COLORECTAL CANCER

Margaret Xaira R. Mercado RN

 Tumors of the colon and rectum Now the 3rd most common site of new cancer cases and deaths in the United States. Colorectal cancer is a disease of Western cultures An estimated 148,300 new cases and 56,000 deaths from the disease in 2002 Incidence: highest for people older than 85 years of age Higher for people with a family history of colon cancer and those with polyps Exact cause of colon and rectal cancer is still unknown Risk factors have been identified

ANATOMY & PHYSIOLOGY

ANATOMY & PHYSIOLOGY

Sections of large intestine: Ascending colon Transverse colon Descending colon Sigmoid colon Rectum

Difference between Colon and Rectum

Tube-shaped organ inside abdomen stretch from right side of abdomen over to the left like an upside down U

Muscular bands of the colon splay out and create a pouch (last 15 cm of large intestine)

4 layers of colon: Mucosa Innermost layer of colon Submucosa Lies below mucosa Contain microscopic blood vessels & lymph channels that supply the colon Muscularis Push the contents of colon toward rectum Serosa Outermosts layer of tissue

POLYP
any growth arising from the intestine and protruding into the lumen
Generally, polyp arise from sub epithelial tissue . In colon cancer, polyp is arise from intestinal epithelium. Polyp can be either malignant or benign. The polyp in colon cancer is malignant.

POLYP

RISK FACTORS
KGenetic factors KPolyps of the colon and / or rectum familial adematous polyposis KLynch syndrome KDiet KInflammatory bowel disease KExposure to radiation

PATHOPHYSIOLOGY
Predisposing factors

Increases population of anaerobic bacteria

Anaerobes convert bile acids into carcinogens

Carcinogens trigger polyps, cell mutation, and reproduction

Tumor formation

BOARD EXAM QUESTION The nurse is interviewing a male client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? a. Duodenal ulcers b. Hemorrhoids c. Weight gain d. Polyps

BOARD EXAM QUESTION Answer D. Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids arent preexisting conditions of colorectal cancer Weight loss not gain is an indication of colorectal cancer.

Percentage distribution of cancer sites in the colon and rectum

MANIFESTATIONS
1. Change in bowel habits most common symptom 2. Passage of blood second most common symptom 3. Other symptoms include: unexplained anemia anorexia weight loss fatigue

MANIFESTATIONS
Right-sided lesions dull abdominal pain and melena Left-sided lesions associated with obstruction as well as bright red blood in the stool Rectal lesions tenesmus, rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating constipation and diarrhea, and bloody stool

MANIFESTATIONS
Bowel cancer produces no manifestations until it is advanced It grows slowly 5 to 15 years of growth may occur before manifestations develop

COMPLICATIONS
1. Bowel obstruction 2. Perforation of bowel wall by the tumor 3. Direct extension of tumor to involve adjacent organs *most reccurences of colorectal cancer after tumor removal occur within the first 4 years

GERONTOLOGIC CONSIDERATIONS
These cancers are considered common malignancies in advanced age. Only prostate cancer and lung cancer in men exceed colorectal cancer. In women, only breast cancer exceeds the incidence of colorectal cancer Cancer patients usually report fatigue In early stages, minor changes in bowel patterns and occasional bleeding The later symptoms are abdominal pain, obstruction, tenesmus, and rectal bleeding.

GERONTOLOGIC CONSIDERATIONS
Colon cancer in the elderly has been closely associated with dietary carcinogens. Lack of fiber is a major causative factor Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties

SCREENING
Beginning age 50:  FOBT or FIT  Flexible sigmoidoscopy  Yearly FBOT or FIT plus flexible sigmoidoscopy every 5 years  Double contrast barium enema  Colonoscopy

ASSESSMENT & DIAGNOSIS

5 Abdominal and rectal examination 5 Fecal occult blood testing 5 Barium enema 5 Proctosigmoidoscopy 5 Colonoscopy 5 CBC 5 Radiologic examinations chest x-ray computed tomography scan magnetic resonance imaging ultrasonic exam

ASSESSMENT & DIAGNOSIS

Sigmoidoscopy with biopsy or cytology smears can identify as many as 60% of colon cancer Carcinoembryonic antigen (CEA) studies may not be a highly reliable indicator in diagnosing colon

MEDICAL MANAGEMENT
If with symptoms of intestinal obstruction:  intravenous fluids and nasogastric suction If with bleeding:  blood component therapy Surgery Supportive therapy Adjuvant therapy Adjuvant therapychemotherapy Radiation therapy Immunotherapy Multimodality therapy

ADJUVANT THERAPY
Administeredto patients with Dukes class C colon cancer is the 5-fluorouracil plus levamisole regimen Patients with Dukes class B or C rectal cancer are given 5-fluorouracil and high doses of pelvic irradiation. Mitomycin is also used. Radiation therapy is used before, during, and after surgery For inoperative or unresectable tumors intracavity and implantable devices are used

SURGICAL MANAGEMENT
Primary treatment for most colon and rectal cancer Curative or palliative The type of surgery recommended depends on the location and size of the tumor. Colonoscope Laparoscopic colotomy with polypectomy

SURGICAL MANAGEMENT
Neodymium/yttriumaluminum-garnet (Nd:YAG) laser Bowel resection for most class A lesions and all class B and C lesions. Surgery recommended for class D colon cancer, goal is palliative Nonresectable if the tumor has spread and involves surrounding vital structures

SURGICAL MANAGEMENT
1. Segmental resection with anastomosis

SURGICAL MANAGEMENT
2. Abdominoperineal resection with permanent sigmoid colostomy

SURGICAL MANAGEMENT
3. Temporary colostomy followed by segmental resection and anastomosis and subsequent reanastomosis of the colostomy allowing initial bowel decompression and bowel preparation before resection 4. Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions

SURGICAL MANAGEMENT
Colonic J pouch coloanal reservoir 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

COLOSTOMY
Is the surgical creation of an opening into the colon. It can be created as a temporary or permanent fecal diversion. It allows the drainage or evacuation of colon contents to the outside of the body. With improved surgical techniques, colostomies are performed on fewer than one third of patients with colorectal cancer

COLOSTOMY

NURSING MANAGEMENT
ASSESSMENT: 1. Health history usual bowel patterns & any recent change, weight loss, fatigue, decreased activity tolerance, presence of blood in the stool, pain with defacation, abdominal discomfort, perineal pain, usual diet: family history of colon cancer, other specific factors 2. Physical examination general appearance, weight, abdominal shape, contour: bowel sounds, abdominal tenderness, stool hemoccult or guiac

NURSING MANAGEMENT
NURSING DIAGNOSES & INTERVENTIONS

Colorectal cancer often advanced at the time of diagnosis, prognosis even with treatment may be poor. denial & anger are common extensive abdominal surgery, potential for colostomy fatigue effect of radiation & chemotherapy
PRIORITY:

Acute pain Imbalanced nutrition: less than body requirements Anticipatory grieving Risk for sexual dysfunction

NURSING MANAGEMENT
FOODS THAT INCREASE FOOD ODOR: FOODS THAT INCREASE INTESTINAL GAS

Asparagus Beans Cabbage Eggs Fish Garlic Onions & some spices

Beer Brocolli, Brussels sprouts, Cabbage Carbonated drinks Cauliflower, Cucumbers, Corn Dairy products Dried beans, Peas Radishes, Spinach

NURSING MANAGEMENT
FOODS THAT THICKEN FOODS THAT LOOSEN STOOLS STOOLS

Applesauce Bananas Bread Cheese Yogurt Pasta, Pretzels Rice, Tapioca Creamy peanut butter

Chocolate Dried beans Fried foods Greasy foods Highly spiced foods Leafy green veggies Raw fruits & juices Raw veggies

GOODLUCK SA EXAM!

GOODLUCK SA EXAM!