77 year-old Lady With Left Iliac Fossa Pain

Madam LGY,77 years old presented with left iliac fossa pain for the past 3 weeks radiating to the whole abdomen and constant. The pain has been there for the past 5 years but has increased in intensity in the past 3 weeks. She has tenesmus also for 3 weeks. She has altered bowel habits for the past 5 years where she passes 4-5times each day. There was no blood in the stools.She has associated dizziness and tiredness. She has loss of appetite and loss of weight and sleep is also disturbed.Patient was discharged while awaiting appointment for MRI.

On examination, the patient was comfortable and not in obvious pain.Her pulse rate was 52bpm and regular. There was pallor under her conjunctiva. On examination,her abdomen was distended but umbilicus was inverted. It was soft on palpation with slight guarding and tenderness at the left iliac fossa.

INVESTIGATION
Ultrasound:Bowel mass noted.
Colonoscope:Mass found at sigmoid colon,scope was unable to pass through.

FBC

RBC: 3.0X10¹² /L

Hb    :11g/dL

1. What are your differential diagnosis and provisional diagnosis?

2. How do we manage the patient ?

Differential Diagnosis:

1.Colorectal carcinoma

2.Diverticulitis

3.Perforated diverticula

Provisional Diagnosis

Sigmoid colon cancer

Simple Management Plan

To try colonoscopy again as outpatient

Discharge when pain subsides

Pain control- analgesics

If colonoscopy shows cancerous mass- biopsy

CT scan for TNM staging

LEARNING ISSUES

1.What are the risk factors for sigmoid colon cancer?

High fat with low fiber diet,Adoption of a western diet, over 50 years old of age, personal or family history of colorectal adenoma or carcinoma, Familial polyposis coli,HNPCC, Peutz-Jeghers syndrome, Juvenile polyposis syndrome, Inflammatory bowel disease. Males and females are equally affected.

2.What are the investigations used for sigmoid colon cancer?

Proctoscope or flexible sigmoidoscope are used initially.In patients with changed bowel habit and unexplained anaemia,colonoscopy or barium enema examination will be performed. CT scan or MRI are then performed to check if there is metastases to the liver,lung bone or local spread. If neither are available,chest X-ray can be performed to check for lung metastases and liver ultrasound for liver metastases.