Write Up: Rectal Cancer, Part 4 (Discussion)

Case Discussion:

Major issues in this patient are 1) difficulty in obtaining a proper objective history (quantifying bowel and urinary habits during and before illness), 2) presence of history that was proven wrong during physical examination etc. (melena, clear vomiting), 3) the uneducated nature of the patient.

This patient in particular would go off in random tangents in history taking, requiring several repeats of the same question before he would answer the question itself properly. The patient would also give contradicting answers, e.g. that he defecates 2-3 times when experiencing constipation, but 2-3 times as well when he does not experience constipation. Acquiring history from such patients require that the history taker use more closed-ended questions following less open ended questions to achieve more objective history, while at the same time still avoiding leading questions to avoid bias.

The patient himself also appears to be uneducated regarding his own illness, being aware of only the fact that he has a large intestinal tumor and the presence of liver metastases; he was completely unaware of what happened during surgery, of his heart condition, and the significance of chemotherapy. This ignorance was probably contributory to his indecisiveness to have a future resection of his tumor.

His initial complaint was of dull suprapubic abdominal pain. This generally narrowed down the probable organ of involvement to the bladder and colon. The presence of constipation, reduced size of stool (both of which suggested lower intestinal obstruction) and tenesmus suggested a colonic pathology, but bladder-related pathologies were still not ruled out due to presence of urinary symptoms. A colonic pathology was supported when the pain progressed to involve the whole abdomen, and especially when a mass was felt per rectally with per rectal bleeding. His urinary symptoms were probably explained by the finding of being diabetic during admission.

His cancer is at Duke’s stage D, with a probable TNM staging of T2-3N2-3M1, based on the history/physical (jaundice, hepatomegaly), histology (advanced adenocarcinoma), operative findings (mesenteric node involvement, liver nodularity), and imaging (confirmation of liver metastases, no other organ involvement, no change in organ outline). In such patients, the mode of management is of palliative intent, achieved by diversion of obstruction, palliative resection of primary tumor (and nodes), and adjuvant chemotherapy to reduce the metastases (but not remove them altogether.

In view of the advanced nature of his disease, a palliative course was taken, with a plan of Hartmann procedure (with possible tumor resection) and adjuvant chemotherapy. However, the operation itself was complicated by the presence of a right bundle branch block. This patient is a good example of the requirement of the surgical personnel to identify possible contraindications/risks of surgery. It is thus important to get a good systemic review of each patient, as patients usually do not complain about their concomitant medical illnesses, instead only talking about their main (surgical) complaint.

In such patients, adequate education is required in order to achieve proper management, as such patients, as shown in this case, have a tendency to refuse medical options. As the patient is old and poor, strong welfare support is required for this patient, which is also partially provided by the tabligh group he follows. Such support will help achieve proper patient compliance, allowing him optimum medical support.

The medical student is also at a great position to educate the patient regarding his disease. However, despite repeated explanations, the patient was still quite ignorant regarding the nature of his disease and the treatment by the doctors.