Change In Bowel Habit Station

Presenting Complaint: Santiago presents with a 3-month history of changes in his bowel habits, including occasional blood in stool.

Quote: "I've noticed my toilet habits have changed. Sometimes, there's blood when I go, which has really got me worried."

HPC and symptoms (SOCRATES):

- Site: Lower abdomen; "It feels like the cramps are right down low in my stomach."

- Onset: Gradual onset, worsening over the past 3 months; "It's been getting worse over the last few months."

- Character: Intermittent cramping; "It comes and goes, but it's like a bad cramp when it hits."

- Radiation: Does not radiate; "No, it just stays in one place really."

- Associated Symptoms: Occasional blood in stool, weight loss, tenesmus, constipation; "Besides the constipation, I’ve lost a good bit of weight without trying, and I’ve now had blood from the back passage for 4 weeks. Sometimes I feel as if I have to go even when there’s nothing coming out."

- Timing: Most severe in the morning; "Mornings are the worst, especially right after I wake up. But it is near constant."

- Exacerbating and Relieving Factors: No specific exacerbating factors noted; minimal relief with over-the-counter pain medication. "Nothing seems to make it much worse, but painkillers don’t do much to help either."

- Severity: Moderate severity; "It's bad enough to make me really worry, you know? 6/10."

Systemic Symptoms (answer only if asked):

- Unintended weight loss; "I've lost nearly 10 kilos without even trying."

- Generalised fatigue; "I just feel tired all the time lately."

- Occasional night sweats; "Some nights, I wake up drenched for no reason. My wife says I’m soaking the sheets."

- No N+V.

- No fevers, coughs, chills, SOB, chest pain.

- Urinary history and details: Long-term mild LUTS due to BPH, no acute change.

- Sexual history and details: Santiago is in a monogamous relationship with his wife; no recent changes or concerns.

Past Medical History:

- BPH.

- No previous surgeries or hospitalisations.

Quote: "No, I've been pretty healthy all things considered. Rarely visited doctors before all this."

Drug History:

- Occasional ibuprofen for cramping, not regular.

- Tamsulosin.

- No long-term medications.

Quote: "I try to avoid taking medicines unless I really have to. Just some painkillers now and then for the cramps."

Allergies:

- No known drug allergies.

Family History: 

- Mother had unspecified cancer diagnosed at age 60.

- Father is healthy.

- Children healthy.

Quote: "Mum had some sort of cancer but I can’t remember exactly what.”

Social History:

- Occupation: Retired, previously a journalist.

- Married, living with wife, has 2 children and 5 grandchildren.

- Non-smoker.

- Occasional alcohol, socially (3-4 pints at weekends).

- Walks regularly, good functional status, iADLs.

- Healthy, balanced diet until recent changes due to symptoms.

- No recent travel.

Quote: "I've tried changing what I eat, thinking maybe it was something in my diet causing the issues."

Ideas, Concerns, and Expectations:

- Ideas: Worries that it might be cancer, given family history with mother.

- Concerns: Anxious about the potential diagnosis and impact on his family.

- Expectations: Wants a thorough investigation to identify the cause of his symptoms and appropriate treatment to manage them.

Quote: "Given my mum’s history and now this, I’m worried it's something serious."

Physical Examination:

Observations:

- Respirations: 16 breaths/min.

- Oxygen Saturation: 98% on room air.

- Blood Pressure: 130/85 mmHg.

- Pulse: 78 beats/min.

- Consciousness: Alert and oriented.

- Temperature: 37.1 Celsius.

- NEWS Total Score: 0

General Inspection:

- Appears mildly anxious.

- No obvious jaundice or skin lesions, slight pallor noted.

- No visible scars or marks indicating previous surgeries.

Hands:

- No clubbing or tremor.

- Capillary refill time <2 seconds.

- Regular pulse.

Face:

- Mild pallor noted.

- No jaundice or scleral icterus.

- Hydrated mucous membranes.

Neck:

- JVP not raised.

- No scars or palpable lymphadenopathy.

Chest:

- No spider angiomas or gynaecomastia.

- Percussion notes are resonant.

- Normal heart sounds, no added sounds.

- Lungs clear on auscultation, no crackles.

Abdomen:

- Mild distension observed.

- No visible scars or striae.

- Soft on palpation, with mild tenderness over lower abdomen without rebound tenderness.

- No hepatomegaly or splenomegaly palpable.

- Bowel sounds present, normal on auscultation.

- No palpable masses.

Other:

- No peripheral or sacral oedema.

- Examination of lower limbs normal.

Digital Rectal Examination (DRE) (if asked about): A palpable mass is appreciated in the anterior wall of the rectum, approximately 6 cm from the anal verge. The mass is firm, irregular in shape, and measures approximately 4 cm in diameter. 

Prostate: No palpable abnormalities detected on examination of the prostate gland.

Choose EITHER examiner viva questions OR patient communication questions

Examiner Questions (1–6):

1. What is your differential diagnosis?

- Colorectal carcinoma – most important diagnosis to rule out with systemic symptoms of weight loss, night sweats and fatigue, examination findings of mass on DRE, age and sex demographics, lower GI bleeding.

- IBD – typically presents in a younger age demographic, can also present with weight loss and PR bleeding, however the age and examination findings (especially on DRE) make colorectal cancer more likely.

- Haemorrhoids – typically wouldn’t present with the systemic features in the history, can sometimes be identified on examination. Mass on DRE here is highly suspicious for cancer.

- Diverticular disease – does present in older populations and associated with constipation and sometimes PR bleeding, however typically doesn’t present with the systemic features seen here.

- Benign polyps – again less likely due to presence of systemic features and DRE findings.

- IBS - less likely due to weight loss, blood in stools, systemic symptoms, examination findings. IBS is defined by change in stool frequency, form and pain relieved on defecation.

2. What initial investigations would you recommend for Santiago based on his presenting complaints and why?

- Bloods tests: FBC, iron studies and blood film may detect iron deficiency/microcytic anaemia, CRP may be slightly raised, baseline LFTs and U&Es, check tumour markers (CEA +/- CA 19-9). Clotting screen due to bleeding and for surgical planning.

- Colonoscopy to visualise the colon and identify any lesions + biopsy for histology (CT colonography if not possible).

- CT CAP for staging.

- MRI rectum/pelvis for rectal cancers only.

- Genetic referral/testing if relevant family history and familial cancer syndrome suspected.

3. What staging systems can be used in assessing colorectal carcinoma

- TNM system; detailed knowledge of each grade not required but should give general overview.

- Dukes (older system)

A – confined beneath muscularis propria (90% 5-year survival)

B – extends through muscularis propria (65%)

C – involvement of regional lymph nodes (30%)

D – distant metastasis (<10%)

4. Summarise the treatment options in the management of colorectal carcinoma

- MDT referral

- Depends on stage e.g. advanced metastatic for palliation vs curative surgery for limited disease.

- Surgery is the mainstay of curative treatment where appropriate and the operation depends on the location of the cancer e.g. right hemicolectomy, left hemicolectomy, sigmoid colectomy, anterior resection, abdominoperineal (AP) resection. Chemotherapy and radiotherapy can be used in adjuvant and neo-adjuvant treatment regimes, with palliative input in advanced disease. Radiotherapy is typically used in rectal cancer rather than colon cancer.

- Follow up in clinic, follow up colonoscopy.

5. What is the role of Carcinoembryonic Antigen (CEA) level in this context?

- CEA is a tumour marker that can be elevated in colorectal cancer and other conditions; Due to poor sensitivity and specificity it should not  be used for diagnostic purposes, however it can aid in assessing response to treatment and disease recurrence.

6. What are some familial cancer syndromes that you know of?

- Lynch Syndrome (HNPCC) – mutations in mismatch repair genes MLH1/MSH2, autosomal dominant, associated with colorectal, endometrial and gastric cancers.

- Familial Adenomatous Polyposis (FAP) – autosomal dominant, mutations in APC gene, development of many colonic polyps and 100% chance of colorectal carcinoma if left untreated; genetic testing and regular surveillance endoscopy + resection if polyps identified; also associated with duodenal and gastric tumours.

Patient Questions (1–3):

1. "Does this mean I definitely have cancer?" 

Possible answer - “At the moment we can’t say for sure, however your symptoms do suggest we should urgently investigate further with blood tests, scans and camera tests to rule out any serious conditions, including cancer. We will also refer your case to be discussed at an Multidisciplinary meeting of specialists to carefully plan further steps.”

2. "Am I going to be alright doctor? What are the outcomes like in bowel cancer?”

Possible answer – “I’m very sorry but at the moment with the limited information we have I can’t give you a certain answer. We will have a better idea once we’ve done some further investigations.

In general outcomes depend on how large the cancer has grown and what other structures in the body it has invaded or spread to, such as lymph nodes and other organs separate from the bowel. The larger the cancer and the more it has spread, the worse the outcome. If detected early on, outcomes can be very good.”

3. "What does the colonoscopy involve, and will it be painful?"

Possible answer - “A colonoscopy involves examining the inside of your colon using a long, flexible tube with a camera. It's usually done under sedation to make it as comfortable as possible for you, however it is not typically done under general anaesthetic due to the risks. To give us the clearest image, you will need to take a laxative beforehand to prepare your bowel.”