Case Study 92

Djordjevic Dragan

Scenario R.T. is a 64-year-old man who comes to his primary care providers (PCPs) office for a yearly examination. He initially reports having no new health problems; however, on further questioning, he admits to having developed some fatigue, abdominal bloating, and intermittent constipation. His nurse practitioner completes the examination, which includes a normal rectal exam with a stool positive for guaiac. Diagnostic studies include a CBC with differential, chem 14, and carcinoembryonic antigen (CEA). R.T. has not had a recent colonoscopy and is referred to a gastroenterologist for this procedure. A 5-cm mass found in the sigmoid colon confirms a diagnosis of adenocarcinoma of the colon. A referral is made for surgery. The pathology report describes the tumor as a Dukes stage B, which means that the cancer has extended into the mucous layer of the colon. A metastatic work-up is negative. 1. What is a risk factor? 64-year-old (no information about heredity, diet, polyps, etc) . 2. Identify six risk factors for colon cancer. Age older than 50 yo Polyps of the colon / rectum Family Hx of colorectal cancer Inflammatory bowel disease Exposure to radiation Diet: high animal fat and kilocalorie intake 3. Discuss the American Cancer Societys recommended screening procedures related to colon cancer. Screening is recommended beginning at age 50. Yearly fecal occult blood / fecal immunochemical test (take home, multiple sample); flexible sigmoidoscopy every 5 years; double-contrast barium enema every 5 years; colonoscopy q 10 years. 4. According to the American Cancer Society, what warning signs did R.T. have? stool positive for guaiac = rectal bleeding abdominal bloating, and intermittent constipation 5. Discuss common early versus late signs and symptoms (S/S) found in individuals with colorectal cancer. Often there's no Sx until advanced (grows slowly 5-15 years). Manifestations depend on its location, type and extent, complication. Rectal bleeding is initial Sx, than change in bowel habits (diarrhea / constipation). Advanced disease Sx: pain, anorexia, weight loss, palpable abdominal / rectal mass, anemia. 6. What is a CEA? How does it relate to the diagnosis of colon cancer? Carcinoembryonic antigen (CEA) is a tumor marker that can be detected in the blood of clients with colorectal cancer. CEA level is used to estimate prognosis, monitor treatment, and detect cancer recurrence.

7. After bowel prep, R.T. is admitted to the hospital for an exploratory laparotomy, small bowel resection, and sigmoid colectomy. List at least five major potential complications for Infection (Leakage from Colon) Bleeding Blood Clots Damage to Internal Organs bulging of tissue through surgical incision colon blockage due to the formation of scar tissue incomplete joining of the reattached sections of your colon and rectum 8. After surgery, R.T. is admitted to the surgical intensive care unit (SICU) with a large abdominal dressing. The nurse rolls R.T. side to side to remove the soiled surgical linen, and the dressing becomes saturated with a large amount of serosanguineous drainage. Would the drainage be expected after abdominal surgery? Explain. Serosanguineous drainage is expected after abdominal surgery because of incision and time needed for clotting process. It is not normal if the bandage is soaked with blood, if green or yellow drainage is coming from it, or patient have black or tarry stools, or there is blood in his stool. 9. Four weeks after surgery, R.T. is scheduled to begin chemotherapy. List three chemotherapy drugs used to treat adenocarcinoma of the colon. 5-Fluorouracil (5-FU) folinic acid (leucovorin) Irinotecan (CPT-11)

10. Discuss some of the toxicities and side effects of these drugs. Side effects include myelosuppression, mucositis, dermatitis and diarrhea. 5-FU injection and topical even in small doses cause both acute central nervous system (CNS) damage and progressively worsening delayed degeneration of the CNS. Serious adverse reactions to fluorouracil are; chest pain, EKG changes and increases in cardiac enzymes - which may indicate problems with the heart. Folinic acid is also used in combination with the chemotherapy agent 5-fluorouracil in treating colon cancer. In this case, folinic acid is not used for "rescue" purposes; rather, it enhances the effect of 5-fluorouracil by inhibiting thymidylate synthase. Adverse effects of irinotecan treatment include severe diarrhea, myelosuppression, and neutropenia. 11. Given the side effect profiles of the drugs used to treat colon cancer, develop a teaching plan for R.T. Contact your health care provider immediately if you should experience any of the following symptoms: Fever of 100.5 F (38 C) or higher, chills (sx of infection). Avoid crowded places. Contact your health care provider within 24 hours of noticing any of the following: Nausea, vomiting more than 4-5 times in a 24 hour period, diarrhea (4-6 episodes in a 24-hour period), unusual bleeding or bruising, black or tarry stools, or blood in the stools or urine, extreme fatigue, mouth sores, tingling or burning, redness, swelling of the palms of the hands or soles of feet.