CLINICAL CASE

COLON SURGICAL PATHOLOGY

A 63-year-old man complains of dyspnea and chest pain on exertion. His current
symptoms have been present for approximately 3 to 4 weeks. Over approximately the same
period of time, the patient has noted post-prandial bloating in his abdomen. His past medical
history is significant for hypertension and stable angina. On physical examination, he appears
well-nourished and in no acute distress. The abdominal examination reveals an obese
abdomen without masses or tenderness. The rectal examination reveals no rectal masses, a
smooth and mildly enlarged prostate gland, and strongly Hemoccult-positive stool in the
rectal vault. His complete blood count reveals normal WBC count, hemoglobin 8.2 g/dL,
hematocrit 28.5%, and mean cell volume 72 fL (normal range, 76-100 fL). The electrolytes
and liver function tests are within normal limits. A 12-lead ECG reveals normal sinus rhythm
with mild left ventricular hypertrophy. A chest x-ray reveals normal cardiac silhouette, no
pulmonary infiltrations, no pleural effusion, and no pulmonary masses.

» What is the most likely cause of his current condition?

» How would you confirm the diagnosis?

ANSWER
Colorectal Cancer and Polyps

Summary:
A 63-year-old man presents with a recent onset of dyspnea on exertion, chest pain, and
nonspecific gastrointestinal tract complaint related to occult GI blood loss and possibly mild
mechanical obstruction symptoms.
Most likely cause:
The combination of anemia and post-prandial bloating are compatible with symptoms
produced by colorectal (CRCs) cancers.
Confirmation of diagnosis:
GI endoscopy, with esophagogastroduodenoscopy (EGD) to evaluate the upper GI tract and
colonoscopy to evaluate the lower GI tract. Biopsies of abnormalities are important for tissue
diagnosis.
ANALYSIS

Objectives
1. Learn the clinical presentation and management of CRCs.
2. Know the risk factors for CRC and surveillance and screening strategies for patients based
on risk factors.
3. Learn the evolving trend in the treatment of patients with advanced stages of CRC.
Considerations
This 63-year-old man presents with new-onset angina, dyspnea with exertion, postprandial
bloating, and guaiac-positive stool. His laboratory studies indicate microcytic anemia. It is
highly probable that his angina and dyspnea are caused by the severe anemia.
Because he is quite symptomatic at point, addressing the anemia should be one of our
initial priorities in management. We should treat the anemia with iron supplementation and
then resort to RBC transfusion if he does not improve with iron therapy.
The rationale behind limiting transfusional treatment is that blood transfusions have been
known to adversely affect immune functions and can independently affect cancer-related
outcome in the transfused patients. A thorough GI evaluation will need to be done once his
cardiopulmonary symptoms improve, and this work-up will include colonoscopy with
biopsies and EGD. Once CRC is identified and confirmed by biopsy, we need to stage the
disease and formulate a multimodality treatment strategy best suited for this patient and his
stage of disease.