Chief Complaint: 65-year-old woman with a loss of appetite, abdominal cramps,

constipation, and blood in her stool.

History: Delores Murphy, a 65-year-old white female, was in good health until about 6
weeks ago, when she noted occasional cramps in the left lower quadrant of the
abdomen associated with constipation. The episodes of cramping last about 30 minutes
each and are most severe in the hour following her meals. She has taken laxatives
which have partially relieved her symptoms, but she has had a decreased appetite and
12-pound weight loss over the past four weeks. In addition, she has become
increasingly fatigued over this period. When questioned about her bowel habits, she
reported bright red blood in her stools and a smaller caliber (i.e. diameter) of stool over
the past two weeks.
Physical Examination: She appeared fatigued and distressed. Head and neck exams
were normal, as was her thorax. Palpation of the abdomen revealed a 10 x 10 cm mass
and tenderness in the left lower quadrant. Percussion over this area revealed a hollow,
tympanic sound. Hepatomegaly was noted, and a hard and slightly tender liver edge
was felt in the right upper quadrant. Bowel sounds were noticeably reduced. A stool
sample was tested with Guaiac paper and was positive for blood.
Questions:
1. Propose an explanation for Delores's:
A. abdominal cramps and left lower quadrant mass:

Answer
B. reduced bowel sounds and smaller-caliber stools:

Answer
C. weight loss and decreased appetite:

Answer
Delores was referred to the radiology department to have an "air-contrast barium
enema" procedure which revealed the silhouette of a 3 x 3 x 4 cm polyp in the distal
sigmoid colon and a nearly 100% obstruction of the proximal sigmoid colon. The
remainder of the large intestine appeared normal.
2. How is an "air-contrast barium enema" performed?

Answer
3. What kinds of information can be gained by performing an air-contrast barium
enema?

The suspicious lesions noted on the air-contrast barium enema convinced Delores's
physician to examine her sigmoid colon via flexible sigmoidoscopy. During this
procedure, biopsies of the polyp and obstructed area were taken and sent to the
pathology lab. The obsructed area of the sigmoid colon appeared to be slowly bleeding
prior to the biopsy procedure.
Answer
4. What is "flexible sigmoidoscopy"?

Answer
5. Why was it important to biopsy the suspicious lesions?

The report from the pathologist described the polyp as an "adenoma" and the tissue
taken from the obstructed area as a "carcinoma".
Answer
6. Define the terms "adenoma" and "carcinoma."

Answer
7. How would the appearance of an adenoma differ from that of a carcinoma under the
microscope?

Answer
8. Ninety percent of all cancers are carcinomas. Propose an explanation for why such a
disproportionately high number of cancers are carcinomas.

Delores is told that she has colon cancer and that the cancer has already metastasized.
She is told that her best chance for a cure is via surgery, followed by chemotherapy.
Answer
9. Define the term "metastasis."

Answer
10. Where might a cancer like Delores's metastasize to?

Answer
11. Why do you think Delores's liver edge was hard and tender on physical
examination?

Answer
12. A blood sample from Delores revealed iron-deficiency anemia. Propose a cause of
this anemia.