DIFFERENTIAL DIAGNOSIS

Colorectal Cancer
Colorectal cancer is a malignancy, often adenocarcinoma, arising between the cecum and rectum.
Presentation can be variable. The most common sites of metastasis of colorectal adenocarcinoma are the
liver and lungs; rarely, metastatic oral lesions occur. Cutaneous metastases of colon adenocarcinoma most
commonly occur on the abdominal skin and may occur in the area of abdominal surgical scars.
Prognosis is related to cancer staging (tumor depth, lymph node involvement, metastatic spread) at time
of diagnosis. Treatment often includes a combination of surgical resection and chemotherapy.

RULE IN RULE OUT

62 y/o, Male (-) No history of colon cancer
Chronic smoker (-) hematochezia
Alcohol drinker (-) unintentional weight loss
Sedentary lifestyle (-) diarrhea
(+) left lower quadrant pain Supporting evidence Needed:
(+) Distended abdomen  Rectal Exam
 Sigmoidoscopy,
(+) Constipation Colonoscopy with
biopsy

62 y/o, male – Colorectal cancer (CRC) is the third most commonly diagnosed malignancy and
the fourth leading cause of cancer-related deaths in the world with higher prevalence in male.
This was also supported by Kim et al in 2015 wherein the study found out Colorectal cancer exhibits
different molecular and pathological characteristics depending on tumor location. Differences between
right- and left-sided colon cancers are possibly due to differences in genetic makeup, life style, and/or
dietary habits (Figure (Figure1).1). Chromosomal instability, which is associated with 60%-70% of
colorectal cancer, is more often observed in left-sided colon cancer, and defective genes include
adenomatous polyposis coli, Kirsten-ras, deleted in colorectal cancer, and p53 gene.

Chronic smoker – Limsui et al in 2010 found out that cigarette smokers tend to activate carcinogenic
pathways h like microsatellite instability leading to MSI-high tumors (RR = 1.99, 95% CI = 1.26 to 3.14),
CpG island methylator phenotype resulting to CIMP-positive tumors (RR = 1.88, 95% CI = 1.22 to 2.90),
and BRAF mutation causing –positive tumors (RR = 1.92, 95% CI = 1.22 to 3.02) all of which mechanisms
of colorectal cancer development.

Alcohol drinker- Gin bilog, is usually a 350 ml liquor that's bottled at least 40 percent alcohol by
volume. According to the NIH, one "standard" drink or shot (or one alcoholic drink equivalent)
contains roughly 14 grams of pure alcohol According to a study by Fedirko et al 2011, A meta-
analysis of eight cohort studies from North America and Europe found a modestly
increased colorectal cancer risk (45% for colon and 49% for rectal cancers) with regular
high alcohol intake (≥45 g/day), compared with nondrinkers, in men and women combined. In the
case of our patient,he usually consumes 2 bottles (700 ml ) of gin bilog in a week or A 700ml
bottle of alcohol yields approximately 23 shots or 322 g in a week or 46 g/day thus a
risk factor.
Sedentary lifestyle -Cong et al in 2014 found out that in about 4. 3 million cases of cancer on colon and
rectum, Sedentary behaviour is associated with an increased risk of colon cancer at relative risk (RR):
1.30, 95% confidence interval (CI): 1.22–1.39). Sedentary behaviour, which is distinctly different from
physical inactivity, is defined as activities that are done sitting or in reclining posture that expend <1.5
times the basal metabolic rate. It is characterised by prolonged sitting or lying down and absence of
whole body movement, such as watching television, desk-bound work, using computer and game-
consoles, sitting at work, and sitting in automobiles. (Pate et al, 2008)

Constipation – According British Journal of Cancer (2004), in constipation, there is prolonged intestinal
transit time might not only increase the duration of contact between carcinogens in the stools and the
gut wall, but could also concentrate carcinogens by increasing colonic water absorption thereby
increasing risk of colorectal cancer.  

Rule out

No hx of colorectal cancer -  A study published in the Clinics Colon and Rectal Surgery Journal (2005)
found out that increased risk of colorectal cancer in first-degree relatives of patients with the disease,
ranging from no increased risk to a 6.3-fold increased risk to as high as an 8-fold increased risk in first-
degree relatives. Approximately 20% to 25% of cases occur in patients who have other family members
who have also had colon cancer.

(-) diarrhea -diarrhea is a frequent symptom among colorectal cancer patients, both during and
after treatment for the disease. Chronic diarrhea is the frequent passage of loose stools (>3
unformed stools and/or a volume of stool >200 g in 24 hours) with urgency and duration of more
than 4 weeks. Diarrhea can result in metabolic disturbances and poor quality of life (Lippincot
Nursing Center) Managing Chronic Diarrhea With Colorectal Cancer

DRE - Digital rectal examination in primary care for palpable rectal tumour has a sensitivity of
0.762, specificity of 0.917. usually it reveals palpable tumor, and rctal bleeding.
Sigmoidoscopy-  sensitivity = 82.3 ± 8.7%; specificity = 83.9% (Allemah et al –2011)
Researchgate

Colonoscopy - colonoscopy has the highest sensitivity and specificity among the selected
screening methods  for colorectal cancer at  sensitivity =94.7 ± 4.6%, specificity of 99.8 ± 0.2%.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4419057/
https://calgaryguide.ucalgary.ca/colorectal-carcinoma-pathogenesis-and-clinical-findings/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915616/
Kojima, M., Wakai, K., Tokudome, S., Tamakoshi, K., Toyoshima, H., Watanabe, Y., Hayakawa, N.,
Suzuki, K., Hashimoto, S., Ito, Y., Tamakoshi, A., & JACC Study Group (2004). Bowel movement
frequency and risk of colorectal cancer in a large cohort study of Japanese men and women. British
journal of cancer, 90(7), 1397–1401. https://doi.org/10.1038/sj.bjc.6601735

http://figmintcatering.com.au/beverage-quantity-charts-tips/