NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: How might this recommendation change if the patient has previously had a colon cancer removed? A: One of the most productive ways to detect cancer recurrence after primary colon cancer is by screening with carcinoembryonic antigen (CEA) measurements . If patients with stage II or stage III cancer are free of disease, CEA measurement every 2–3 months for at least 2 years is worthwhile. This method detects up to 80% of recurrences. Production of CEA does not occur in up to 30% of recurrences, especially with poorly differentiated tumors or in patients who had normal CEA measurements with their primary cancer. Physical examination, which should be performed every 3–6 months, detects up to 20% of recurrences. Screening for liver function studies is also recommended. Case 8.19 Heme-Positive Stool A 45-year-old man is referred to you because he has noted bright red blood streaks on his stool intermittently for the past 3 weeks. Otherwise, the patient complains of occa- sional constipation. The stools have been normal caliber and brown. The history (past, family, and social) and review of symptoms are negative. On physical examination, it is found that the vital signs are normal. The patient does not appear anemic. The head, neck, chest, abdomen, extremity, and neurologic examination are all normal.

Q: What is the appropriate diagnosis or initial management of the following findings on rectal examination or sigmoidoscopy?

Case Variation 8.19.1. Several hemorrhoids with evidence of recent injury ◆ ◆ With a negative family history of colon cancer and no history of IBD or past history of co- lon cancer, it is likely that the source of the bleeding is hemorrhoids. Figure 8-20 illustrates internal and external hemorrhoids. Conservative management, with sitz baths, stool soft- eners, and the addition of fiber to the diet, is one option. If the hemorrhoids continue to bleed despite medical management, surgical removal may be necessary. ◆ ◆ External hemorrhoids are surgically excised, and internal hemorrhoids can be excised or banded. Figure 8-21 shows rubber band application to internal hemorrhoids. Most surgeons still recommend colonoscopy to rule out colon cancer. Case Variation 8.19.2. Thrombosed hemorrhoids ◆ ◆ Conservative management with sitz baths and stool softeners may be appropriate for thrombosed hemorrhoids. However, if individuals present with extreme pain, incision and drainage (I&D) of the hemorrhoids if thombosed may be necessary. Surgeons should be certain to excise the overlying skin and subcutaneous tissue to remove the underlying ves- sels. It is permissible to leave the skin open. Thrombosed hemorrhoids usually heal well after I&D, with mild analgesics and sitz baths. SAMPLE Digging Deep Colorectal cancers presenting with heme-­ positive stools are often diagnosed late because the presence of blood in the stool is falsely attributed to hemorrhoids.