Patient will present as → a 65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST.
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Progression of adenomatous polyp into malignancy (adenocarcinoma) usually occurs within 10-20 years - Colon CA is the third leading cause of cancer death after lung cancer and skin cancer
- Risk factors include age > 45 y/o, inflammatory bowel disease, polyps, low fiber, high animal fat diet, smoking, ETOH
- Presents as painless rectal bleeding and a change in bowel habits
Colon cancer screening for average-risk patients should begin at 45 years and end at 75 years of age
- Stool tests:
- Guaiac based fecal occult blood (gFOBT) – once per year**
- Fecal immunochemical test (FIT) – once per year**
- FIT-DNA test (combines FIT with a test that detects altered DNA in stool) – once every one or three years**
- Flexible sigmoidoscopy – once every 5 years or every 10 years with a FIT every year (serious complications occur in approximately 3.4 per 10,000 procedures)
- Colonoscopy: once every 10 years
- Perforation of the colon occurs in an estimated 3.8 per 10,000 procedures
- Serious complications—including perforation, major bleeding, diverticulitis, severe abdominal pain, and cardiovascular events occur in an estimated 25 per 10,000 procedures
- CT colonography: once every 5 years (1 additional individual per 1000 would develop cancer in his or her lifetime due to radiation exposure)
USPSTF colorectal cancer screening guidelines
**When adequate screening colonoscopy is accomplished, intercurrent stool tests (i.e., between colonoscopy examinations) are not necessary. In addition, for patients who have had a negative colonoscopy and have been recommended to have routine screening in 10 years, screening with FIT or other screening tests is not indicated prior to the end of the 10-year period.
"Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. Recommended screening in a single first-degree relative with colorectal cancer diagnosed before age 60 is beginning colonoscopy at age 40 or ten years younger than the age at diagnosis of the youngest affected first-degree relative. Then if negative, every 5 years."
**There is adequate evidence that the benefits of detection and early intervention decline after age 75 years
Treatment is surgical resection and chemotherapy for nodal involvement
- 5FU is mainstay of chemotherapy
- Monitor CEA with treatment
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Colorectal cancer is the third most common cancer in both men and women with the majority of cases being adenocarcinoma. Risk factors include a family history of colorectal cancer, personal history of inflammatory bowel diseases such as ulcerative colitis or Crohn’s disease, a diet high in red meat, obesity, alcohol consumption greater than four drinks per week, and cigarette smoking. Clinical manifestations of early-stage colorectal cancer are usually non-specific, while manifestations of late-stage colorectal cancer include hepatomegaly, peritonitis, and abdominal pain. Patients aged 45 and older should undergo a colonoscopy once every 10 years to assess for polyps and/or the presence of cancer.
Play Video + QuizQuestion 1 |
complete blood count (CBC) Hint: See D for answer | |
fecal occult blood samples Hint: See D for answer | |
air-contrast barium enema Hint: See D for answer | |
colonoscopy |
Question 2 |
irritable bowel syndrome | |
lactose intolerance | |
adenocarcinoma of the pancreas | |
adenocarcinoma of the colon |
Question 3 |
total colectomy Hint: See B for explanation | |
surgical removal of the mass | |
removal of the appendix Hint: See B for explanation | |
abdominoperineal resection of the rectum Hint: See B for explanation |
Question 4 |
an adenomatous polyp | |
an inflammatory polyp Hint: See A for explanation | |
a hyperplastic polyp Hint: See A for explanation | |
a benign lymphoid polyp Hint: See A for explanation |
Question 5 |
5% Hint: See D for explanation | |
10% Hint: See D for explanation | |
15% Hint: See D for explanation | |
25% |
Question 6 |
there is good evidence to include fecal occult blood testing in screening asymptomatic patients older than 50 years for colorectal carcinoma | |
there is fair evidence to include fecal occult blood testing in screening asymptomatic patients older than 50 years for colorectal carcinoma | |
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 | |
none of the above |
Question 7 |
CEA is a cost-effective screening test for colorectal cancer Hint: See B for explanation | |
elevated preoperative CEA levels correlate well with postoperative recurrence rate in colorectal cancer | |
CEA is a sensitive test for colorectal cancer Hint: See B for explanation | |
CEA is a specific test for colorectal cancer Hint: See B for explanation | |
CEA has no value in predicting recurrence in colorectal cancer
Hint: See B for explanation |
List |
References: Merck Manual · UpToDate