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Colorectal Carcinoma

Colorectal carcinoma, the commonest type of gastrointestinal carcinoma, accounts for a significant proportion of morbidity and mortality worldwide. It results from a combination of genetic and environmental risk factors.


Presentation

The clinical features of colorectal carcinoma manifest due to the tumor itself or due to a local and metastatic spread of the tumor. However, it must be remembered that a certain proportion of patients are asymptomatic and are only detected incidentally or during screening. The common clinical manifestations arising from the tumor are rectal bleeding, change in bowel habits, rectal/ abdominal mass, anemia, weight loss, abdominal pain, pelvic pain, and urinary symptoms [1] [2] [3].

Rectal bleeding is a common manifestation. This presents as either drops of fresh blood or as blood streaked on the stools [4]. Dark-colored blood, in general, is more likely to be associated with colorectal cancer than bright red-colored blood [5]. Sometimes, bleeding can occur in an occult fashion without the patient having taken any notice. However, long-term blood loss, even in minute quantities, leads to symptoms of anemia [6].

Change in bowel habits is yet another common symptom. This presents as diarrhea, constipation, a sensation of incomplete evacuation, and tenesmus.

Other symptoms due to a local and metastatic spread of colorectal carcinoma are the pelvic pain, back pain, urinary symptoms, and yellowish discoloration of the sclera.

Related signs that may be identified on general physical examination are cachexia, paleness, and jaundice. Abdominal examination may help in the detection of ascites and hepatomegaly.

Digital rectal examination is the most specific test in physical examination and it may reveal the size of the tumor and features such as ulceration and local spread. It may also reveal a change in anal sphincter tone, which will indicate whether the tumor has spread locally to involve the nerves. Proctoscopy will help to further visualize the tumor.

Cervical Lymphadenopathy
  • A 61-year-old man presented with cervical lymphadenopathy 18 years after undergoing surgery for right lung carcinoma [poorly differentiated adenocarcinoma stage IIb (T3N0M0)].[ncbi.nlm.nih.gov]
Weight Loss
  • A 16-year-old girl presented to our unit with crampy abdominal pain, change in bowel habit, a subjective impression of weight loss and a single episode of haematochezia.[ncbi.nlm.nih.gov]
  • The common clinical manifestations arising from the tumor are rectal bleeding, change in bowel habits, rectal/ abdominal mass, anemia, weight loss, abdominal pain, pelvic pain, and urinary symptoms. Rectal bleeding is a common manifestation.[symptoma.com]
  • loss with no known reason Fatigue Nausea or vomiting Because you may not have symptoms at first, it's important to have screening tests.[medlineplus.gov]
Fatigue
  • Four months later the patient was admitted to the gastroenterology department for further examination because of chronic fatigue, subfebrile temperature and a positive fecal occult blood test.[ncbi.nlm.nih.gov]
  • Common in Colorectal Cancer survivors Consider evaluating for alternative Fatigue cause (e.g Anemia , Hypothyroidism ) VIII.[fpnotebook.com]
  • Common side effects include: hair loss nausea fatigue vomiting Combination therapies often mix multiple types of chemotherapy or combine chemotherapy with other treatments.[medicalnewstoday.com]
  • Diarrhea or constipation A feeling that your bowel does not empty completely Blood (either bright red or very dark) in your stool Stools that are narrower than usual Frequent gas pains or cramps, or feeling full or bloated Weight loss with no known reason Fatigue[medlineplus.gov]
Weakness
  • RESULTS: Our results confirm that the nuclear VDR expression is strongest in normal colorectal mucosa and in hyper plastic polyps, is gradually weakened in low and high grade adenoma while it is extremely weak or absent in colorectal carcinoma.[ncbi.nlm.nih.gov]
  • As a person loses blood over time, they will develop anemia, or lowered red blood cell count, causing them to feel tired and weak. Unexplained weight loss is another sign that a cancer may be present, but this is by no means exclusive to CRC.[pharma.bayer.com]
  • “go” to save your life) that lasts for more than a few days Unintended or unexplained weight loss (or weight gain) Vomiting Narrow stools – poo looks pencil-thin Change in stools – poo just looks different, smells different Gas, bloating and cramps Weakness[colonclub.com]
  • The intensity score (0, no immunoreactivity; 1, weak; 2, strong) was used as well as the extent score (1, 1-10%; 2, 10-50%; and 3, 50-100%).[omicsonline.org]
  • If you do experience symptoms, they may include: constipation diarrhea changes in stool color changes in stool shape, such as narrowed stool blood in the stool bleeding from the rectum unexplained weakness passing excessive gas fatigue unintended weight[healthline.com]
Aspiration
  • We present 2 cases of colorectal adenocarcinoma metastatic to the thyroid gland, diagnosed by fine-needle aspiration (FNA).[ncbi.nlm.nih.gov]
  • It entails endometrial aspiration biopsy and transvaginal ovarian ultrasound, respectively, and CA125 blood testing. Screening for ovarian cancer is particularly limited.[surgwiki.com]
Diarrhea
  • This presents as diarrhea, constipation, a sensation of incomplete evacuation, and tenesmus.[symptoma.com]
  • […] adenomatous polyposis syndrome (FAP) Gardner syndrome variant Turcot syndrome variant Peutz-Jeghers syndrome hereditary non-polyposis colon cancer syndrome (HNPCC) Clinical presentation is typically insidious: altered bowel habit (constipation and/or diarrhea[radiopaedia.org]
  • Radiation Proctitis ( Diarrhea , bleeding) Endoscopic argon plasma coagulation Sucralfate enemas Hanson (2012) Dis Colon Rectum 55(10): 1081-95 [PubMed] Abdominal Pain Acute pain (esp.[fpnotebook.com]
  • He experienced extreme bouts of constipation and diarrhea. There are some common signs and symptoms of colorectal cancer (CRC)… and some not so obvious when you are a young adult![colonclub.com]
Abdominal Pain
  • A 16-year-old girl presented to our unit with crampy abdominal pain, change in bowel habit, a subjective impression of weight loss and a single episode of haematochezia.[ncbi.nlm.nih.gov]
  • The common clinical manifestations arising from the tumor are rectal bleeding, change in bowel habits, rectal/ abdominal mass, anemia, weight loss, abdominal pain, pelvic pain, and urinary symptoms. Rectal bleeding is a common manifestation.[symptoma.com]
  • Right Sided Tumors Left Sided Tumors Anemia Change in Bowel Habits Abdominal Pain Rectal Blood Loss Weight Loss Abdominal Pain Change in Bowel Habits * Associated with chronic occult bleeding linked to iron deficiency & anemia Early Stage Advanced Stage[physio-pedia.com]
Constipation
  • This presents as diarrhea, constipation, a sensation of incomplete evacuation, and tenesmus.[symptoma.com]
  • Constipation is commonly prevalent in Kuwait more so in females than males [ 45 ]. Efforts to avoid the constipation may help minimize the CRC risk in this and other similar populations.[bmccancer.biomedcentral.com]
  • […] include: familial adenomatous polyposis syndrome (FAP) Gardner syndrome variant Turcot syndrome variant Peutz-Jeghers syndrome hereditary non-polyposis colon cancer syndrome (HNPCC) Clinical presentation is typically insidious: altered bowel habit (constipation[radiopaedia.org]
  • He experienced extreme bouts of constipation and diarrhea. There are some common signs and symptoms of colorectal cancer (CRC)… and some not so obvious when you are a young adult![colonclub.com]
  • Symptoms of colorectal cancer include Diarrhea or constipation A feeling that your bowel does not empty completely Blood (either bright red or very dark) in your stool Stools that are narrower than usual Frequent gas pains or cramps, or feeling full or[medlineplus.gov]
Rectal Bleeding
  • The common clinical manifestations arising from the tumor are rectal bleeding, change in bowel habits, rectal/ abdominal mass, anemia, weight loss, abdominal pain, pelvic pain, and urinary symptoms. Rectal bleeding is a common manifestation.[symptoma.com]
  • Only increased awareness of this malignancy in this age-group and a high index of suspicion can help when a child complains of persistent pain of abdomen, altered bowel habits or rectal bleeding, and may provide diagnosis at an earlier stage, thereby[ncbi.nlm.nih.gov]
  • bleeding Occasionally metastatic disease may be the first sign.[radiopaedia.org]
  • The most common presenting symptoms and signs of cancer or large polyps are rectal bleeding, persisting change in bowel habit and anaemia.[patient.info]
  • bleeding is found to have an adenocarcinoma of the sigmoid colon; an enlarged axillary lymph node is also detected.[pathologyoutlines.com]
Blood in Stool
  • […] in stool (although not always visible.)[colonclub.com]
  • stools Colicky abdominal pain due to obstruction Rectum (50%) and sigmoid (30%) Hematochezia Stool caliber ( pencil-shaped stool) Rectal pain Tenesmus Flatulence with involuntary stool loss Symptoms according to stage of disease Colorectal cancer must[amboss.com]
  • Other screening tests include: annual fecal occult blood tests stool DNA testing flexible sigmoidoscopy every 5 years CT colonography every 5 years These frequency recommendations depend on the individual's risk of colon cancer.[medicalnewstoday.com]
  • […] in stool sample Annually No bowel preparation No direct risk to bowel Sample can be collected at home Dietary restrictions before testing Cannot detect precancerous changes Detects any blood, not just from cancers but from food or dental procedures May[labtestsonline.org]
Cutaneous Manifestation
  • Cutaneous manifestations of visceral carcinomas are scarce, occurring in around 0.7-12% of internal malignancies. Lung cancer is one of the most common sources of skin metastasis, particularly in male patients.[ncbi.nlm.nih.gov]
Testicular Mass
  • The authors report a case of 35-year-old man with right testicular mass. Contrast-enhanced CT scan (CECT) of testes showed testicular mass with ascitis and enlargement of retroperitoneal lymphnodes.[ncbi.nlm.nih.gov]

Workup

Screening is an important part of diagnosing colorectal carcinoma and has led to its decline in incidence over time [7]. The recommended mode of screening is colonoscopy every ten years from 50 years of age [8].

The mainstay of diagnosing colorectal carcinoma is colonoscopy followed by biopsy of the suspicious lesions.

Further testing is aimed at grading and staging the tumor that may have an implication on management.

Blood studies such as complete blood count, renal function tests, and hepatic function tests are important too as they serve as indicators of organ damage.

Serum carcinoembryonic antigen (CEA) levels give an insight into prognosis.

Other tests which must be considered are ultrasonography (US) and magnetic resonance imaging (MRI) to assess the spread of the disease.

A chest radiography and abdominal computed tomography (CT) may also help to assess metastatic spread. Positron emission tomography (PET) scans are gaining popularity as an effective imaging modality to detect metastatic lesions.

Molecular genetic testing to detect various genetic mutations is rapidly gaining evidence as a guide for the treatment of metastatic colorectal cancer.

Treatment

  • The concept of treatment for unresectable colorectal carcinoma consists of surgical treatment, chemotherapy, and radiotherapy.[ncbi.nlm.nih.gov]

Prognosis

  • KEYWORDS: HIF1A-AS; Long chain noncoding RNA; clinicopathological features; colorectal carcinoma; diagnosis; prognosis[ncbi.nlm.nih.gov]

Etiology

  • In the clinical setting, treatment of the underlying malignancy should be first considered in patients with a tumor presenting with kidney disease which is suspected to be paraneoplastic in etiology.[ncbi.nlm.nih.gov]
  • […] versus non-etiological nature of the association is also not clearly defined.[romanianjournalcardiology.ro]
  • Several lines of evidence, including a 25-fold worldwide variation in CRC incidence rates and results from migration studies, implicate dietary and lifestyle factors as central to CRC etiology.[epic.iarc.fr]
  • The etiology of this malignant tumor is unknown. Although urethritis glandularis has been proposed to be a precursor lesion for urothelial-type adenocarcinoma, our patient did not have evidence of urethritis glandularis.[scielo.br]

Epidemiology

  • Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. 5 Department of Epidemiology, Harvard T.H.[ncbi.nlm.nih.gov]
  • Meat consumption and colorectal cancer risk: dose-response meta-analysis of epidemiological studies. Int J Cancer. 2002;98(2):241–56. 34. Norat T, Lukanova A, Ferrari P, Riboli E.[bmccancer.biomedcentral.com]
  • We assessed the overall and age-specific risks of colorectal SPTs within the national Surveillance, Epidemiology, and End Results (SEER) 1 Program database population.[academic.oup.com]
Sex distribution
Age distribution

Pathophysiology

  • We report a case where nephrotic syndrome due to membranoproliferative glomerulonephritis developed in a patient with colorectal carcinoma and elucidate some of the pathophysiological mechanisms underpinning this presentation.[ncbi.nlm.nih.gov]
  • Differential diagnosis for a colorectal mass Other rare colonic cancers: lymphoma, carcinoid tumours, Kaposi’s sarcoma, invasive prostatecancer Benign polyps Pseudopolyps in colitis Endometriosis Lipoma Tuberculosis Video on colon cancer, focusing on pathophysiology[oxfordmedicaleducation.com]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management . 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 126. National Cancer Institute website.[medlineplus.gov]
  • Renehan AG, Roberts DL, Dive C: Obesity and cancer: pathophysiological and biological mechanisms. Arch Physiol Biochem 2008;114(1)71-83 72.[revista.spcir.com]
  • Pathophysiology Genetically, colorectal cancer represents a complex disease, and genetic alterations are often associated with progression from premalignant lesion (adenoma) to invasive adenocarcinoma.[emedicine.medscape.com]

Prevention

  • BACKGROUND: Chemo preventive and antitumor role of vitamin D is manifested through genetic and non genetic ways with a powerful antproliferatory and proapopoptic effect, which is proven by numerous epidemiologic studies.[ncbi.nlm.nih.gov]
  • Meat consumption and colorectal cancer risk: an estimate of attributable and preventable fractions. IARC Sci Publ. 2002;156:223–5. 35. Song M, Garrett WS, Chan AT: Nutrients, foods, and colorectal Cancer prevention.[bmccancer.biomedcentral.com]

References

Article

  1. Guidice MED, Vella ET, Hey A, et al. Systematic review of clinical features of suspected colorectal cancer in primary care. Can Fam Physician. 2014;60(8):405-415.
  2. Barwick TW, Scott SB, Ambrose NS. The two week referral for colorectal cancer: a retrospective analysis. Colorectal Dis. 2004;6(2):85–91.
  3. Panzuto F, Chiriatti A, Bevilacqua S, et al. Symptom-based approach to colorectal cancer: survey of primary care physicians in Italy. Dig Liver Dis. 2003;35(12):869–875.
  4. Robertson R, Campbell C, Weller DP, et al. Predicting colorectal cancer risk in patients with rectal bleeding. Br J Gen Pract. 2006;56(531):763–767.
  5. Ellis BG, Thompson MR. Factors identifying higher risk rectal bleeding in general practice. Br J Gen Pract. 2005;55(521):949–955.
  6. Hamilton W, Lancashire R, Sharp D, Peters TJ, Cheng KK, Marshall T. The importance of anaemia in diagnosing colorectal cancer: a case-control study using electronic primary care records. Br J Cancer. 2008;98(2):323–327.
  7. American Cancer Society. Cancer Facts & Figures 2016. American Cancer Society. Available at https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2016.html
  8. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104 (3):739-750.

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Last updated: 2019-07-11 21:06