Colorectal Cancer CRC P 1035 1039 Definition Third most common cancer Symptoms do not appear until disease is advanced Regular screening can help detect precancerous lesions o From adenomatous polyps detected and removed by sigmoidoscopy or colonoscopy Most common CRC is adenocarcinoma Beginning as adenomatous polyps Because the venous blood leaving the colon and rectum flows through the portal vein liver metastasis is common Risk Factors Male African American Age 50 Family History Hereditary nonpolposis colorectal cancer HNPCC Colorectal polyps IBD Lifestyle Risk Factors Obesity BMI 30 Smoking Alcohol 4 drinks wk Intake of processed foods red meat 7 servings Risk Decreased by o Exercise o Diet fruits veg grains o Women NSAIDS and hormone replacement therapy Obstruction bleeding perforation peritonitis and fistula formation Complications Signs Symptoms Ascending Colon Pain Mass Change in Bowel habits Anemia Transverse Colon Pain Obstruction Change in Bowel habits Anemia Rectum Descending Colon Pain Obstructon Change in Bowel Habits Bright red blood in stool Change in Bowel habits Blood in stool Rectal Discomfort Rectal bleeding is the most common symptom of CRC Left sided lesions can lead to alternation constipation and diarrhea change in stool narrow ribbon like and sensation of incomplete evacuation Right side of the colon is usually asymptomatic Vague abdominal discomfort cramping colicky abdominal pain Iron deficienc y anemia occult bleeding weakness and fatigue Teach regular screening if age 50 Men and Women to detect and remove precancerous polyps o IF first degree relative had CRC before age 60 Screening should begin at age 40 every 5 years Diagnostic Tests CRC Diagnostic Tests Digital Rectal Exam Occult blood in the stool Barium Enema q 5 years Sigmoidoscopy q 5 years Colonoscopy with tissue biopsy q 10 years GOLD Liver Enzymes CT abdomen MRI U S Tumor Lymph Node Involvement and Metastasis Carcinoembryonic antigen CEA glycoprotein produced by 90 of CRC CT Colonography virtual colonoscopy q 5 years Fecal occult blood q year Fecal immunochemical test q year Stool DNA test o DNA markers of precancerous lesions get released in the stool o Done frequently because shedding occurs at different intervals Cannot be assessed because of incomplete information Carcinoma in situ Cancer has not grown beyond mucosa layer Cancer from mucosa to submucosa Cancer from submucosa to muscularis propia Cancer from musclaris propia into subserosa Tumor spread through colon or rectal wall and into nearby tissues Tumor X S 1 2 3 4 Node X 0 1 2 Metastasis X 0 1 Lymph nodes cannot be assessed No regional node involvement is found Cancer found in 1 to 3 nodes Cancer found in 4 or more Cant be assessed No distant metastasis seen Metastasis present Surgery is the only cure Polypectomy during colonoscopy to resect CRC in situ Right and Left hemicolectomy Abdominal perineal resection Laprascopic Colectomy Radiation Chemotherapy lymph nodes Goals Complete resection of the tumor with healthy tissue Abdominal exploration to check for metastasis Removal of affected lymph nodes Restoration of bowel Prevention of surgical complications if the bowel perforated peritonitis is present the patient will have temporary colostomy Reduce the colonic bacteria before surgery to prevent anastomic leakage of bacteria and decrease post op infections Bowel is cleaned with polyethylene glycol lavage solution Miralax Golytely and oral Antibiotics Laprascopic colectomy faster return of bowel function decreased incisional infection shortedned hospital stay Complications Delayed wound healing hemorrhage persistent perineal sinus tracts infections and urinary tract and sexual dysfunction Patients with sphincter sparing procedures may experience diarrhea constipation and incontinence years after procedure Chemotherapy used for positive lymph nodes o Usually combined with 5 fluoracil and leucovorin o For those not considered appropriate candidates for triple therapy capecitabine Xeloda is the alternative Do not get immunizations without physician s approval o Oxaliplatin Eloxatin is also used for metastasis Biological therapy Bevacizumab prevents the formation of new blood vessels Metastasis Change in Bowel habits Constipation diarrhea urgency rectal bleeding mucoid stools black tarry stools increased Nursing Assessment Check for Risk Factors Medications Those that affect bowel function Laxative Antidiarrheals Statements of weakness or fatigue Anemia Diet High Calorie High Fat Low Fiber Anorexia Weight Loss N V Elimination gas feelings of incomplete evacuation Abdominal or low back pain Tenesmus constant feeling of need to evacuate even though bowel is empty General Pallor cachexia lymphadenopathy GI palpable abdominal mass distention ascites and hepatomegaly Nursing Diagnosis Diarrhea or constipation related to altered bowel elimination patterns Acute pain related to difficulty in passing stools because of partial or complete obstruction from tumor Fear related to diagnosis of CRC surgical or therapeutic interventions and possible terminal illness Ineffective coping related to diagnosis of cancer and side effects of treatment Normal bowel elimination Qualitiy of life appropriate to disease Relief of pain Feelings of comfort and well being Nursing Interventions Plan Recommend Screening at age 50 or earlier if family was diagnosed prior to age 60 Bowel cleansing prior to colonoscopy for a good visual Enema Clear liquid diet for 24 hours before procedure Give 2 to 4 L of oral polyethylene glycol lavage solution alone or with magnesium citrate solution or bisacodyl tablets Many people find this solution difficult to drink and experience nausea and bloating o o Pre Op Post Op Inform patient of prognosis and future screening Provide support for the diagnosis of cancer Care for temporary or permanent ostomy General Post Op care due to reanastomies of the bowel May have open wound drain JP Hemovac or permanent stoma Assess amount color consistency usually serosanguineous o Bleeding excessive drainage and unusual odor Sterile dressing changes frequently since there might be profuse bleeding and education about stoma care Examine wounds for redness erythema warmth swelling fever elevated WBC Refer to wound and ostomy nurse Rectal procedure patients may feel phantom rectal sensation because the nerves were not severed Sexual dysfunction can occur as a complication discuss the possibility Nerve pathways for erection ejaculation and orgasm