Colon Cancer (Diagnosis + Treatment)
Hematological / Oncological
- Colorectal cancer (CRC) (comprised of colon cancer and rectal cancer) is the 3rd most common cancer diagnosis (excluding non-melanoma skin cancers) in Canada.
- Up to 40% of those individuals may receive their diagnosis through the emergency department (ED).
- One study found that those who were diagnosed through the ED have a nearly twofold mortality risk increase.
- Of those with CRC, up to 55% visit the ED within 12 months, and 69% of those are admitted.
- British Columbia offers screening for colon cancer, performed by primary care providers as per guidelines from the BC Cancer Agency.
- If presenting with symptoms, the colon cancer is likely more advanced in staging
- Common symptoms include hematochezia, abdominal pain, or change in bowel habits.
- Less common symptoms include anorexia, weight loss, nausea/vomiting, malaise
- Red flags for more advanced or metastatic disease include right upper quadrant pain, abdominal distension, early satiety, supraclavicular adenopathy, or periumbilical nodules
- Emergent cases may present with obstruction, hemorrhage or bowel perforation
- General physical examination, including digital rectal exam
- There is no diagnostic role for routine laboratory investigations although screening for anemia seems reasonable.
- Liver function tests should not be used to detect liver metastases, due to their low sensitivity
- If clinically suspected plain films for obstruction/perforation only if CT not available
- A CT of the abdomen and pelvis is helpful for investigating tumor-related complications such as obstruction, perforation, or fistula formation.
- Tumour markers such as carcinoembryogenic antigen (CEA) should not be used as a diagnostic tool for CRC due to low sensitivity and limited specificity
- Age (increases greatly > age 50)
- Sex (males>females)
- Family history of colorectal cancer
- Hereditary cancer syndrome (e.g. Lynch syndrome)
- High intake of red or processed meat
- High alcohol consumption
- Smoking history
- Inflammatory bowel disease
- Ashkenazi ethnicity
Differential Diagnostic Considerations:
- Due to its nonspecific symptoms, the differential considerations for colon cancer include other malignancies, as well as benign lesions such as hemorrhoids, diverticulitis, infection, or inflammatory bowel disease
- If the patient is presenting with emergent symptoms such as perforation or obstruction acute surgical consult is warranted
- For acute GI bleed, a colonoscopy or CT angiography is indicated.
- In hemodynamically unstable patients, CT angiography is preferred over colonoscopy.
- If the patient is presenting with non-emergent symptoms/signs of colorectal cancer, referral to a gastroenterologist should be made in order to organize a colonoscopy
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
A colonoscopy is an appropriate diagnostic investigation for CRC in both asymptomatic and symptomatic patients. A meta-analysis of 25 studies revealed a miss rate of 5.3% in symptomatic patients and 4 studies showed a miss rate of between 2-6% in asymptomatic patients.
Government of Canada. (2019, December 9). Colorectal cancer. Retrieved November 17, 2021 from https://www.canada.ca/en/public-health/services/chronic-diseases/cancer/colorectal-cancer.html
Cappell, M.S. (2008). Pathophysiology, Clinical Presentation, and Management of Colon Cancer. Gastroenterology clinics of North America, 37(1), 1-24. https://doi.org/10.1016/j.gtc.2007.12.002
Baer, C., Menon, R., Bastawrous, S., & Bastawrous, A. (2017). Emergency Presentations of Colorectal Cancer. The Surgical clinics of North America, 97(3), 529–545. https://doi.org/10.1016/j.suc.2017.01.004
Walls, R.M., Hockberger, R.S., & Gausche-Hill, M. (2018). Rosen’s Emergency medicine: concepts and clinical practice (9th ed.). Elsevier.
BC Cancer. (n.d.). Colorectal. Retrieved November 19, 2021 from http://www.bccancer.bc.ca/health-info/types-of-cancer/digestive-system/colorectal
Macrae, F.A., Parikh, A.R., & Ricciardi, R. (2021). Clinical presentation, diagnosis, and staging of colorectal cancer. UpToDate. Retrieved November 17, 2021 from https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-staging-of-colorectal-cancer
BC Cancer. (2012, September 5). Retrieved November 19, 2021 from (http://www.bccancer.bc.ca/health-professionals/clinical-resources/cancer-management-manual/gastrointestinal/colon#Diagnostic-and-Staging-Work-Up-colon)
Bass, G., Fleming, C., Conneely, J., Martin, Z., & Mealy, K. (2009). Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients. Diseases of the colon and rectum, 52(4), 678–684.
Weidner, T. K., Kidwell, J. T., Etzioni, D. A., Sangaralingham, L. R., Van Houten, H. K., Asante, D., Jeffery, M. M., Shah, N., & Wasif, N. (2018). Factors Associated with Emergency Department Utilization and Admission in Patients with Colorectal Cancer. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 22(5), 913–920. https://doi.org/10.1007/s11605-018-3707-z
Weithorn, D., Arientyl, V., Solsky, I., Umadat, G., Levine, R., Rapkin, B., Leider, J., & In, H. (2020). Diagnosis Setting and Colorectal Cancer Outcomes: The Impact of Cancer Diagnosis in the Emergency Department. The Journal of surgical research, 255, 164–171. https://doi.org/10.1016/j.jss.2020.05.005
Nasseri, Y., & Langenfeld, S. J. (2017). Imaging for Colorectal Cancer. The Surgical clinics of North America, 97(3), 503–513. https://doi.org/10.1016/j.suc.2017.01.002
Kim, B. S., Li, B. T., Engel, A., Samra, J. S., Clarke, S., Norton, I. D., & Li, A. E. (2014). Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World journal of gastrointestinal pathophysiology, 5(4), 467–478. https://doi.org/10.4291/wjgp.v5.i4.467
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 07, 2021
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