Gastrointestinal: weight loss

Mr Brown is a 67 year old gentleman who presents to his GP. He has not been to his GP in a long time, but he recently noticed when shopping for new clothes, as his old clothes were feeling looser, that he was more tired than usual. This had been going on for some time. He also had some alternating bowel habits over the last few months, but did not feel too worried as he had not passed any blood. What is the most important differential for the GP?

Hyperthyroidism

Diverticular disease

Inflammatory bowel disease

Colorectal cancer

Mr Brown also mentions that one of the real reasons he is concerned is that he feels as if he cant evacuate his bowels completely. What is this symptom called?

Mr Brown mentions that his brother had a polyp after he was invited for a screening test in the mail. He asks if this kind of test would be a good idea for him to have. Why is the screening test (looking for faecal occult blood) not useful for Mr Brown?

FOB testing takes a long time to do

FOB testing has low sensitivity

FOB testing has low specificity

The GP finds recent blood results for Mr Brown showing Hb at 11.4g/dl, MCV at 65fl and platelets at 230. What do the bloods indicate?

Nothing abnormal

Normocytic anaemia

Microcytic anaemia

Macrocytic anaemia

What symptoms match best with which type of colorectal cancer?

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Proximal colorectal

Distal colorectal

Rectal

To sort

Small bowel obstruction
Altered bowel habit
Weight loss
PR bleeding
Tenesmus
Altered bowel habits
Large bowel obstruction
Fresh PR bleeding
Iron deficiency anaemia
Mucus PR
RIF mass

Given Mr Browns symptoms and recent blood test, the GP is very concerned over the possibility that Mr Brown may colorectal cancer, and starts the two-week referral process for people with suspected malignancy in primary care. This means for Mr Brown an urgent colonoscopy. Mr Brown attends the colonoscopy later in the week, and unfortunately the doctor finds a lesion in the sigmoid colon, of which he takes a biopsy for histology. With a primary lesion identified, it is important to look for distal metastases. To which organ does colorectal cancer most commonly metastasise?

Fortunately there is no evidence of organ metastases, and a CT abdomen rules out lymph node spread, giving sufficient information for staging of the cancer, usually with Duke’s staging for colorectal cancer. What defines the different levels of Duke’s staging and what are their survival rates?

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Duke’s A

Duke’s B

Duke’s C

Duke’s D

To sort

1% 5 year survival
30-40% 5 year survival
Penetrated bowel wall
Limited to bowel wall
Distant metastases
65-75% 5 year survival
95-100% 5 year survival
Lymph node metastases

Mr Brown’s cancer has penetrated the bowel wall, and is therefore Duke’s B. He undergoes a sigmoid colectomy. During this operation the surgeon will limit blood loss by clamping the supplying artery. Which artery supplies the sigmoid colon?

The tumour is removed and an end-to-end anastomosis is successful, so no stoma is needed. Mr Brown has an uncomplicated recover and remains in hospital for a week as his bowel is allowed to slowly recover. However, cancer can return so vigilance is always needed. What tumour marker is most commonly used for colorectal cancer?

Fortunately Mr Brown's cancer does not come back and the only evidence that remain are the abdominal scars.

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Gastrointestinal: weight loss

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