Write Up: Rectal Cancer, Part 3 (Investigations, General Management)

Preoperative Investigations (chronological order):

Full Blood Count - Normal hemoglobin (14.6), WBC (8.3) and platelet (310) counts.

Blood for Urea and Serum Electrolytes - Normal creatinine (82) and urea (12.1) levels, normal electrolyte level (Na 131/ K 4.1/ Cl 93).

Coagulation Profile - All normal (PT 12.2, INR 1.05, APTT 26.2)

Random Blood Sugar - Normal (6.7)

Urinalysis - Leucocytes present (+1), Proteinuria (+4), Bilirubinuria (+1), Erythrocytes present (+2). No nitirite in urine. Consistent with direct hyperbilirubinemia in LFT.

Liver Function Test - No obvious bilirubun derangements (total bilirubin 14, direct 7.6 (slightly high), indirect 6.4). There is a low protein content (total protein is 53.3, with hypoalbuminemia (29), and an albumin: globulin ratio of 1.2). Liver enzymes are normal (AST 39, ALT 21, ALP 102). Consistent with chronic disease.

Renal Profile - Electrolyte imbalance is present; Na/K/Cl of 135 (borderline low)/3.16 (hypokalemia)/101. Uric acid is high (286). Urea (9.2) and creatinine (61) are both normal.

Creatinine Kinase - High (249). Consistent with heavy cell turnover.

LDH - High (1457). Consistent with tumor/necrosis.

Preoperative Imaging:

Erect Abdominal X-Ray - Dilated large intestine. Slight dilatation of small intestine, not marked. Consistent with chronic obstruction.

PA Chest X-Ray - Lungs clear, borderline cardiomegaly.

ECG:

M shaped QRS complex in V1 and V2, with a wide S wave in lead I, consistent with right bundle branch block.

Preoperative Colonoscopy:

There is as constricting mass in the rectum from 5 cm above the anal verge towards just below the rectosigmoid junction. Punch biopsies were taken.

Preoperative Histology:

Advanced adenocarcinoma

Intraoperative Findings:

Noted that both small and large bowel were dilated, with thinning of the small bowel wall. There is a site of perforation in the small bowel with minimal fecal soiling. There is a constricting mass at the rectosigmoid junction measuring about 5 cm towards the anal verge.

Intraoperatively, a Hartmann procedure was performed, and the perforation was repaired. The tumor was not resected as the patient’s cardiovascular function was unstable intraoperatively due to his cardiac condition.

Postoperative Investigations:

Full Blood Count - Not anemic (11.8), normal leucocyte and platelet counts (4.0, 223).

Liver Function Test - Slight hyperbilirubinemia (16.6), primarily due to direct hyperbilirubinemia (7). Normal serum protein, but with slight hypoalbuminemia (31.6), and a slightly below 1 albumin: globulin ratio (0.95:1). AST/ALT is normal (both 20), with significantly high ALP (523). Consistent with chronic disease also causing slight biliary obstruction.

Renal Profile - Electrolytes mainly normal (Na/K/Cl of 130/4.3/96 (Na and Cl slightly low). Urea and creatinine are within normal (5.3, 61). Uric acid is high (361). Consistent with high cell turnover.

Prostatic Specific Antigen - Normal (0.48)

Carcinoembryonic Antigen - High (15.23). Consistent with gastrointestinal tumors, may be used as baseline reference value for determining progress of illness.

Postoperative Imaging:

Portable Chest X-Ray - Lungs clear, borderline cardiomegaly.

Chest, Abdominal, Pelvic CT - Multiple heterogenous masses in the liver, with one compressing on the inferior vena cava. Inferior vena cava and portal vein are still patent. Spleen and kidneys are all normal. There is no fluid accumulation in the abdomen and pelvis, and no intraabdominal lymph node enlargement. There is a circumferential constricting mass seen in the rectosigmoid colon, causing lumen narrowing with slight dilation of proximal bowel. Colon, rectum and bladder still have normal outline. Bilateral pleural effusions present.

Diagnosis:

Duke Stage 4 colon adenocarcinoma of the rectosigmoid colon.

Principles of Management of this Patient:

Patient was identified as having intestinal obstruction secondary to a colorectal tumor based on history and examination.

Investigations done in view of need for an emergency operation (blood tests, X-rays, colonoscopy). Nasogastric tube was done, having both diagnostic (showed feces) and therapeutic (slight relief of obstruction) function. Identified cardiovascular risk (medium risk in view of right bundle branch block)

Emergency laparotomy. Hartmann procedure done to relieve obstruction. Unresected tumor due to unstable cardiovascular function intraoperatively.

Admission to ICU due to patient instability, with transfer to general ward once stabilized.

Postoperative investigations to monitor progress and establish proper (radiological) nature of disease, including baseline CEA.

Chemotherapy (Mayo regime) initiation.

Discussion of plan for future tumor resection, for which there is still no concrete decision on behalf of the patient.

Handling of his welfare issues (poor, uneducated, unemployed) with the welfare authorities.