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Cecum

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11%

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Ascending Colon

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25%

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Transverse Colon

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12%

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Descending Colon

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6%

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Sigmoid Colon

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24%

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Rectum

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24%

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*Symptoms

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-may not be evident in the beginning of the disease process -location of cancer determines symptoms

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Clinical Manifestations-Cancer of Right Sided Ascending Colon

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-dull pain (vague) -anemia -black stool -weakness

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Clinical Manifestations-Cancer of Left Sided Descending Colon

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-dull pain -change in bowel habits -alternating diarrhea and constipation -obstruction -bright red blood in stools -ribbon-like stools (due to narrower lumen)

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Clinical Manifestations-Cancer of the Rectum

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-blood in stool -tenesmus (straining to move bowels, but fail to have a BM) -rectal pain -feeling of incomplete evacuation -constipation/diarrhea

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What is the most common symptom that prompts the patient to seek health care?

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Rectal Bleeding

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Etiology of Colorectal (What puts a person at risk?)

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-generally unknown -occurs equally in men and women -greater than 50 years old -family hx of colorectal cancer -previous hx of colorectal cancer (site of surgical anastomosis) -hx of ovarian, breast, or uterine cancer -high fat and low fiber diet (controversial) -2 genetic links to colorectal cancer (FAP and HNPCC) -colorectal polyps (adenomatous polyps) -chronic inflammatory bowel diseases

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Polyps

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benign, non-cancerous tumor

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Adenomatous Polyps (Adenomas)

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polyps that have the potential to change into cancer

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Familial Adenomatous Polyposis (FAP)

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-autosomal dominant disorder -it is a mutation in the adenomatous polyposis coli (APC) gene -characterized by the presence of colorectal polyps (hundreds to thousands) -polyps begin in teenage years -individuals with FAP tend to develop colon cancer early in life (avg. age 39)

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Screening FAP

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-screening should begin between age 10-12 for those with a family hx of FAP, and be repeated every year until polyps are gone -once polyps appear, removal of the colon is usually recommended (total colectomy with ileostomy, or ileoanal pull through)

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HNPCC-Hereditary Non-Polyposis Colorectal Cancer/Lynch Syndrome

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-a mutation in the gene that "error checks" DNA (repairs genes) -autosomal dominant disorder -people with this gene have 80-90% lifetime risk of developing colorectal cancer -*Arises from a single colorectal lesion

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HNPCC Screening

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-People with this known HNPCC should be monitored with colonoscopy every 1-2 years, begins at the age of 20 -avg. age of onset is 44 years old -less aggressive than colorectal cancers without a known risk factors -occurs on the right side in 50% of cases -children have a 50% chance of inheriting the gene

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Possible Protectants (Chemoprotection)

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-NSAIDs -Aspirin -High fiber, low fat diet, lots of fruits and vegetables -regular physical exercise

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Clear Liquids before Colonoscopy

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tea, black coffee, water, apple juice, white grape juice No: OJ, creamer in coffee, milk, etc.

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Screening for the general population

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-begins at age 50 Tests: -Flexible sigmoidoscopy (every 5 years) if positive, the patient will get a colonoscopy -Colonoscopy (every 10 years) -Double contrast barium enema (every 5 years) if positive, patient will get a colonoscopy -CT colonoscopy

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Screening Tests primarily for cancer

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-Fecal Occult Blood Test (FOBT): (perform every year) if positive, patient will get a colonoscopy -Fecal Immunochemical Test (FIT): (perform every year) if positive, pt will get a colonoscopy

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Digital Rectal Exam (DRE)

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-part of routine physical exam -detects masses in anal canal and lower rectum -*can't detect colorectal cancer

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Colonoscopy vs. Sigmoidoscopy

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-colonoscopies examine the entire colon -sigmoidoscopies examine only the sigmoid colon, or the lower 1/3 of the colon

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Virtual Colonoscopy

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-less invasive, less expensive -computer recreation of the colon -greater detail than fiberoptic view -takes 15 minutes -no sedation necessary -Patient can continue to take Warfarin (Coumadin) -*Can not remove polyps or take biopsy

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Ascending/Transverse Colostomy

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-loose stool, liquid consistency -requires colostomy pouch

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Descending Colostomy/Sigmoidostomy

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-more formed stool -does not necessarily require a pouch

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Screening For People at Increased Risk

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History of polyp on prior colonoscopy -small rectal polyp, same as those at average risk -adenomas or villous features-colonoscopy 3 years after polyp removal Patient with CRC-colonoscopy within one year after recection (if normal, repeat in 3 years) Patient with family hx-CRC in first degree relative before age 60-colonoscopy at age 40, or 10 years before youngest case in immediate family

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Screening For High Risk Individuals

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-FAP: screening begins at age 10-12 -HNPCC: begin at age 20-25, colonoscopy every 1-2 years with biopsy for dysplasia (abnormality)

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2 Staging Systems for Colorectal Cancer

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-DUKES -TNM

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TNM

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T-how far primary tumor grew into wall of intestine N-extent of spread to nearby lymph nodes M-whether or not cancer has metastasized

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Metastasis to the Liver

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-commonly metastasizes to the liver because the venous blood flow from the colorectal tumor goes through the portal vein

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Treatments for Colorectal Cancer

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Surgery -polypectomy with colonoscopy (only when margins of polyp are free of cancer) -Colectomy-with reanastamosis -Colectomy with Colostomy-temporary or permanent (Abdominalperineal resection with colostomy) -Ileostomy -K Pouch-continent Ileostomy Adjuvant Therapy -Radiation -Chemotherapy

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Kock Pouch (K Pouch)

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-Form of ileostomy (continent) -a reservoir is created with the ileum and then a stoma is created with the ileum

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Transverse Colostomy with Double Barreled Stoma

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-Transverse colon is cut and two stomas are created with each cut end -one is the functional ostomy, the other is for mucous elimination-called a mucous fistula

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Loop Stoma

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-the colon is pulled through the omentum, a bridge is created, and the skin and peritoneum are sutured under the loop

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Laproscopic Surgery for Colon Cancer-what should you expect post-op?

answer

5 puncture wounds on the patient's abdomen

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Radiation for Colorectal Cancer

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-used most often for RECTAL cancer -Radiation to the pelvis can be used before surgery to shrink the tumor and make it more resectable -Radiation to the pelvis can be used after surgery to prevent recurrence as well -Palliative treatment: reduce tumor size and offer relief of symptoms -Brachytherapy ("seed radiation"): external or internal

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Chemotherapy For CRC

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-most patient will need some sort of chemo after surgery (except those in the earliest stages) *It is recommended for patient with: -positive lymph nodes -metastatic disease -in conjunction with radiation therapy

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Types of Chemo

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*5-Fluorouracil (5-FU) *Folinic Acid (Leucovorin) *Avastin (Monoclonal Antibody)-cuts off blood supply to tumor so it can't grow

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Chemo S/Es

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-loss of appetite -mouth sores (stomatitis) -diarrhea -rash -alopecia -leukopenia, anemia, thrombocytopenia, neutropenia -fatigue

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Pre-Op Physical Teaching

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-Ostomy Care -Extent of Surgical Procedures -*Side to Side Positioning -Sitz Baths (bath in which a person sits in a warm pool of water, causes vasodilation and quickens healing, used for perineal incision) -Sexual Function/Sexual Activity may be altered

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Pre-Op Psychological/Psychosocial Teaching

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-fear/anxiety -role change -alteration in body image -coping

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General Pre-Operative Teaching

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-bowel prep (laxatives "whole gut lavage", enemas, antibiotics) -oral antibiotics (Neomycin, Erythromycin) -Phantom pain -catheter -N/G tube -blood transfusion -diet -TPN post-op -mucosal drainage -pain management (PCA, Epidural) -IV central or peripheral

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Nursing Assessment Post-Op

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-Assess incisional sites -Assess stoma and surrounding skin (functioning ostomy) Monitor: -vitals -NG placement, can be removed when bowel sounds return -Bowel sounds-return of peristalsis -I & O -Pain -Drainage in colostomy pouch

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Characteristics of Stomas-Color

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-rose to brick red: viable stoma -pale: may indicate anemia -blanching, dark red, purple to black: indicates inadequate blood supply to the stoma or bowel from adhesions, low flow, or excessive tension on the bowel at the time of construction, EMERGENCY situation needing immediate attention

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Characteristics of Stomas-Edema

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-mild to moderate: normal in the initial postoperative period -moderate to severe: obstruction of the stoma, allergic reaction to food, gastroenteritis

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Characteristics of Stomas-Bleeding

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-small amount: normal -moderate to large amount: abnormal

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Management of a Perineal Wound

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-packing of the entire wound -partial closure -primary closure of the perineum

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Ileostomy

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-stoma will be positioned as close to the midline as possible -skin care -avoid foods high in fiber or hard to digest -fluids

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Colostomy Irrigation

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Ascending and Transverse colostomies: liquid to semi-liquid stool, *can not be successfully irrigated Sigmoid and Descending colostomies: semi-formed to formed stool, *can often be regulated with the irrigation method

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Diverticulitis

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-avoid foods with seeds (strawberries, raspberries, popcorn) -can lead to perforation, peritonitis, and sepsis *Often treated with antibiotics and a temporary ostomy

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Patient Problems related to colostomies

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-pain -grieving -altered skin integrity -body image disturbance -anxiety -risk for sexual dysfunction -fear -risk for fluid volume deficit -risk for infection -Altered nutritional balance

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Goals for Ostomy Patients/CRC Patients

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-obtain normal bowel elimination pattern -QOL appropriate to disease progression -relief of pain -evidence of self care -feeling of self-worth, comfort -no metastases or recurrence of cancer

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Interventions for Ostomy Patients/CRC Patients

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-PCA for pain management -Use of Sitz baths -Side to side positioning -aseptic technique -clear liquid diet when diet resumes -have person of same sex discuss concerns with patient -encourage self care -TPN

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Discharge Planning

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-wound care -stoma care in collaboration with enterostomal therapist (ET) -avoid heavy lifting -refer to ostomy society -discuss potential adjuvant therapies -well balanced diet in collaboration with dietary

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Role of the Home Care Nurse

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-overall health -skin integrity: appearance/function of stoma -bowel output -complications -acceptance and progression -adjustments -follow up treatments and MD visits

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CRC Research and Treatment

answer

Chemoprevention (primary prevention) -Aspirin, NSAIDs and Statins: for a healthy GI tract (inhibits prostaglandins) -Calcium -Vitamin D and Folic Acid -Smoking cessation -Lose weight -Avoid high meat consumption (esp. red meat) New in Research: -genetics -earlier detection -Colon Cancer specific antigen-2 (CCSA-2) -Immunotherapy -Stool DNA testing -Tumor Growth Factors -Advancements in Chemotherapy

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