair
Average grade
• Undifferentiated• Prognosis is poor
High grade
Histological Grading
H & E stain: Rectal carcinoma
Limited to rectal wall
Extension to extra rectal tissue
C1: Pararectal lymph nodes involvedC2: Lymph nodes accompanying vessels involved
Widespread metastasis
A
B
C
D
Dukes’ Staging
TNM Staging
• T1 : Tumor invasion through muscularis mucosa.• T2 : Tumor invasion into muscularis propria• T3 : Tumor invasion through the muscularis propria but
not through the serosa• T4 : Tumor invasion through the serosa or esorectal
fascia
• N0 : No lymph node involvement• N1 : Between 1 and 3 involved lymph nodes• N2 : 4 or more involved lymph nodes
• M0 : No distant metastasis• M1 : Distant metastasis
Types of rectal carcinoma spread1. Local spread:
Circumferential spread rather than in a
longitudinal direction.
2. Lymphatic spread:
It occurs almost exclusively in an upward
direction.
3. Venous spread: Principal sites of metastasis are,
Liver (34%)
Lungs(22%)
Adrenal gland (11%)
Other organs (33%)
4. Peritoneal dissemination:
It occurs in case of high lying rectal carcinoma.
Epidemiology
•More common in developed countries.•Higher rates in Australia New Zealand Europe USA.•Lower rate in South Central Asia , Africa.•More common in men.
Principles of surgical treatment:
• Curative treatment
• Palliative treatment
Curative treatment: Even in the presence of widespread
metastasis a rectal excision should be considered.
• Tumor whose lower margin is ≥2 cm above the anal canal:
Anterior resection (sphincter saving operation):
Temporary colostomy is done.
• Tumor in upper 1/3rd of rectum or rectosigmoid tumor:
High Anterior Resection
• Tumor involving the lower 1/3rd of the rectum:
SCAPR (Synchronized Combined Abdominoperineal
Resection): Permanent sigmoid end colostomy is done.
• Tumor involving middle & lower 1/3rd :
TME (Total mesorectal excision)
• Others:
TEM (Trans anal Endoscopic Microsurgery): In case
of unfit patients & small low grade T1 tumor.
Hartmann’s operation: for old and frail patient.
Palliative treatment:
• Radiotherapy:
Preoperative radiotherapy can be given for inoperable
primary tumor or local recurrence, especially when painful.
• Chemotherapy:
Adjuvant chemotherapy can improve survival in node
positive diseases.
• Combined radiotherapy & chemotherapy can be given to
shrink an extensive tumor prior to surgical excision.
• Palliative colostomy
When there is intestinal obstruction.
When there is gross infiltration of neoplasm.