Colorectal Cancer and Other Colonic Disorders

Chapter 40 Colorectal Cancer and Other Colonic Disorders




Clinical Case Problem 1: A 48-Year-Old Man with Weakness, Fatigue, and Lower Right-Sided Abdominal Fullness


A 48-year-old man comes to your office with a vague lower right-sided abdominal fullness (not pain). He describes to you a general feeling of “not feeling well,” fatigue, and a somewhat tender area “down near my appendix.” He states, “I have no energy. I’m tired all the time.” He also suspects that his skin changed color, first to a pale color and then to slightly yellow.


On direct questioning, he admits to anorexia, weight loss of 30 pounds in 6   months, nausea most of the time, vomiting twice, some diarrhea that seems to be mucus, and blood in the stool almost every day for the past 3   months. When you ask him what he makes of all of this, he tells you, “Maybe a very bad flu.”


On examination, the patient looks very pale. Examination of the abdomen reveals abdominal distention. You record the abdominal girth as a baseline. There is a sensation of “fullness” in the right lower quadrant of the abdomen. This area is also dull to percussion and is slightly tender. There is definite percussion of tympani on both sides of the area of dullness. The liver span is approximately 20   cm. The sclerae are yellow.



Select the best answer to the following questions




1. At this time, what would you do?


a. tell the patient to relax and recheck with your office in 6 months

b. diagnose irritable bowel syndrome and start the patient on dietary therapy

c. tell the patient that he probably is going through a viral illness; relax and come back in 2   months if the symptoms have not improved

d. order a complete workup on the patient

e. none of the above

2. What is the definitive diagnostic procedure of choice in this patient?


a. complete blood count (CBC)

b. fecal occult blood samples

c. air-contrast barium enema

d. colonoscopy

e. three views of the abdomen

3. What is the most likely diagnosis in this patient?


a. irritable bowel syndrome

b. lactose intolerance

c. adenocarcinoma of the pancreas

d. adenocarcinoma of the colon

e. ruptured appendix

4. A correct diagnosis is made from question 3. What is the definitive treatment of choice?


a. total colectomy

b. surgical removal of the mass

c. removal of the appendix

d. abdominoperineal resection of the rectum

e. neodymium:yttrium-aluminum garnet (Nd:YAG) laser photocoagulation of the identified lesion

5. Carcinoma of the colon most commonly originates in which of the following?


a. an adenomatous polyp

b. an inflammatory polyp

c. a hyperplastic polyp

d. a benign lymphoid polyp

e. a leiomyoma

6. Adenomatous polyps are found in approximately what percentage of asymptomatic patients who undergo screening?


a. 5%

b. 10%

c. 15%

d. 20%

e. 25%

7. A barium enema is performed on a patient with a suspected carcinoma of the descending colon after an unsuccessful colonoscopy. What is the best radiologic description that fits the probable diagnosis in this patient?


a. a “strawberry cutout” lesion

b. an “orange dimpled” lesion

c. an “apple core” lesion

d. a “cabbage fulgurating” lesion

e. a “banana peel” lesion

8. Colorectal polyps are thought to be the origin of most colorectal cancers. Which of the following statements regarding colorectal polyps is false?


a. the larger the colorectal polyps, the greater the chance of malignancy

b. hyperplastic polyps have the highest malignant potential of all colorectal polyps

c. adenomatous polyps increase in incidence with each decade after the age of 30 years

d. routine removal of adenomas from the colon reduces the incidence of subsequent adenocarcinoma

e. villous adenomas carry the highest malignant potential of all adenomas

9. Which of the following statements best describes the current evidence for fecal occult blood screening as a measure to reduce the morbidity and mortality from colorectal cancer?


a. there is good evidence to include fecal occult blood testing in screening asymptomatic patients older than 50    years for colorectal carcinoma

b. there is fair evidence to include fecal occult blood testing in screening asymptomatic patients older than 50    years for colorectal carcinoma

c. there is insufficient evidence to include or to exclude fecal occult blood testing as an effective screening test for colorectal cancer in asymptomatic patients older than 50 years

d. none of the above

10. Which of the following statements regarding carcinoembryonic antigen (CEA) and colorectal cancer is true?


a. CEA is a cost-effective screening test for colorectal cancer

b. elevated preoperative CEA levels correlate well with postoperative recurrence rate in colorectal cancer

c. CEA is a sensitive test for colorectal cancer

d. CEA is a specific test for colorectal cancer

e. CEA has no value in predicting recurrence in colorectal cancer


Clinical Case Problem 2: A 78-Year-Old Man with Acute and Severe Abdominal Pain


A 78-year-old man comes to your office with acute and severe abdominal pain, left lower quadrant tenderness, left lower quadrant mass, and temperature of 39°C. The patient has had no significant illnesses in the past. He is very healthy. He sees his physician once a year and has had a normal heart, normal blood pressure, and normal “everything else,” as he says, for many years.


On examination, the patient’s temperature is 39.5°C. His pulse is 102 beats/minute and regular. His blood pressure is 210/105   mm Hg. There is significant tenderness in the left lower quadrant. Rebound tenderness is not present. There is a definite sensation of a mass present.



11. What is the most likely diagnosis in this patient?


a. adenocarcinoma of the colon

b. diverticulitis

c. diverticulosis

d. colorectal carcinoma

e. atypical appendicitis

12. What is the treatment of choice for this patient?


a. primary resection of the diseased segment with anastomosis

b. primary resection of the diseased segment without anastomosis

c. colectomy

d. abdominal perineal resection

e. none of the above

13. Which of the following is (are) a component(s) of the acute treatment of this patient’s condition?


a. IV fluids

b. IV (broad-spectrum) antibiotics

c. nasogastric suction, if abdominal distention or vomiting is present

d. a, b, and c

e. a and c

14. Which of the following investigations is contraindicated at this time in this patient?


a. computed tomography (CT) scan of the abdomen and pelvis

b. magnetic resonance imaging scan of the abdomen and pelvis

c. three views of the abdomen

d. air-contrast barium enema

e. none of the above is contraindicated

15. Which of the following statements regarding this patient’s blood pressure elevation is true?


a. this patient most likely has essential hypertension

b. this patient’s abdominal pain is most likely related to his hypertension

c. this elevation of blood pressure could be caused by the pain he is experiencing

d. this patient’s physician (the one he has been seeing every year) obviously has made a serious mistake in labeling this patient as normotensive

e. none of the above

16. What is the analgesic of choice for control of pain in this patient?


a. morphine

b. hydromorphone

c. methadone

d. pentazocine

e. codeine

17. Which of the following organisms is (are) most likely to be involved in the condition described?


a. Escherichia coli

b. Bacteroides fragilis

c. Streptococcus pneumoniae

d. a and b

e. a, b, and c


Clinical Case Problem 3: A 35-Year-Old Man with Rectal Bleeding and Mucoid Discharge from the Rectum


A 35-year-old man comes to your office with rectal bleeding, mucoid discharge from the rectum, and protrusion of certain structures through the anal canal. On proctoscopic examination, large internal hemorrhoids are seen.



18. What is the best next step in the management of this patient?


a. proceed with definitive treatment

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Colorectal Cancer and Other Colonic Disorders

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