Case
Presentation
Group IV
Surgery 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 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
 Dehydration
: Present
 Body built
: Normal
 Pulse
: 80 bpm
 Nutrition
: Malnourished  Blood pressure
 Co-operation : Co-operative  Temperature
: 110/70 mm Hg
: 98◦F
 Decubitus
: On choice
 Respiratory rate
: 20 breaths/min
 Anemia
: Present
 Neck vein
: Not engorged
 Jaundice
: Absent
 Lymph node
: Not palpable
 Edema
: Absent
 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 present
Palpation:
 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 absent
Auscultation:
 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
Palpation:
present
 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 tuberculosis
ii. 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)
Endoluminal USG of rectum
• 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
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.
Accumulation of genetic abnormalities
Increase in dysplasia in adenoma
Adenocarcinoma
[adenoma-carcinoma sequence]
Low grade
• Well differentiated
• Prognosis is good
Average grade
• Moderately differentiated
• Prognosis is fair
High grade
• Undifferentiated
• Prognosis is poor

H & E stain: Rectal carcinoma
Dukes’ Staging
A
Limited to rectal wall
B
C
D
Extension to extra rectal tissue
C1: Pararectal lymph nodes involved
C2: Lymph nodes accompanying vessels involved
Widespread metastasis
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 spread
1. 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.
•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.