1. Explain the significance of the following in the protocol that my have a bearing to this patient's chief complaint.
Normal bowel movements / Three times a week to three times a day
Constipation alternating with diarrhea / Consider Iriitable bowel syndrome, Cancer Colon
Stool caliber / Narrows with obstructive lesions in Rectum
Stool with streaks of blood on surface / Often suggests bleeding Hemorrhoids
Weight loss / Consider malignancy, Many other possibilities
Low blood 6 months back / Should have been worked up for etiology.
Pale conjunctiva / Anemia
Stool positive for occult blood / When properly collected, requires workup for an etiology
Type of anemia / Microcytic anemia
Alkaline phosphatase / Elevated in Liver and Bone disease
2. What is/are the major clinical problem/s (not the diagnosis)?
Change in bowel habit
Positive occult blood in stools
Anemia
3. What type of anemia does this patient have?
4. What are the most common causes for this type of anemia. What is the most likely etiology in this patient and why?
Iron deficiency
5. Is this the result of acute bleeding or chronic bleeding?
Chronic blood loss.
6. What are the type of lesions that can cause chronic bleeding in GI tract?
Cancer small bowel
Hereditary
hemorrhagic telengiectasia
7. Let us next address the next major problem. Develop a differential diagnosis for constipation.
The differential can be wide.
Deficient fiber in diet
Irritable bowel syndrome
Mechanical obstruction
Colon cancer
CHronic diverticulitis
Hernias
Adhesions from previous surgery
Volvulus
Fecal impaction
Medications that alter GI motility
Anticholinergics
Antacids
Analgesics
Depression
Metabolic disease (hypothyroidism)
8. What is the most likely reason in this patient and why? Cite data from protocol to support your diagnosis.
Adenocarcinoma of the colon with mets to liver.
Patient presents with a
change in bowel habit
possible weight loss
occult positive stools
microcytic anemia
This together with hepatomegaly makes the diagnosis of metastatic colon cancer very likely.
9. What is the significance of the laboratory in this case? How would you proceed to investigate the significance for elevated alkaline phosphatase?
The microcytic anemia is that of iron deficiency from chronic blood loss.
The elevated alkaline phosphatase and slight elevated of bilirubin suggesting intrahepatic obstruction from mets.
10. How would you confirm your clinical suspicion? What procedures will you request?
Colonoscopy
CT Liver
11. What do you think the liver CT will show?
Defects consistent with metastasis from colon cancer.
A single met may be amenable to resection.
12. What would you have done 6 months ago when the anemia was first discovered? Was there a malpractice?
The patient’s microcytic anemia should have been evaluated.
The best first test, in view of the positive stool and change in bowel habits, would have been a full colonoscopy.
Flexible Sigmoidoscopy in this case would be inadequate, as it would evaluate at best to the level of the splenic flexure.
If the colon was negative, then the remainder of the GI tract would have to be examined (EGD and small bowel series with barium).
13. How would you treat this patient?
Surgical resection (palliative / curative)
Replacement of Iron
Treat metastasis