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Colorectal Cancer (CRC)

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Cancer of the colon or the rectum

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Most CRCs are *Adenocarcinomas*, which are

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tumors that arise from the glandular epithelial tissue of the colon

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Adenocarcinomas develop as a multi-step process resulting in a number of molecular changes

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- loss of key tumor suppressor genes - activation of certain oncogenes that alter colonic mucosa cell division - increased proliferation of colonic mucosa forms polyps that can transform into malignant tumors *Most CRCs are believed to arise from adematous polyps that present as a visible protrusion from the mucosal surface of the bowel*

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Colorectal cancer can metastasize by

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1) Direct Extension 2) Spreading through the blood or lymph 3) Peritoneal seeding

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The most frequent site of metastasis from circulatory spread is the

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liver

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Peritoneal Seeding

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May occur when a tumor is excised and cancer cells break off from the tumor and into the peritoneal cavity. Special techniques are used during surgery to decrease this possibility

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Complications related to the increasing growth of the tumor locally or through metastatic spread include:

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Bowel obstruction or perforation with resultant peritonitis Abscess formation Fistula formation to the urinary bladder or the vagina

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*Major* risk factors for the development of CRC

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Older than 50 yrs Genetic predisposition Personal or family history of cancer and/or diseases that predispose the patient to cancer such as: Familial Adenomatous Polyposis (FAP) Crohns disease Ulcerative colitis

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Genetic consideration

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People with a first degree relative (sibling or child) diagnosed with CRC have 3-4 times the risk for developing the disease

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Lifestyle risk factors for development of CRC

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Long term smoking Increased body fat Physical inactivity Heavy alcohol use A high fat diet *particularly animal fat from red meats* Diets with large amounts of refined carbohydrates

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Some lower GI cancers are related to certain infectious agents such as:

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H. Pylori Streptococcus bovis JC Virus *HPV* - incidence of CRC in in younger adults is slowly increasing, most likely due to increases in HPV infections

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CRC is most common in African Americans *and* their survival rate is less than Caucasians Possible reasons:

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Less use of diagnostic testing Decreased access to health care Cultural beliefs Lack of education about the need for early cancer detection

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Those with family members who have had hereditary CRC should be genetically tested for what 2 genetic disorders?

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FAP - familial adenomatous polyposis NHPCC - Hereditary nonpolyposis colorectal cancer

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Screening for CRC

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- At 40 years old, screening should be discussed with HCP - 50 yrs and older, w/o family history, who are at average risk, should undergo regular CRC screening which consists of: Fecal Occult Blood Testing and Sigmoidoscopy every 5 years OR a double contrast barium enema every 5 yrs OR a colonoscopy every 10 years - Those with personal or family history should begin screening earlier and more frequently

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Clinical Manifestations of CRC

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*The most common signs* are rectal bleeding, anemia and a change in stool consistency or shape

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Right sided tumors

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Can grow quite large without disrupting bowel patterns or appearance because the stool consistency is more liquid in this part of the colon These tumors ulcerate and bleed intermittently --> stools can contain dark or mahogany colored blood Mass may be palpated at lower right quadrant Anemia from blood loss

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Tumors in the transvers and descending colon

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can result in symptoms of obstruction as growth blocks the passage of stool patient may report gas pains, cramping, or incomplete evacuation

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Tumors in the rectosigmoid

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Associated with hematochezia (passage of red blood via the rectum) Straining to pass stools Narrowing of stools Dull pain

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Laboratory testing for CRC *Fecal Occult Blood Test (FOBT)*

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Positive test indicates bleeding in the GI tract Remind patient to avoid: * Aspirin, Vitamin C, and red meat for 48 hrs before giving a stool specimen Anti-inflammatory drugs*(ibuprofen, corticosteroids, or salicylates) should be discontinued for a designated period before the test

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Laboratory testing for CRC Hgb and Hct, & Liver function tests

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-Hgb and Hct values are often decreased as a result of intermittent bleeding associated with the tumor -CRC that has metastasized to the liver cause liver function tests to be elevated

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Imaging Assessment - Double contrast barium enema

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Air and barium are instilled into the colon May show an occlusion in the bowel where the tumor is decreasing the size of the lumen

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Imaging Assessment - Computed Tomograpy CT or MRI

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of the chest, abdomen, pelvis, lungs, or liver helps confirm the existence of a mass, the extent of disease, and location of distant metastases.

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Sigmoidoscopy

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Visualization of the *lower colon* using a fiberoptic scope. Polyps can be visualized, and samples can be taken for biopsy.

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Colonoscopy

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Same as a sigmoidoscopy except it can provide views of the *entire large bowel* from the rectum to the ileocecal valve. Polyps can be seen and removed for biopsy.

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The definitive test for the diagnosis of colorectal cancer is

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Colonoscopy

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Radiation therapy may be used as a _____ measure, to control the following complications of CRC

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A palliative measure To control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease *Radiation therapy has not improved overall survival rates for colon cancer* - hence it is a palliative therapy

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Drug therapy - chemotherapy

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Adjuvant chemotherapy after primary surgery is recommended for patients with stage II or stage III disease. The chemotherapy drugs of choice cannot discriminate between cancer and healthy cells. Therefore common side effects are: diarrhea mucositis leukopenia mouth ulcers peripheral neuropathy

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The best method of ensuring removal of CRC

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Surgical removal of the tumor with margins free of disease

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Most common CRC surgeries performed

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*Colon resection* - removal of the tumor and regional lymph nodes with reanastomosis *Colectomy* - colon removal with colostomy (temp or perm) or ileostomy/ileoanal pull-through *Abdominoperineal (AP) resection* - removal of the sigmoid colon, rectum, and anus through combined abdominal and perineal incisions. Done when rectal tumors are present.

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Postoperative risks of low rectal surgery (AP resection)

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Sexual dysfunction and urinary incontinence as a result of nerve damage

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Bowel prep for elective surgery (when the bowel is not obstructed or perforated) - Whole gut lavage

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Patient may drink large quantities of a sodium sulfate and polyethylene glycol solution (e.g. GoLytely). This solution overwhelms the absorptive capacity of the small bowel and clears feces from the colon.

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What is the purpose of bowel prep?

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To minimize bacterial growth and prevent complications

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Use of bowel preps is controversial because

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Patient discomfort Older adults may become dehydrated from it Infection rates are no different with or without them

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Operative procedures - Colostomy

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A colostomy is created when anastomosis of the colon is not feasible because of the location of the tumor or the bowel is inflamed - Can be created in the ascending, transverse, descending, or sigmoid colon

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Loop colostomy

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made by bringing a loop of the colon to the skin surface, severing and everting the anterior wall, and suturing it to the abdominal surface - Usually performed in the transverse colon and are usually temporary

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End stoma

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Most often in the descending or the sigmoid colon when the colostomy is intended to be permanent

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Postoperative care for the patient with *open colon resection*

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NG tube IV PCA for the first 24-36 hours After NG tube removal diet is liquids to solids as tolerated

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Colostomy management

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-Assess the color and integrity of the stoma frequently, a healthy stoma should be reddish pink and moist and protrude about 2 cm from the abdominal wall - Colostomy should start functioning *2-4* days postoperatively. Stool is liquid immediately post operatively but becomes more solid, depending on where the stoma is placed - when it begins to function may need to be emptied frequently because of excess gas collection. Should be emptied when it is one third to one-half full of stool

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Stool from a colostomy in the ascending colon is

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liquid

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Stool from a colostomy in the transverse colon is

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pasty

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Stool from a colostomy in the descending colon is

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more solid

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Wound management for an AP resection

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-Perineal wound is generally surgically closed and two bulb suction drains such as JP drains are placed in the wound or through stab wounds near the wound - drains are left in place for several days, depending on the character and mount of drainage. - Monitoring drainage from the perineal wound and cavity is important because of the possibility of infection and abscess formation - *Serosanguineous drainage from the perineal wound may be observed for 1-2 months after surgery* - complete healing may take 6-8 months

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Patient with a perineal wound may experience

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Phantom rectal sensations Rectal pain and itching *Interventions* - use of antipruritic drugs and sitz baths - continually assess for signs of infection, abscess or other complications

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Assisting with the Grieving process

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Encourage patient to verbalize feelings about diagnosis, treatment, and anticipated alteration in body functions if a colostomy is planned. Encourage him or her to look at and touch the stoma As them to participate in colostomy care *participation helps restore the patients sense of control over his or her lifestyle and thus facilitates improved self-esteem*

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Before discharge teaching

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-Avoid lifting heavy objects or straining on defecation to prevent tension on the anastomosis site -For open surgery - no driving for 4-6 weeks -Teach those with colon resections to watch for and report clinical manifestations of intestinal obstruction and perforation (cramping, abdominal pain, N&V) - Avoid gas producing foods and carbonated beverages

Mini 2 – Unit 4 – Colon Cancer – Flashcards

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