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General and Colorectal
CASE 17: bright reD reCtal bleeDing
history
A 43-year-old man attends the surgical outpatient clinic complaining of intermittent bleeding per rectum for the past 2 months. The blood is always bright red, separate from the stool and drips into the pan. He also complains of itching around the anus. There is no other past medical history of note.
examination
Abdominal examination is unremarkable. Rectal examination and proctoscopy shows internal haemorrhoids at the 3 and 7 o’clock positions.
Questions
•What are the differential diagnoses?
•What other examinations are required?
•How would you classify haemorrhoids?
•What are the treatments for haemorrhoids?
35
100 Cases in Surgery
ANSWER 17
The most likely cause for the per rectal bleeding is haemorrhoids. Haemorrhoids are congested vascular cushions containing dilated veins and small arteries. They arise from the connective tissue in the anal canal and are classically described as lying in the 3, 7 and 11 o’clock positions. A low-fibre diet results in straining with defecation, causing engorgement of the tissue. This leads to enlargement of the cushions and prolapse. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause haemorrhoidal problems.
!Differential diagnoses
•anal fissure
•perianal haematoma
•Carcinoma
•anal polyp
•inflammatory bowel disease
Sigmoidoscopy is mandatory to exclude rectal pathology up to the rectosigmoid junction. If there is any doubt as to the cause of bleeding, especially in the older patient, a flexible sigmoidoscopy or full colonoscopy should be carried out.
Haemorrhoids can be classified as:
•First-degree haemorrhoids: remain in the rectum
•Second-degree haemorrhoids: prolapse through the anus on defecation but reduce spontaneously
•Third-degree haemorrhoids: prolapse but require manual reduction
•Fourth-degree haemorrhoids: prolapse and cannot be reduced
Patients should be advised to take plenty of fluid, fruit, fibre and laxatives to keep the stool soft and to avoid straining. Treatments include phenol injections into the submucosa above the haemorrhoid and/or rubber-band ligation. Large second-degree and third-degree piles may require haemorrhoidectomy.
KEY POINT
• eighty per cent of patients will not require surgical intervention.
36
General and Colorectal
CASE 18: Change in boWel habit
history
You are asked to see a 69-year-old retired baker in the outpatient clinic. For the past 7 weeks he has been passing more frequent stools (3–4 times per day). The motions are looser than normal, but do not contain any blood. He has lost a stone in weight in the past 6 months. Past history includes a fractured femur 8 years ago and an appendicectomy at the age of 20 years. His mother had ulcerative colitis. He is very active and a keen golfer.
examination
The temperature is 36.5°C, the pulse rate is 69/min and the blood pressure is 150/85 mmHg. The abdomen is soft and non-tender with no masses or organomegaly. Digital rectal examination is unremarkable and rigid sigmoidoscopy to 20cm does not show any abnormality.
Urgent investigation is requested and shown below.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
14.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
4.1 × 109/l |
4.0–11.0 × 109/l |
platelets |
220 × 109/l |
150–400 × 109/l |
Sodium |
141 mmol/l |
135–145 mmol/l |
potassium |
4.6 mmol/l |
3.5–5.0 mmol/l |
urea |
7.1 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
53 μmol/l |
44–80 μmol/l |
C-reactive protein (Crp) |
1 mg/l |
<5 mg/l |
Carcinoembryonic antigen |
550 ng/ml |
<2.5 ng/ml |
a barium enema is performed (Figure 18.1).
QuESTIONS
•What does the barium enema in Figure 18.1 show?
•What investigation is required for adequate preoperative staging?
•How can the tumour be staged upon histological examination of the resected specimen?
•Which groups of patients are at risk of developing colorectal cancer?
Figure 18.1 barium enema.
37
100 Cases in Surgery
ANSWER 18
The study shown is a barium enema in a patient with a tumour at the splenic flexure (arrow). The appearance is typical of the narrowing of the colon lumen caused by an ‘apple-core lesion’.
A colonoscopy would help to delineate the pathology within the colon and would allow biopsy to provide a tissue diagnosis. The colon can also be examined for synchronous tumours (found in 3 per cent). A CT scan of the chest, abdomen and pelvis is then required to stage the tumour and to determine operability. Once resected, the tumour is staged by the Dukes’ classification.
!Dukes’ staging for pathological staging of colorectal cancer
•A: carcinoma not breaching the muscularis propria
•B: carcinoma breaching the muscularis propria but no involvement of local lymph nodes
•C: carcinoma involving local lymph nodes
•D: carcinoma with distant metastases
•Five-year survival: 90 per cent, 70 per cent and 30 per cent for Stages a, b and C, respectively
Colorectal cancer is the second commonest cancer causing death in the UK, with over 19,000 new cases diagnosed each year. Most cancers are thought to arise within pre-existing adenomas. Right-sided lesions can present with iron-deficiency anaemia, weight loss or a right iliac fossa mass. Left-sided lesions present with alteration in bowel habit, rectal bleeding, or as an emergency with obstruction or perforation. Adjuvant radiotherapy is given for rectal cancer either preor postoperatively to prevent local recurrence. Adjuvant chemotherapy improves survival in locally advanced tumours.
!Patients at high risk of colorectal malignancy
•patients with family history
•Familial polyposis
•Sporadic adenomatous polyps
•inflammatory bowel disease
KEY POINTS
•Colorectal cancer is the second commonest malignancy in the uK.
•the Dukes’ classification is used to stage the tumour after resection.
38
General and Colorectal
CASE 19: looSe StoolS, Weight loSS anD
right iliaC FoSSa pain
history
A 33-year-old man presents to the surgical outpatient clinic complaining of increasing stool frequency (up to 5 times/day) for the past 4 months. His stool is looser than normal and occasionally contains mucus. His appetite has been healthy, but he has lost half a stone in weight. He also describes an intermittent colicky lower abdominal pain that occurs most days and is relieved by opening his bowels. He is otherwise well with no history of recent foreign travel. His father died at the age of 50 years from a colonic tumour.
examination
The temperature is 37.5°C, the pulse rate is 90/min and the blood pressure is 130/70 mmHg. The right side of the abdomen is tender to deep palpation. No masses are palpable. Digital rectal examination is normal. Rigid sigmoidoscopy to 15 cm from the anal verge shows normal mucosa.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
10.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
6.0 × 109/l |
4.0–11.0 × 109/l |
platelets |
232 × 109/l |
150–400 × 109/l |
Sodium |
145 mmol/l |
135–145 mmol/l |
potassium |
4.0 mmol/l |
3.5–5.0 mmol/l |
urea |
6.2 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
79 μmol/l |
44–80 μmol/l |
C-reactive protein (Crp) |
98 mg/l |
<5 mg/l |
A colonoscopy is arranged and reveals injected, erythematous caecal and terminal ileal mucosa. A biopsy is taken and is reported as showing non-caseating granulomata with transmural inflammation of the bowel mucosa and frequent lymphoid aggregates in the subserosa.
Questions
•What is the diagnosis?
•What other intestinal manifestations of the disease are possible?
•What are the extra-intestinal manifestations of this disease?
•How is this condition treated medically?
•What are the indications for surgery?
39
100 Cases in Surgery
ANSWER 19
Increasing frequency of stool, anorexia, low-grade fever, abdominal tenderness and anaemia suggest an inflammatory bowel disease. The histological findings are characteristic of Crohn’s disease.
!Presentation of Crohn’s disease
•perforation of the affected bowel
•Stricturing of the bowel causing partial/complete obstruction
•Fistulation: e.g. enteroenteric, enterovesical, enteroureteric, enterocutaneous
•uncontrollable haemorrhage (rare)
!Extra-intestinal manifestations of Crohn’s
•Conjunctivitis and iritis
•Cirrhosis of the liver
•Cholangiocarcinoma
•primary sclerosing cholangitis
•renal stones and gallstones
•erythema nodosum
•pyoderma gangrenosum
•psoriasis
•ankylosing spondylitis
Potent anti-inflammatory drugs are the mainstay of medical therapy. Corticosteroids are used orally or intravenously. If the disease only affects the distal colon, topical (suppository/ enema) steroids can be used. Salicylic acid derivatives (e.g. sulfasalazine) are used to control the disease and reduce the dose of steroids required to maintain remission. Other drugs used include anti-tumour necrosis factor alpha antibodies (e.g. infliximab) and immunosuppressives (e.g. methotrexate and azathioprine). Treatment with metronidazole can also help control symptoms.
!Indications for surgery
•bowel perforation
•massive haemorrhage
•Colonic dilatation
•Failure to respond to medical treatment
•Complicated fistulae
•bowel stricturing and obstruction
•Failure to thrive in children
KEY POINTS
•Crohn’s disease can affect any part of the bowel from the mouth to the anus.
•the initial management of uncomplicated Crohn’s disease should be medical.
40
General and Colorectal
CASE 20: inCreaSeD boWel FreQuenCy
anD reCtal bleeDing
history
A 40-year-old woman presents to the emergency department complaining of a 2-month history of bright red rectal bleeding, motions up to six times per day and cramping lower abdominal pains. She has lost 2 stone in weight. She finished a course of Augmentin for a chest infection 2 weeks ago. She had an appendicectomy at the age of 16 years with no other past history of note. She visited Thailand on a family holiday 3 weeks ago.
examination
The temperature is 37.5°C with a pulse rate of 98/min and a blood pressure of 140/70 mmHg. There is no lymphadenopathy. The abdomen is soft with tenderness to deep palpation in the left iliac fossa. Digital rectal examination shows soft stool with a small amount of bright red blood and mucus mixed in. Rigid sigmoidoscopy to 20 cm from the anal verge reveals bright red, friable rectal mucosa. A biopsy is taken.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
13.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
5.9 × 109/l |
4.0–11.0 × 109/l |
platelets |
302 × 109/l |
150–400 × 109/l |
Sodium |
147 mmol/l |
135–145 mmol/l |
potassium |
4.8 mmol/l |
3.5–5.0 mmol/l |
urea |
6.9 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
50 μmol/l |
44–80 μmol/l |
amylase |
68 iu/dl |
0–100 iu/dl |
aspartate transaminase (aSt) |
32 iu/l |
5–35 iu/l |
alkaline phosphatase (alp) |
74 iu/l |
35–110 iu/l |
gamma-glutamyl transferase (ggt) |
42 iu/l |
11–51 iu/l |
albumin |
37 g/l |
35–50 g/l |
bilirubin |
16 mmol/l |
3–17 mmol/l |
erythrocyte sedimentation rate (eSr) |
49 mm/h |
1–13 mm/h |
Questions
•What differential diagnoses would you consider?
•The biopsy suggests ulcerative colitis. What are the typical histological findings?
•How should the patient be managed acutely?
•What is the potential for malignant change associated with this condition?
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