In: Nursing
Bruce is a 47-year-old man, who decides he needs to visit his doctor due to some gastrointestinal symptoms. At first it just started out as a bit of abdominal pain and cramping, followed by diarrhea so at first Bruce just thought he had a stomach bug. But weeks went by and the diarrhea just increased in frequency, and instead of feeling better, he started to feel really fatigued. This has been going on for 8 months before his wife finally convinced him to make an appointment with a doctor, who then referred him to a gastroenterologist. A couple of months later when he finally goes to his specialist appointment, Bruce admits after questioning that he has had bleeding with his stool but he didn’t want to tell the doctor as he was embarrassed and didn’t want to get checked for hemorrhoids. The gastroenterologist also asks many questions about Bruce’s diet and his weight and discovers that Bruce has lost 15 kg in the past year despite eating a lot of hot chips and mashed potatoes – the only thing Bruce feels doesn’t make his diarrhea worse. The gastroenterologist then tells Bruce he would like to perform a colonoscopy to investigate further. After the colonoscopy, the surgeon tells Bruce that they found a number of polyps in his bowel which is not necessarily a cause for concern as many polyps are benign, but they will have to wait on the results of the biopsies to make sure none of them were malignant. A week later the surgeon calls Bruce, unfortunately it is bad news – the biopsy shows evidence that the growth is malignant and anaplastic and that they can’t rule out metastatic growths. Bruce is called back in for follow-up tests, and they find that there is an abnormal growth in his liver also. Bruce is now sent to an oncologist, who recommends that he has surgery to remove any remaining polyps, a small portion of his bowel, and the abnormal growth from his liver. Based on the advice from his oncologist, Bruce also decides to undergo chemotherapy treatment. Whilst doing some routine checks after his treatment, Bruce is informed he has neutropenia.
Question 3
Explain why Bruce experiences the clinical manifestations of increased risk of infection and fatigue, both before and after treatment for his cancer.
The above case divided by three approaches easy to understand, they are mainly,
1. Acute or chronic severe Lower gastrointestinal hemorrhage,
2. Diagnostic procedures and their complications,
3. Actual diagnosis and explain about that.
1.Lower gastro intestinal hemorrhage: Mr. Bruse suffering from colorectal polyps, he is having long lasting complications of abdominal pain due to gastrointestinal infections. The lower gastro intestinal bleeding is common, resulting in approximately 25-40 hospitalisations per 100000 adults per year and accounting for an estimated 30% of all major gastrointestinal bleeding. It is more common in the elderly and in patients on anticoagulation, aspirin, or NSAIDs. It's presentation can range from tribal bleeding to massive ,life threatening hemorrhage with reported mortality rate upto 5%.
Definition : Acute severe LGIB is of recent limited duration and associated with hemodynamic instability as measured by Tachycardia,hypotension and anemia possibly requiring transfusion. It also emaanates from a source between the ligament of teietz and the anus.
Presentation and diffential diagnosis : as bright red blood per rectum,maroon stools or melana,
- bleeding from colonic diverticula is the most common etiology of Acute lower gastrointestinal bleed followed by hemorrhoids and malignancy.
Management : the severity and acuity of bleeding should be assessed and an upper gastrointestinal source of bleeding excluded.
- colonoscopy is the diagnostic and therapeutic procedure of choice,
- emphasize a multidisciplinary team approach with close coloboration between the gastroenterologist,radiologist,surgeon and internist in the successful approach to Acute severe LGIB.
2.Laboratory and colonoscopy: The normal investigations are CBP, LFT,RFT, coagulation profile.
Colonoscopy - introduced in 1960s, allows diagnosis and treatment of wife range of conditions and symptoms and is the hold standard for early detection and removal of colorectal cancer and it's precursors.
The major complications of colonoscopy are bleeding from biopsy and polypectomy sites , colonic perforation and post polypectomy syndrome.
3. Actual diagnosis and their management: The pt Mr.Bruce finally diagnosis with matastatic colorectal cancer. The grading of cancer is by the three . They are
1. Well differentiated,
2.poorly differentiated,
3.Anaplaatic ( without any form).
General principles : Epidemiology: third most common malignancy world wide, Risk factors more than 50 yrs, physical activity, obesity,diet with increased red meat,decreased fiber diet, personal history of polyps or colorectal cancer, IBD,and hereditary syndromes.
Diagnosis: clinical presentation: Most common symptoms include bleeding,abdominal pain, change in bowel habits, and obstruction. Any unexplained iron deficiency anemia, GI malignancy. Otherwise carcinomas are identified from screening colonoscopy.
Diagnostic Testing: Diagnosis made through colonoscopy with biopsy,
- imaging studies include CT scan of the chest,abdomen and pelvis. FDG-PET scan is not routinely indicated,
- additional studies include serum carcinoembryonic antigen (CEA) levels.
Treatment: based on Localisation, metastatic and Isolated disease.
1.) Localised disease: should be treated with surgical resection, adjuvent chemotherapy indicated in pts with stage III disease and may also beneficial in selected pts with stage II disease, surveillance after successful therapy includes A)History, physical exam, and CEA levels every 3 to 6 months, for 2 yrs and then 6 months for 3 yrs.
B) CT scan annually for first three yrs and
C) Colonoscopy within one year of resection, at 3 yrs and then every 5 yrs.
2) Metastatic disease : is treated with combination chemotherapy usually include Flurouracil, Leucovorin, Oxaliplatin or irinotecan. The combination of bevacizumab, a VEGF monoclonal antibodies and chemotherapy improves survival compared with chemotherapy alone, Cetuximab an antibody against the EGFR is also associated with improved outcomes if the K-ras Gene is not mutated.
3) Isolated liver metastases: may be treated with surgical resection, proceeded or not by neoadjuvant chemotherapy with curative intention.