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69 Cards in this Set

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it is the ----- most common
site of new cancer cases and deaths in the United States
the colorectal area (the colon and rectum combined) is now the third most common site of new cancer cases and deaths in the United States.
what are the risk factors ?
* is highest for people older than 85 years of age
* family history of colon cancer
* IBD
* polyps
* High-fat, high-protein (with high intake of beef ), low-fiber diet
5
Etiology
idiopathic
distribution of cancer sites throughout the colon
*ascending=22%
*transeverse=11% *descending=6%
*sigmoid=33%
*rectum=27%
5
the most common site of colorectal cancer is
sigmoid
survival rates
If the disease is detected and treated at an early stage, the 5-year survival
rate is 90%

but only 34% of colorectal cancers are found at
an early stage
what is the most common type among all colorectal cancers
adenocarcinoma (95%)
adenocarcinoma histology
arising from the epithelial lining of the intestine
clinical manifistation depends on ...
1.location of the cancer
2.the stage of the disease
3.function of the intestinal
segment in which it is located
3
most common symptoms
1.change in bowel habits
(most common)
2.hematochezia
3.unexplained anemia, anorexia, weight loss, and
fatigue
5
The symptoms most commonly associated with right-sided lesions are
*dull abdominal pain
*melena
2
The symptoms most commonly associated with left-sided lesions are
*abdominal pain and
cramping
*narrowing stools
*constipation
*distention
*well as bright red blood in the stool
those associated with obstruction (5)
Symptoms associated with rectal lesions
*ineffective, painful straining at stool
*rectal pain
*the feeling of incomplete evacuation after a bowel movement
*alternating constipation and diarrhea
*bloody stool
tenesmus (5)
the most important diagnostic procedures for cancer of the colon are
*fecal occult blood testing, *barium enema *proctosigmoidoscopy
*colonoscopy
4
(CEA) studies
Carcinoembryonic antigen studies

*may not be a highly reliable indicator in
diagnosing colon cancer
(because not all lesions secrete CEA)
*are reliable in predicting prognosis.
2
when the elevated levels of CEA should return to normal
*within 48 hours
Elevations of CEA at a later date (after 48hrs)suggests...
*recurrence
complications
1.partial or complete bowel obstruction
2.hemorrhage
(Extension of the tumor and ulceration into the surrounding blood vessels)
3.Perforation, abscess formation, peritonitis,
sepsis, and shock
3
medical management
depends on the stage of the
disease
medical management
1.The patient with symptoms of intestinal obstruction :
- intravenous fluids and nasogastric suction
2.patients with Dukes’ class C colon cancer :
*adjuvant therapy
** the 5-fluorouracil + levamisole regimen
3.Patients with Dukes’ class B or C rectal cancer given *5-fluorouracil and high doses of pelvic irradiation
Radiation therapy
Radiation therapy is used before,during, and after surgery to shrink the tumor, to achieve better results from surgery, and to reduce the risk of recurrence
For inoperative or unresectable tumors, irradiation is used to...
provide significant relief from symptoms
surgical management
1.Segmental resection with anastomosis
2.Abdominoperineal resection with permanent sigmoid colostomy
3.Temporary colostomy followed by segmental resection and anastomosis and subsequent reanastomosis of the colostomy
4.Permanent colostomy or ileostomy
5.Construction of a coloanal reservoir called a colonic J pouch
(5)

is the primary treatment for most colon and rectal cancers

It may be:
*curative/palliative

*depends on the location
and size of the tumor *Cancers limited to one site can be removed through the colonoscope
Laparoscopic colotomy with polypectomy
minimizes the extent of surgery needed in some cases
Segmental resection with anastomosis is...
removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes
Temporary colostomy followed by segmental resection and
anastomosis and subsequent reanastomosis of the colostomy allows
initial bowel decompression and bowel preparation
before resection
Construction of a coloanal reservoir called a colonic J pouch is
A temporary loop ileostomy is
constructed to divert intestinal flow, and the newly constructed J pouch (made from 6 to 10 cm of colon) is reattached to the anal stump. About 3 months after the initial stage, the ileostomy is reversed, and intestinal continuity is
restored. The anal sphincter and therefore continence are
preserved.
performed in two steps
Staging of Colorectal Cancer: Dukes’ Classification
Class A: Tumor limited to muscular mucosa and submucosa
Class B1: Tumor extends into mucosa
Class B2 : Tumor extends through entire bowel wall into serosa or pericolic fat, no nodal involvement
Class C1: Positive nodes, tumor is limited to bowel wall
Class C2 : Positive nodes, tumor extends through entire bowel wall
Class D: Advanced and metastasis to liver, lung, or bone
The TNM classification, may be used to describe ...
the anatomic extent of the primary tumor
The colostomy begins to function...
3 to 6 days after surgery
Potential complications that may develop include
-Intraperitoneal infection
-Complete large bowel obstruction
-GI bleeding
-Bowel perforation
-Peritonitis, abscess, and sepsis
5
The major goals for the patient may include
-attainment of optimal
level of nutrition
-maintenance of fluid
and electrolyte balance
-reduction of anxiety
-learning about the diagnosis, surgical
procedure, and self-care after discharge
-maintenance of optimal
tissue healing
-protection of peristomal skin
-learning how to irrigate
the colostomy and change the appliance
-expressing feelings
and concerns about the colostomy and the impact on himself or herself
-avoidance of complications
8
Physical preparation for surgery involves
-building the patient’s
stamina in the days preceding surgery
-cleansing and sterilizing
the bowel the day before surgery
2
A full-liquid diet may be prescribed --- hours before surgery to decrease bulk
24-48 hours
Antibiotics such as --- are administered the day before surgery to reduce intestinal bacteria
sulfonamides, neomycin, and cephalexin
3
A nasogastric tube may be inserted to
-drain accumulated fluids
-prevent abdominal distention
2
Monitoring serum electrolyte levels can detect
-the hypokalemia
-hyponatremia
occur with GI fluid loss
signs of hypovolemia
-tachycardia
-hypotension
-decreased pulse volume
-decreased skin turgor
-dry mucous membranes
-concentrated urine
6
The nature of the discharge
varies with the site
With a sigmoid colostomy the
feces are
solid
With a descending colostomy the feces are
semimushy (полу-кашеобразный)
With a transverse colostomy the feces are
mushy
With an ascending
colostomy the feces are
fluid
The nurse monitors the patient for complications such as
-leakage from the site of the
anastomosis
-prolapse of the stoma
-perforation
-stoma retraction
-fecal impaction
-skin irritation
-pulmonary complications associated with abdominal surgery
7
It is important to help patients with a colostomy ---on the first postoperative day and encourage them to begin participating
in managing the colostomy
out of bed
The patient avoids foods that cause --- including foods in the cabbage family, eggs, fish,beans, and high-cellulose products such as peanuts
excessive odor and gas
which drugs help control the diarrhea?
1.Intestinal absorbents :
-bismuth subsalicylate
(Pepto-Bismol,Kalbeten)
-bismuth subcarbonate

2.Non-specific antidiarrhea drugs:
-diphenoxylate+atropine
(Lomotil)
- Paregoric=diluted tincture of opium

3.Mg
2 groups
For constipation,
1.prune/apple juice
2.a mild laxative :
-plantago ovata seeds+ispaghula husk+
senna (Agiocur)
-Psyllium+Sena
(Perdiem)
The nurse suggests fluid intake of at least --- of fluid per day
2 L
If the patient has a colostomy, the stoma is examined for
-swelling
-color
((a healthy stoma is pink or red)
-discharge
-bleeding
4
If the malignancy has been removed using the perineal route,the perineal wound is observed for
-signs of hemorrhage
-infection
-necrosis
The nurse monitors vital signs
-which may indicate an intra-abdominal infectious process
increased temperature, pulse, respirations and decreased BP for
---complications are always a concern with abdominal surgery; patients older than 50 years of age are at risk, especially if they are or have been receiving sedatives or are being maintained on bed rest for a prolonged period
Pulmonary
Two primary pulmonary
complications are
-pneumonia
-atelectasis
what can reduce the
risks for pulmonary complications?
-turning the patient from side to side every 2 hours
-deep breathing, coughing
-early ambulation
3
The incidence of complications related to the colostomy is about one half that seen with an ---
ileostomy
Some common complications with ileostomy are
-prolapse of the stoma (usually from obesity)
-perforation
(from improper stoma irrigation)
-stoma retraction
-fecal impaction
-skin irritation

Leakage from an anastomotic site can occur if the remaining bowel segments are diseased or weakened.
Care of the peristomal skin is an ongoing concern because
-excoriation (сдирание кожи)or ulceration can develop quickly

Other skin problems include:
-yeast infections
-allergic dermatitis
The stoma is measured to determine the correct size for the pouch; the pouch opening should be about
0.3cm
pouch=мешочек
After the skin is cleansed (around stoma), the patient applies the peristomal skin barrier such as
-wafer, paste, or powder(Stomahesive powder)
before attaching the pouch
A stoma has/does not have
voluntary muscular control and may empty at regular/irregular intervals
does not have;irregular
באיזה סוג ניתוח חולה
לחולה יש /אין שליטה
על היציאות
colostomy כן מרגיש
ileostomy לא מרגיש בכלל
איזה כלכלה מתאימה לחולה עם
colostomy
רבת תאית
השיטה האמינה והמקובלת ביותר
היום לשם איתורסרטן המעי הגס
אצל אוכלוסייה מעבר לגיל 50 ללא תלונות היא
קולונוסקופיה גמישה
A 19-year-old college freshman undergoes colonoscopy because of a family history of multiple polyps in his young siblings. His brother underwent total proctocolectomy at age 23, and his sister underwent a total proctocolectomy at age 29, after both were found to have hundreds of colonic adenomas on colonoscopy. Both siblings are alive and well 5 years later and without any other findings of neoplasms. The patient undergoes sigmoidoscopy and is found to have several dozen small colonic polyps within the rectosigmoid. Five of these are biopsied and are all benign adenomas. Which of the following is the most appropriate next step in management?

A. Schedule a repeat sigmoidoscopy in 1 year
B. Schedule a colonoscopy in 1 year
C. Evaluate the more proximal colon with a barium enema
D. Schedule a full colonoscopy
E. Schedule a total proctocolectomy
The correct answer is E. This patient has two first-degree relatives who have undergone total proctocolectomies for a polyposis syndrome. This most likely represents the familial polyposis coli syndrome in that both siblings had high numbers of colonic adenomas and underwent an appropriate total proctocolectomy. If this patient is found to have several dozen polyps during the flexible sigmoidoscopy, it is evidence that he is expressing the phenotypic trait of the familial adenomatous polyposis (FAP) gene. Rather than wait for any of these polyps to undergo malignant degeneration, he should have a total proctocolectomy in the immediate near future. Once many polyps have been demonstrated, the likelihood of one of these becoming malignant is high.

Scheduling repeat sigmoidoscopy (choice A) or colonoscopy (choice B) in 1 year is wrong because this patient with already extensive polyposis has passed the point of needing only periodic monitoring.

Evaluating the complete colon with either a barium enema (choice C) or full colonoscopy (choice D) is not needed, since there is already sufficient evidence to warrant total proctocolectomy.
A 37-year-old accountant presents to ask for advice regarding the future management of his ulcerative colitis. He has had pancolitis for the past 19 years and has been told that he is at an increased risk for developing colorectal cancer. He asks for the physician's recommendation regarding appropriate surveillance. Which of the following is the most appropriate response?

A. Annual stool guaiac testing
B. Barium enema
C. Colonoscopy
D. Colonoscopy and multiple biopsies
E. Flexible sigmoidoscopy with multiple biopsies
The correct answer is D. Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia.

None of the other choices allows sampling of the entire colonic mucosa for histologic examination for the precancerous lesion of low- or high-grade dysplasia.
A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?

A. Acute renal failure
B. Damage to the bladder during the operation
C. Damage to the ureters during the operation
D. Dehydration
E. Plugged or kinked catheter
The correct answer is E. In the presence of normal perfusion pressure, biological problems do not suddenly drive the urinary output from normal to zero. Such a change is invariably due to a mechanical problem.

Acute renal failure (choice A) does not result in a urinary output of zero. Some urine is still produced, although it is a small volume, on the order of 5 or 10 mL per hour.

Intraoperative damage to the bladder (choice B) or the ureters (choice C) would have become obvious immediately after the operation.

Dehydration (choice D) would have produced a gradual decline in the urinary volume. The 3 hours preceding the onset of the problem had shown normal values (about 1 mL per kg of body weight per hour), with no downward trend.
A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?

A. Anal fissure
B. Cancer of the cecum
C. Cancer of the rectum
D. External hemorrhoids
E. Internal hemorrhoids
The correct answer is C. The combination of red blood coating the stools and a change in bowel habit and stool caliber spells out cancer of the rectum in someone in this age group.

Anal fissure (choice A) is typically seen in young women who have very painful bowel movements with streaks of blood. Pain is the dominant symptom in this condition.

Cancer of the cecum (choice B) leads to anemia and occult blood in the stools, but the blood is rarely seen. If it is, the entire stool is bloody. Furthermore, there is no change in bowel habit or stool caliber when the tumor is so proximal in the colon.

External hemorrhoids (choice D) hurt and itch, but they rarely bleed.

Internal hemorrhoids (choice E) do indeed bleed, but they do so without changing the pattern of bowel movements or the caliber of the stools.
A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following is the most likely diagnosis and the expected mortality?

A. Intraoperative air embolus, 100%
B. Myocardial infarction, 5% to 10%
C. Myocardial infarction, 50% to 90%
D. Pulmonary embolus, 5% to 10%
E. Pulmonary embolus, 50% to 90%
The correct answer is C. Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo (ie, unrelated to surgery), reaching the levels quoted.

Air embolism (choice A) can happen when big veins are open, allowing air to be sucked in; however, the location of the open veins is typically the upper chest or lower neck. The patient dies while undergoing a procedure under local anesthesia, breathing spontaneously rather than having air blown into his lungs.

Choice B correctly identifies the problem, but assigns it a low mortality more typical of infarcts that do not happen during surgery.

Pulmonary emboli (choices D and E) are not usually seen during surgery; they typically occur 5-7 days later.