RECTAL

ADENOCARCINOMA
ADUNA, ALYANA
MAGTAKA, MARIO KRISANTO
MEDALLA, PAOLINE
MERCADO, WILLIAM JOSHUA
MORENO, JOAQUIN DIEGO
INTRODUCTION
Rectal cancer is a disease in which cancer cells form
in the tissues of the rectum; colorectal cancer occurs in
the colon or rectum. Adenocarcinomas comprise the vast
majority (98%) of colon and rectal cancers; more rare
rectal cancers include lymphoma (1.3%), carcinoid
(0.4%), and sarcoma (0.3%).
 Tumor spreads by invading the bowel wall. Once it crosses through
the muscle layer within the bowel wall, it enters the lymphatic
vessels, spreading to local and then regional lymph nodes. People who
are 50 year old and above are most at risk, with gender incidence
being slightly more common in females. Colorectal cancer is the
number one gastrointestinal cancer in the Philippines. Philippine
Society of Gastroenterology (PSG) recent data shows that there are
over 3,000 new cases of colorectal cancer (CRC) among Filipinos
annually. According to Dr. Frederick Dy, more than 3,000 over 2,000
die in a year. The global research found out that the Philippines has
the highest increase in mortality rate among the 37 countries
surveyed because of lack of screening programs, awareness and
financial burden on the patient.
PATIENT’S PROFILE
• Name: U.S.C
• Age: 80 years old
• Address: Norzagaray, Bulacan
• Birthdate: May 25, 1938
• Birthplace: Norzagaray, Bulacan
• Sex: Female
• Nationality: Filipino
• Civil Status: widowed
• Occupation: none
• Religion Affiliation: Roman Catholic
• Health Care Financing: Philhealth
• Usual source of medical care: Family
• Attending Physician: Dr. Habacon
• Admitting Doctor: Dr. Seguismunoz
• Admitting Diagnosis: Rectal Adenocarcinoma
• Date of Admission: 10/30/18
• Time of Admission: 9:40 am
• Type of Admission: Emergency
• Habits: Watching TV, gardening
• Attitude: Cooperative and positive
• Availability of relatives: Lives with grandson

• Personal and Social History:

Patient is an elementary graduate and now a widow. Patient practices proper waste
segregeation and source of water is Maynilad. Patient eats three times a day, in which the
diet usually consists of fruits and vegetables. She is a 0.15 pack year smoker and non-
alcoholic beverage drinker. She sleeps an average of 8 hours per day. There are no history
of illicit drug used and no history of sexually transmitted diseases.
• Chief Complaint or Reason for Visit:
Difficulty in defecation

• Pre-Operative Diagnosis:
Rectal Adenocarcinoma (10cm FAV)
S/P Colonoscopy with Biopsy

• Post-Operative Diagnosis:
Rectal Adenocarcinoma (10cm FAV)
• History of Present Illness
Started 2 months prior to admission, patient experienced constipation with
associated symptoms such as bloatedness, abdominal cramps and fever. She usually
assists her defecation by inserting a gloved finger in the anal canal and upon
retraction of finger, patient noticed bloody discharge. Patient opted in using
suppositories every other day and provided relief of constipation. Consult was done
at a private clinic and was prescribed tranexamic acid 500mg three times a day that
provided relief of hematochezia. Patient decided to go on a diet that consists of
fruits and vegetables.

One month prior to admission, the patient still has the above symptoms but now
with decreased in caliber of stool, straining, feeling of bloatedness and “corn-like”
pieces of stool. Consulted at a private hospital with a finding of rectal mass.
Colonoscopy and biopsy was requested. Lactolose was also prescribed to be given
once a day at bedtime.
 Three weeks prior to admission, patient still has the above
symptoms, she consulted a different private clinic.
Colonoscopy revealed a mass 10cm from the anal verge and
biopsy revealed to be rectal adenocarcinoma, was given
options if she wanted to undergo surgical removal of the said
mass or to only receive chemotherapy.

One day prior to admission, the patient still has the above
symptoms, patient had an approximate weight loss of 10% and
blamed it on her diet. Patient decided to undergo surgical
removal of the mass, hence, the admission in FEU-NRMF
Medical Center.
 • Past History
Past Medical History:

- Chicken pox and mumps

- Hypertension of more than 10 years
- Diabetes mellitus of more than 10 years
- Stroke (2009)

Childhood Immunizations and date of last tetanus shot:

- Patient has stated that she had child immunizations

- Tetanus Toxoid done

Allergies to drugs, animals, insects, or other environmental agents and the type of
reaction that occur:

- No known allergies to food and medications

 Accidents, injuries: how, when, and where that accident occurred, type of injury,
treatments received, and any complications:

- Fell and hit her head on a rock when she was 6 years old
- Altered visual acuity of the left eye

Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery
performed, course of recover, and any complications:

- Stroke (2009)

Medications: all currently used prescription and over-the-counter medications, such as

aspirin, nasal spray, vitamins or laxatives:

- Amlodipine 5mg per tablet once daily - Caltrate plus three times a day
- Atorvastatin 10mg per table once daily - Mecobalamine 500mg per tablet once
- Clopidogrel 75mg per tablet once daily daily
- Pantoprazole 40mg per 3mg per capsule - Phospholipid three times a day
Family History of Illnesses

- Mother is deceased at 88 years old; known diabetic

- Father is deceased at 63 years old; known asthmatic
- No other heredofamilial diseases such as hypertension, liver disease, kidney disease, thyroid
disease, psychiatric illness
- 1 sibling was diagnosed with colon cancer
- 1 sibling was diagnosed with ovarian cancer

Menstrual and Obstetrical History:

Patient is a G5P5, with a TPAL score of 5005. Menarche at the age of 14 years old with 4 days
in duration and with an interval of 28 days. Menopause for 28 years at the age of 52.
- May 24, 1959 – NSD no complications
- October 17, 1961 – NSD no complications
- October 29, 1963 – NSD no complications
- August 10, 1966 – NSD no complications
- July 29, 1968 – NSD no complications
Patterns of Functioning by Gordon-
Client’s response, Analysis and
Interpretation
Complete Physical assessment
Date performed: November 11, 2018
Time: 1:00 PM
Performed by: Paoline G. Medalla, Mario Krisanto R. Magtaka

Upon physical assessment the patient is awake and alert, coherent,

oriented to time, place. Intact remote, recent, and immediate memory.
Cooperative and not in cardiorespiratory distress, looks appropriate
for her age.
Vital Sign taken and recorded as follows:

BP: 140/70 mmHg

PR: 90 bpm
RR: 20 cpm
T: 36.9 C
Weight: 61 kg
Height: 1.48 m
BMI: 27.85 (overweight)
BP: 170/110 mmHg PR: 88 bpm RR: 24 cpm Temp: 37 C

HEENT: pink palpebral conjunctivae, anicteric sclera, no nasoaural discharge,

no tonsillopharyngeal congestion

NECK: supple neck, no neck vein distention, no cervical lymphadenopathy

CHEST: symmetrical chest expansion, no retraction, no lagging

LUNGS: vesicular breath sounds, no crackles, no wheezes

HEART: adynamic precordium, normal rate, regular rhythm, no murmur

BREAST: symmetrical contour, no dimpling, no palpable mass, no

tenderness, no abnormal nipple discharge
CRANIAL NERVE
Growth and Development Pattern
Changes In The Body

Weight Decline. If in middle age, adults tend to gain weight due to increasing fat deposits in the
body; in old age, adults begin to lose weight as muscle tissue in the body die. It is not clear,
however, if in old age, fat burn alongside significant muscle tissue loss, but presumably because
of lower activity level and lower food consumption, fat get used up faster than normal, thus also
lowering the amount of fat in the body.

Bone Tissue Loss. Not only the muscles die out, but also the bone tissues. Declining estrogen
production in menopausal women during middle age could probably explain why 2/3 of women in
old age have osteoporosis.

Stopped Dendritic Growth. At old age, dendrites grow at significantly lower rate than normal,
and then stop growing at the 90s.

Chronic Diseases. Chronic diseases those that start slow but last long become common in late
adulthood. The most common chronic disease among old-age adults in the US is arthritis, while
the second most common is hypertension (or rising blood pressure). Furthermore, old-age adults
have increased risk for Alzheimer's disease, and the percentage doubles every after 5 years.
Emotional Development in Late Adulthood

Includes achieving what Erikson called Ego Integrity: The feeling that one’s life has been
meaningful, Ego Integrity vs. Despair – feelings of regrets or bitterness about past
mistakes, missed opportunities, or bad decisions; a sense of disappointment in life
Life review - involves looking back on one’s life experiences and evaluating them
Integrity versus despair -individuals engage in a life review that is either positive
(integrity) or negative (despair)
 COURSE IN THE WARD

Day 1: Upon admission

• Vital signs: BP: 130/80 Heart Rate: 60 RR: 18 Temperature: 36.5 degrees Celsius O2Sat:
96%.
•Patient had a globular, non-distended, non-tender, but firm abdomen.
• Was put on soft diet
•X-ray (October 30, 2018) impression: by basal interstitial pneumonia and/or fibrosis,
cardiomegaly, atheromatous aorta, osteodegenerative changes.
•The plan was to hold clopidogrel and procedure to be performed is lower anterior
resection with possible colostomy.
Day 2:
• Vital signs: BP: 130/70 Heart Rate: 60 RR: 18 Temperature: 36.5 degrees Celsius O2Sat:
96%.
• Referred to cardiology and oncology for co management for Carcinoembryonic Antigen
(CEA) Serum Glutamic-Pyruvic Transaminase (SGPT), serum glutamic oxaloacetic
transaminase (SGOT), Total Bilirubin, B1 and B2 prior to OR, and for repeat CEA post
operation.

Day 3:
• Vital signs: BP: 120/70 Heart Rate: 72 RR: 18 Temperature: 36.6 degrees Celsius O2Sat:
96%.
•The plan is the continue present management.

Day 4:
• The patient was seen and examined with no subjective complaints with the following
vital signs: BP: 110/70 Heart Rate: 67 RR: 19 Temperature: 36.5 degrees Celsius O2Sat:
97%.
•On soft diet and to continue management.
Day 5:

• Was seen and examined with subjective complaint of burning sensation in the anal area.
• Vital signs: BP: 130/80 Heart Rate: 76 RR: 20 Temperature: 36.6 degreces Celsius O2Sat:
99%
• On soft diet and to continue medication.
• Laboratory test for repeat were Na, K, Crea and CBC

Day 6:
• Was seen and examined with subjective complaint of burning sensation in the anal area.
• Vital signs: BP: 110/90 HR: 79 RR: 20 Temperature: 36.5 degrees Celsius O2 Sat: 97%
• Laboratory results creatinine 61.0 umol/L, potassium 4.9 mmol/L, sodium 138.0
mmol/L, hemoglobin 128 g/l, hematocrit 0.405 L/L, MCV 85.8 fL, MCHC 316 g/L, platelet
count 440, WBC 12.41, neutrophils 0.578, lymphocytes 0.289, monocytes 0.065,
eosinophils 0.061, basophils 0.007.
• On soft diet, continue present management, possible options to preserve rectal function
1) long cocurse chemo RT, 2) systemic chemo > LCCRT > Surgery, CP clearance
Day 7:

• Seen and examined with a subjective complaint of burning sensation of anal area,
exacerbated by bowel movement post castor oil and fleet enema, no headache, no fever,
bloatedness or hematochezia.
• Vital signs: BP: 130/80, HR: 84, RR:20, Temperature: 36.9 degrees celsius O2 sat: 96%*
CP cleared, schedule for low anterior resection possible colostomy tomorrow.
• Give cefoxitin 1g TIV ANST 1 hour prior to OR, give castor oil 30ml at 4pm and 8pm
today.
• Give fleet enema tomorrow.
• Prepare 1 unit PRBC properly typed and crossmatched for OR use.
• Pre-anesthesia order: NPO by 7am IVF: D5NSS 1L x 50cc/hr once on NPO. Pre-meds:
esomeprazole 40mg TIV 30 mins prior to NPO (6:30am) meds to OR: Fentanyl #1,
Rocuronium #1
Day 8:

• Seen and examined with a subjective complaint of pain on surgical site 3/10
• Vital signs: BP: 110/70 HR: 81 RR: 19 Temperature: 36.8 O2sat: 95%.
• S/P low anterior resection, loop ileostomy. Attached to pulse oximeter, cardiac monitor
and O2 at 3LPM via nasal cannula.
• Medication esomeprazole 40 mg TIV while on NPO, Ketorolac 30mg TIV Q6 x 4 doses,
epidural meds – morphine sulfate 2mg/100cc OD 40 AROD, continue cefoxitin 1g TIV Q8
fL, MCHC 313g/L, platelet count 384x10^9/L, WBC 19.13x10^9L neutrophiles 0.903,
lymphocytes 0.054, monocytes 0.041, eosinophils 0.000, basophils 0.002
Day 9:
• Seen and examined with a subjective complaint of pain on surgical site 7/10, S/P low
anterior resection loop, ileostomy
• Vital signs: BP: 110/60 HR: 77 RR: 18 Temperature: 36.7 degrees celsius O2sat: 96%.
• Maintained on NPO, IVF and IV medications are continued, deep breathing exercises and
early ambulation encouraged.
• Resume the following medications once on diet: amlodipine 5mg/tab OD, atorvastatin
10mg/tab OD clopidogrel 75mg/tab OD once okay with surgery
Day 10:
• S/p low anterior recetion, loop ileostomy, patient was seen and examined with the
following subjective complaints, pain on surgical site 5/10
• Vital signs: BP: 110/70 HR: 83 RR: 20 Temperature: 36.6 O2sat: 98%.
• She was maintained on NPO, IVF and IV medications were continued, awaiting
histopathology result

Day 11:
• S/p low anterior resection, loop ileostomy, the patient was seen and examined with a
subjective complaint of pain on surgical site 4/10
• Vital signs: BP: 120/80 HR: 68 RR: 18 Temperature: 36.5 degrees celsius O2sat: 96%.
• Epidural catheter was removed, blue tip was shown and explained to patient, clear
liquid diet, IVF and IV medications were continued, still awaiting histopath

Day 12:
• S/p low anterior resection, loop ileostomy, the patient was seen and examined with a
subjective complaint of pain on surgical site 4/10
• Vital sign as follows BP: 120/80 HR: 68 RR: 18 Temperature: 36.5 O2sat: 96%.
• Clear liquid diet, IVF and IV medications were continued, still awaiting histopath result.
Day 14:

• S/p low anterior resection, loop ileostomy, patient was seen and examined with the
following subjective complaint, pain on surgical site 6/10
• Vital signs of BP: 130/70 HR: 70 RR: 18 Temperature: 36.6 degrees celsius O2sat: 98%
• With histopathology result of biopsy, rectal tissue: adenocarcinoma, well differentiated.
• Suggest to resume clopidogrel if ok with surgery low salt, low fat diet.

Day 15:

• S/p low anterior resection, loop ileostomy, patient was seen and examined with the
following subjective complaint, pain on surgical site 6/10
• Vital signs of BP: 140/80 HR: 89 RR: 19 Temperature: 36.5 degrees celsius, O2sat: 95%.
• Tramadol was given 50mg TIV decreased IVF to KVO and medications shifted to
cefuroxime 500mg/tab.
• Tramadol + Paracetamol (TDL plus), tab 98. For CBC, K+ with the following result RBC
4.32x10^12/L, hemoglobin 119.0 g/L, hematocrit 0.370 L/L, platelet count 461x10^19/L,
WBC 18.41x10^9/L, potassium 3.14 mmol/L
Day 16:

• S/p low anterior resection, loop ileostomy, patient was seen and examined with no
subjective complaint
• Vital sign were as follows BP: 130/80 HR: 87 RR: 19 Temperature: 36.6, O2sat: 96%
O2sat: 96%.
• Started KCl tablets 2 tabs 3x a day, ambulation and deep breathing exercises were
encouraged – IV fluids to consume then shift to heplock.
• Inform oncology service regarding official biopsy result, continue present diet and
medication, for repeat potassium after third dose of KCL tablet, hold KCl tablets after
third dose
 CT WHOLE ABDOMEN
(TRIPLE CONTRAST)
DATE: October 23, 2018

IMPRESSION:
Irregular rectal wall thickening with adjacent lymphadenopathy, likely neoplastic
in nature. Tissue correlation is advised.
Right hepatic nodules, probably a cyst
Dilated intrahepatic vascular structure, probably aneurysm dilation of a left
portal vein branch. A dedicated study may be done for further evaluation if
clinically warranted.
Bilateral renal cysts (Bosniak 1)
Atherosclerotic vessel disease
Degenerative osseous changes with multi-level disc disease
Thoracolumbar dextroscliosis
Subsegmental atelectasis versus parenchymal fibrosis, both lung bases
 DEPARTMENT OF RADIOLOGY
ROENTGENOGRAPHIC REPORT
DATE: October 30, 2018

CHEST

Streaky densities are seen in both lung base. Pulmonary vascular markings are
within normal limits. Heart is enlarged. Aorta is calcified. Diaphragm is
unremarkable. Vertebral osteophytes are seen.

IMPRESSION
BIBASAL INTERSTITIAL PNEUMONIA AND /OR FIBROSIS
CARDIOMEGALY
ATHEROMATOUS AORTA
OSTEODEGENERATIVE CHANGES