ORIGINAL ARTICLE

Different clinical presentations of patients with Colorectal

Cancer
BUSHRA NISAR, KARIM SHAH FAIZI, ASGHAR ALI

ABSTRACT
Aim: To determine the frequency of different clinical presentations of colorectal cancer
Methods: A total of 105 patients of both sex and of age 30-70 year, diagnosed as a case of colorectal
cancer on CT scan abdomen confirmed on histopathology at stage I, II and stage III were included.
Patients with previously treated for colorectal carcinoma were excluded. Case sheet patients were
prepared for age & sex and symptoms of colorectal cancer (Bleeding per rectum, altered bowel habits,
Anemia, weight loss).
Results: Mean age was 58.697.91 years. Out of 105 patients, 69(65.71%) were males and
36(34.31%) were females with male to female ratio of 2:1. TNM staging revealed 28(26.67%) patients
with stage I, 33(31.43%) with stage II and 44(41.90%) with stage III carcinoma.The main presentation
was rectal bleeding in 91(86.67%) followed by altered bowel habits in 76(72.38%), anemia in
35(33.33%) and weight loss in 26(24.76%) patients.
Conclusion: This study concluded that the rectal bleeding was the most common presentation of
colorectal carcinoma and there was statistically insignificant difference of all clinical symptoms among
different age groups, gender and stage of carcinoma
Keywords: Rectal, carcinoma, bleeding, anemia.

INTRODUCTION
Colorectal cancer, also known asrectal cancer, bowel
cancer orcolon cancer is a cancer from un-controlled
cell growth in therectum orcolon(parts of the large
intestine), or in the appendix. Genetic analysis shows
that essentially rectal and colon tumours are
genetically the same cancer. Colorectal carcinoma is
nd
rd
the 2 most common cancer in women and 3 most
1
common cancer in men affecting 9.7% population
2
worldwide. Its incidence is more common in
developed as compared to developing countries.
Greater than 75-95% of colon cancer occurs in
3,4
people with little or no genetic risk. Risk factors
includemale gender, older age, red meat, high intake
of fat,obesity, smoking, alcohol and a lack of physical
3
exercise . About 10% of cases are linked to
5
insufficient activity . The risk for alcohol appears to
6
increase at greater than one drink per day .
Colorectal cancer is a common malignancy in
developed countries but occurs much less frequently
in the developing world. Worldwide in terms of
incidence, colorectal cancers rank fourth in frequency
7,8
in men and third in women . Many symptoms have
been described with the main ones being altered
bowel habits, rectal bleeding, abdominal pain, weight
8,9
loss and anemia . However, these symptoms are
also common with benign conditions, so the clinician
----------------------------------------------------------------------Department of Surgery, Sahiwal Medical College, Sahiwal
Correspondence to Dr. Bushra Nisar, Assistant Professor
Histopathology, Sh. Zayed Medical College/Hospital,
Rahim Yar Khan Email: [email protected]

has to select patients at higher risk for investigation.

Most cases present with symptoms that prompt
8,9,10
patients to consult their general practitioners
.
There are variations in different studies
conducting in evaluation of different clinical
presentations. According to one study conducted in
England, the most common presentation was
bleeding Per Rectum (89%) and other presentations
11
were; altered bowel habit (58%), weight loss (18%) .
In other study Colorectal cancer presents most
commonly as with the symptoms of anemia (27%)
10
and bleeding per rectum (11%) . With reference of
these statistical values, the rationale of my study was
to see that what is the most common clinical
presentation among bleeding per rectum, altered
bowel habits, abdominal mass, anemia and weight
loss.

MATERIAL AND METHODS

This cross sectional study was conducted at
Department of Surgery Sheikh Zayed Medical
College/Hospital Rahim Yar Khan from October 2014
to April 2015. Total 105 patients of both sex and of
age 30-70 year, diagnosed as a case of colorectal
cancer on CT scan abdomen confirmed on
histopathology at stage I, II and stage III were
included in this study. Patients previously treated for
colorectal cancer were excluded from the study. An
approval was taken from ethical review committee
and written informed consent was taken from every
patient.

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Different clinical presentations of patients with Colorectal Cancer

Operational definitions of study variables:

Bleeding per rectum: Patient passing blood per
rectum either mixed with stool or separate detected
on stool examination.
Altered bowel habits: Patient having diarrhea or
constipation alternatively for more than three months.
Anemia: Patient having hemoglobin level less than
10 g/dl detected on complete blood examination.
Weight loss: Patients weight less than 10% of
normal weight according to age and height; at time of
presentation.
All the selected patients was examined for
colorectal cancer (Bleeding per rectum, Altered bowel
habits, Anemia, Weight loss). All the findings along
with demographic profile of the patients were
recorded in pre-designed proforma. All the data
entered and analyzed by using SPSS version 17.
Mean and SD was calculated for numerical variables.
Frequencies and percentages were calculated for
categorical variables. Chi-square test was used to
see the association between different variables. P
value 0.05 was considered as significant.

RESULTS
Age range in this study was from 30 to 70 years with
mean age of 58.697.91 years. Out of 105 patients,
69(65.71%) were males and 36(34.31%) were
females with male to female ratio of 2:1 (Fig. 1). TNM
staging revealed 28 (26.67%) patients with stage I,
33 (31.43%) with stage II and 44(41.90%) with stage
III carcinoma. (Fig. 2). The main presentation was
rectal bleeding in 91 (86.67%) followed by altered
bowel habits in 76 (72.38%), anemia in 35(33.33%)
and weight loss in 26(24.76%) patients (Table 1).
Stratification of carcinoma presentation with respect
to age groups and gender has shown in Table 2 & 3
respectively which have shown no significant
difference (p>0.05). Stratification of carcinoma
presentation with respect to stage of carcinoma has
shown in Table 4 which has also shown no significant
difference (p>0.05).
Fig. 1: Gender distribution

Female
[VALUE],
[PERCEN
TAGE]

1190

Male
[VALUE],
[PERCEN
TAGE]

P J M H S Vol. 9, NO. 4, OCT DEC 2015

Fig. 2: Stage of carcinoma

Stage-III
[VALUE], [
PERCENT
AGE]

Stage-I
[VALUE], [
PERCENT
AGE]

Stage-II
[VALUE], [
PERCENT
AGE]

Table 1: Presentation of colorectal carcinoma

Presentation
Frequency (%)
Yes
No
Bleeding per rectum
91 (86.67%)
14 (13.33%)
Altered bowel habits 76 (72.38%)
29 (27.62%)
Anemia
35 (33.33%)
70 (66.67%)
Weight loss
26 (24.76%)
79 (75.24%)
Table 2: Stratification of presentation of carcinoma with
respect to age.
30-50 years
51-70 years
P-value
(n=35)
(n=70)
Bleeding per rectum
Yes
30 (85.71%)
61 (87.14%)
0.839
No
05 (14.29%)
09 (12.86%)
Altered bowel habits
Yes
26 (74.29%)
50 (71.43%)
0.758
No
09 (25.71%)
20 (28.57%)
Anemia
Yes
12 (34.29%)
23 (32.86%)
0.884
No
23 (65.71%)
47 (67.14%)
Weight loss
Yes
08 (22.86%)
18 (25.71%)
0.749
No
27 (77.14%)
52 (74.29%)
Table 3: Stratification of presentation of carcinoma with
respect to gender.
30-50 years
51-70 years
P-value
(n=35)
(n=70)
Bleeding per rectum
Yes
59 (85.51%)
32 (88.89%)
0.628
No
10 (14.49%)
04 (11.11%)
Altered bowel habits
Yes
50 (72.46%)
26 (72.22%)
0.979
No
19 (27.54%)
10 (27.78%)
Anemia
Yes
24 (34.78%)
11 (30.56%)
0.663
No
45 (65.22%)
25 (69.44%)
Weight loss
Yes
19 (27.54%)
07 (19.44%)
0.362
No
50 (72.46%)
29 (80.56%)

Bushra Nisar, Karim Shah Faizi, Asghar Ali

Table 4: Stratification of presentation of carcinoma with

respect to stage
PI (n=28)
II (n=33)
III (n=44)
value
Bleeding per rectum
Yes 26(92.86%) 29(87.88%) 36(81.82%) 0.393
No
02(7.14%)
04(12.12%) 08(18.18%)
Altered bowel habits
Yes 21(75%)
22(66.67%) 33 (75%)
0.675
No
07(25%)
11(33.33%) 11 (25%)
Anemia
Yes 06(21.43%) 13(39.39%) 16(36.36%) 0.285
No
22(78.57%) 20(60.61%) 28(63.64%)
Weight loss
Yes 03(10.71%) 09(27.27%) 14(31.82%) 0.119
No
25(89.29%) 24(72.73%) 30(68.18%)

DISCUSSION
In our study, mean age was 58.69 7.91 years which
is very much comparable to the study of Pomerri S et
12
13
al and Ather HM et al who had also observed
mean age of 61 and 58 years respectively. On the
14
15
other hand, Dar RA et al and Irabor DO et al in
their studies had found much lower mean age i.e. 53
% 50 years respectively. In our study, the males were
affected more than females with ratio of 1.8:1 which
15-17
correlates with some previous studies.
So, our
study has shown that colorectal carcinoma was more
common in males with increasing incidence with age.
Age is a well-known risk factor for colorectal cancer,
as it is for many other solid tumors. From 2005-2009,
the median age at diagnosis for cancer of the colon
and rectum in the US was 69 years of age.
Approximately 0.1% were diagnosed under age 20;
1.1% between 20 and 34; 4.0% between 35 and 44;
13.4% between 45 and 54; 20.4% between 55 and
64; 24% between 65 and 74; 25% between 75 and
18
84; and 12% 85+ years of age .
In our study, rectal bleeding was found in 91
(86.67%), altered bowel habits in 76(72.38%),
anemia in 35(33.33%) and weight loss in 26 (24.76%)
patients. The most common presenting complaint
observed in our study was rectal bleeding as was
17
13
also found by Eltinay OF et al and Ather HM et al
while Reis WD et al observed abdominal pain as the
main presenting complaint (86.9%) followed by
anorexia or weight loss (52.1%), diarrhea (52.1%),
13
and rectal bleeding (21.7%). Ather HM et al in his
study has found rectal bleeding in 49.76%, altered
bowel habits in 28.99%, anemia in 4.83% and weight
loss in 24.40% patients
19
Al-Shamsi SR et al
in his study has shown
pain in 81%, altered bowel habits in 72% and
bleeding per rectum in 78% patients of colorectal
carcinoma. According to one study conducted in
England, the most common presentation was

bleeding Per Rectum (89%) and other presentations

11
were; altered bowel habit (58%), weight loss (18%) .
In other study Colorectal cancer presents most
commonly as with the symptoms of anemia (27%)
10
17
and bleeding per rectum (11%) . Eltinay OF et al in
his study on 43 colorectal carcinoma patients had
found sixteen (37.2%) cases with rectal bleeding, ten
(23.2%) with abdominal pain, eight (18.5%) with
altered bowel habits whereas anaemia was found to
be the most frequent clinical result reported in twenty
(46.4%) patients.
20
In a study done in Pakistan by Shaikh AR et al ,
bleeding per rectum was found in 60.0% and altered
bowel habits in 30.0% patients. In another study done
21
in Pakistan by GulA et al , bleeding per rectum was
found in 66.0%, altered bowel habits in 86.0%, weight
loss in 84.0%, abdominal pain in 84.0% and
11
abdominal mass in 34.0% patients. Smith Det al in
his study has compared the clinical presentation of
colorectal carcinoma according to the stage of the
tumour. He concluded that in the early cancer group,
89% had rectal bleeding, 58% a change in bowel
habit and 24% had abdominal pain, as compared to
the advanced group, where abdominal pain (P =
0.001) and change in bowel habit (P < 0.001) were
more common and reached significance. Systemic
symptoms, decreased appetite and tiredness, were
evenly distributed between both groups; though
unexplained weight loss was not significant, there
was a tendency towards this in the advanced
colorectal cancers group (P=0.17). On the other
hand, in our study, we had not found any significant
difference in clinical presentations of colorectal
carcinoma in different stages of cancer.

CONCLUSION
This study concluded that thefrequency of rectal
bleeding was in 86.67% patients, altered bowel
habits in 72.38% patients, anemia in 33.33% patients
and weight loss in 24.76% patients with rectal
bleeding being the most common presentation of
colorectal carcinoma, and statistically insignificant
difference of all clinical symptoms among different
age groups, gender and stage of carcinoma.

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