Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

Intestinal Obstruction 2 to
Rectal Mass Probably Cancer s/p
Abdomino-peritoneal Resection of
Sigmoid with Colostomy Application
and Penrose Drain
In Partial Fulfillment of the
Requirements in the
NCM 107 Related Learning Experience

Presented by:
Roeder Max R. Pangramuyen
BSN IV
Group 7

Presented to:
Mr. Percival C. Verano
Clinical Instructor

December 15, 2013

I.

OBJECTIVES
A. GENERAL OBJECTIVE

After establishing a nurse-patient interaction, providing different nursing interventions

and care to the client and by thorough assessment and careful study about the patients
condition, student will gain knowledge, develop skills and enhance attitude through the
utilization of the nursing process on the care and management for the patient with
intestinal obstruction 2 to rectal mass probably cancer s/p abdomino-peritoneal
resection of sigmoid with colostomy application and penrose drain.

B.

SPECIFIC OBJECTIVES

1. Define what rectal cancer is.

2. Discuss the causes and risk factors for rectal cancer.
3. Study the diagnostic procedures and medical and surgical treatment of the
disease.
4. Trace the pathophysiology of the disease.
5. Determine the health status of the patient through:
i. General Data
ii. Physical Assessment
iii. Present History of Illness
iv. Family Health History
v. Personal and Social History
6. Establish a good nurse-patient relationship.
7. Analyze laboratory results and correlate it with the patients present condition.
8. Familiarize self to some medical and diagnostic procedures related to the
patients present condition.
9. Determine the relevance of the drugs or medications to the patients condition.
10. Formulate nursing diagnoses and provide the necessary nursing management
and intervention based on the clinical manifestations presented by the patients
needs and problems.
11. Evaluate the effectiveness of the nursing care plan and medical management.

II.

INTRODUCTION
Bowel obstruction (or intestinal obstruction) is a mechanical or functional

obstruction of the intestines, preventing the normal transit of the products of digestion. It
can occur at any level distal to the duodenum of the small intestine and is a medical
emergency. The condition is often treated conservatively over a period of 25 days with
the patient's progress regularly monitored by an assigned physician. Surgical
procedures are performed on occasion however, in life-threatening cases, such as
when the root cause is a fully lodged foreign object or malignant tumor.

On the other hand, 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%).

The rectum is the lower part of the colon that connects the large bowel to the
anus. The rectum's primary function is to store formed stool in preparation for
evacuation. Like the colon, the3 layers of the rectal wall are as follows; Mucosa: This
layer of the rectal wall lines the inner surface. The mucosa is composed of glands that
secrete mucus to help the passage of stool. Muscularispropria: This middle layer of the
rectal wall is composed of muscles that help the rectum keep its shape and contract in a
coordinated fashion to expel stool. Mesorectum: This fatty tissue surrounds the rectum.
In addition to these 3 layers, another important component of the rectum is the
surrounding lymph nodes (also called regional lymph nodes). Lymph nodes are part of
the immune system and assist in conducting surveillance for harmful materials
(including viruses and bacteria) that may be threatening the body. Lymph nodes
surround every organ in the body, including the rectum.
Of the 150,000 cases of colorectal cancer diagnosed each year in the United
States, more than 40,000 people are diagnosed with rectal cancer. The most common
type of rectal cancer is adenocarcinoma, which is a cancer arising from the mucosa.
Cancer cells can also spread from the rectum to the lymph nodes on their way to other
parts of the body.
Like colon cancer, the prognosis and treatment of rectal cancer depends on how
deeply the cancer has invaded the rectal wall and surrounding lymph nodes. However,
although the rectum is part of the colon, the location of the rectum in the pelvis poses
additional challenges in treatment when compared with colon cancer.

Furthermore, According to the most recent estimates, colorectal cancercancer

that develops in the colon or the rectumis the third most common cancer in men
(663,000 cases, 10 percent of the total) and the second in women (571,000 cases, 9.4
percent of the total) worldwide.

Over 600,000 deaths from colorectal cancer are estimated occurring annually
worldwide, accounting for 8 percent of all cancer deaths, making it the fourth most
common cause of death from cancer.

With at least 8,000 new cases being diagnosed every year in the Philippines,
colorectal cancer is now the fourth leading cause of cancer-related deaths in the
country, according to the Philippine Cancer Society.

However, not many Filipinos knew that if found in its early stages, colorectal
cancer is one of the most curable of cancers (this type of cancer usually develops over
many years and has a long precancerous stage).

III.

REVIEW OF ANATOMY AND PHYSIOLOGY OF COLON, RECTUM AND

ANUS

Knowledge of anatomy and physiology allows for easy understanding of most

anorectal pathology. Likewise anatomy and physiology is important for managing
certain clinical conditions involving the colon such as constipation, carcinoma, ischemic
and diverticular disease. A review of anatomy and physiology of the colon, rectum, and
anus with clinical correlation is presented.
Colon
The colon is approximately five feet (1.5 meters) in length, begins at the ileocecal
valve, and ends at the rectosigmoid junction. Arterial blood supply to the colon from
cecum to splenic flexure is through the superior mesenteric artery which gives rise to
the ileocolic, right colic, and middle colic arteries. The left and sigmoid colon is supplied
by the inferior mesenteric artery which gives rise to the left colic and sigmoidal arteries.
There can be several anatomic variations in the colic arteries including absent middle
colic artery, absent right colic artery, common trunk for right and ileocolic artery, and the
presence of an Arc of Riolan between the middle and left colic artery. The colonic wall
histologically from lumen outward consists of: (1) a simple columnar epithelium which
forms crypts, (2) lamina propria, (3) muscularis mucosa, (4) submucosa, (5)

muscularispropria formed by an inner circular and outer longitudinal layer of smooth

muscle, and (6) serosa.
The typical colonic malignancy is an adenocarcinoma. Once the neoplastic
epithelial cells penetrate the muscularis mucosa and into the submucosa, a malignant
(the ability to metastasize) adenocarcinoma is formed. The mainstay for treatment is
operative resection of the involved colonic segment along with the draining lymph nodes
located in the mesentery. Neoplastic cells confined by the muscularis mucosa are
termed carcinoma-in-situ or severe dysplasia and are not as yet malignant thereby
typically eliminating the need for segmental colonic resection.
The outer longitudinal smooth muscle of the colon thickens in three locations
called tenia coli. The rectosigmoid junction is the point at which the three tenia fan out
and form a complete outer longitudinal layer. This anatomic point has clinical
significance. Carcinomas proximal to this point are colonic; whereas distal tumors are
rectal and as such may benefit from adjuvant radiation therapy. Likewise, operative
resection for classic sigmoid diverticular disease should include the rectosigmoid
junction with the anastomosis located at the upper rectum.
The function of the colon is (1) absorption of water and electrolytes, and (2)
propulsion and storage of unabsorbed fecal waste for evacuation. Approximately one
liter of fluid chyme enters the cecum each day with an average of only 100cc excreted
in the feces. Parasympathetc innervation by preganglionic vagal fibers and pelvic fibers
result in colonic motility. Sympathetic innervation by the superior mesenteric plexus,
inferior mesenteric plexus, and the hypogastric plexus inhibits colonic motility. It
appears that the major control of motility depends on the colonic wall intrinsic plexus
(myenteric or Auerbachs/submucous or Meissners). An absence of intrinsic plexuses
occurs in Hirschsprungs Disease resulting in tonic wall contraction and functional
obstruction.
Disorders of colonic motility including irritable bowel syndrome, slow-transit
constipation, colonic pseudo-obstruction, and post-operative ileus are poorly understood
but may represent an imbalance in this autonomic imput to the smooth muscle wall of
the colon. Normal colon transit arbitrarily results in one to three bowel movements per
day to one bowel movement every 3 days. Colonic transit is measured by obtaining
abdominal radiographs after ingesting radiopaque markers. Markedly constipated
patients with slow-transit constipation (markers remaining disbursed throughout the
colon after 5 days) but with normal defecation mechanics may benefit from abdominal
colectomy.

Rectum
The rectum is the terminal portion of the large intestine beginning at the
confluence of the three tenia coli of the sigmoid colon and ending at the anal canal.
Generally the rectum is 15 cm in length, is intraperitoneal at its proximal and anterior
end, and is extraperitoneal at its distal and posterior end. The epithelial lining or mucosa
of the rectum is of a simple columnar mucous secreting variety. Therefore, the
characteristic malignancy of the rectum is an adenocarcinoma.
Anal Canal
The anal canal begins a few centimeters proximal to the classic and well
visualized dentate line and it ends at the anal verge. The anal canal is about 5 cm in
length. Histologically the proximal end of the anal canal is the point at which the
columnar epithelium of the rectum becomes a transitional epithelium. This epithelium
transitions to a stratified squamous variety at the dentate line. The distal most end of the
anal canal is the anal verge which is the point where the stratified squamous epithelium
becomes true skin marked by the presence of hair follicles and sweat glands. The anal
verge is readily identified by noting the point at which hair shafts are seen. The anoderm
is a term used to describe the zone between the dentate line and the anal verge.
Perianal skin then describes the anatomic area beyond the anal verge. Malignancies of
the perianal skin are typical skin cancers usually squamous cell carcinomas. Anal canal
carcinomas are described as epidermoid carcinoma, squamous cell carcinoma,
cloacogenic carcinoma, or baseloid carcinoma depending on their particular histologic
features. The importance of locating and anatomically defining the particular malignancy
of the anorectal region is in their treatment.
The dentate line is a clearly observed undulating line near the midpoint of the
anal canal. It is at this location where the anal crypts are found. Anal glands secrete
mucus that empty into the anal crypts by way of anal ducts. The pathologic significance
of anal glands, ducts, and crypts is infection. Cryptoglandular infection can occur
leading to anorectalabcess and its sequelaeanorectal fistula.
Autonomic nerves supply the rectum and upper anal canal whereas somatic
nerves supply the lower anal canal and perianal skin. Rectal polyps, tumors, and
mucosa can be biopsied without anesthesia. Internal hemorrhoids located beneath the
autonomically innervated upper anal canal classically present as painless bleeding and
can be treated without anesthesia using simple fixation techniques. Conversely, lesions
of the distal anal canal and perianal skin such as anal fissure and external hemorrhoids
are painful.
The blood supply to the anorectal region is rich. The terminal branch of the inferior
mesenteric artery is the superior hemmorrhoidal (rectal) artery. The superior

hemorrhoidal artery branches into right and left branches; the right branch further
divides into anterior and posterior branches. The classic hemorrhoidalplexes are then
located at the left later, right anterolateral, and right posterolateral locations. The middle
hemorrhoidal (rectal) arteries are direct branches from the internal iliac arteries. The
inferior hemorrhoidal (rectal) arteries are branches off the pudendal arteries which also
arise from the internal iliac arteries. The superior, middle, and inferior hemorrhoidal
arteries then complete the rich arterial supply to the anorectal region.
The venous drainage of the anorectal region consists of superior hemorrhoidal
veins draining into the portal venous system (by way of the inferior mesenteric vein) and
the middle and inferior hemorrhoidal veins draining into the caval system (by way of the
internal iliac veins). Thus the anorectal region can provide a means of portal
decompression when portal hypertension exists.
The main pathologic significance of the anorectal vasculature is in hemorrhoidal
disease. Two hemorrhoidalplexes are formed in each of the classic locations (left
lateral, right anterolateral, and right posterolateral). The internal (superior) hemorrhoidal
plexus is proximal to the dentate line and the external (inferior) hemorrhoidal plexus is
located distal to the dentate line.
The musculature of the anorectal region forms the anal sphincter mechanism.
The internal anal sphincter is smooth, involuntary muscle and is simply the terminal
thickening of the inner visceral smooth muscle layer of the rectal wall. The role of the
internal anal sphincter in fecal continence may be for flatus control. Division of the
internal anal sphincter is the operative treatment for anal fissure and most often has no
effect on fecal continence.
The external anal sphincter is skeletal muscle and thus under voluntary control.
There is a distinct anatomic plane between the internal and external anal sphincter
occupied by longitudinal connective tissue fibers continuous with the outer longitudinal
muscle wall of the rectum. The external anal sphincter is arbitrarily separated into
subcutaneous, superficial and deep components. The puborectalis muscle is felt to
represent the deep component of the external anal sphincter and appears to be the
most significant muscle for maintainting fecal continence. The puborectalis muscle
originates and inserts on the pubis after encircling the rectum at the anorectal junction.
When contracted the puborectalis muscle creates a 90 degree angle between the anal
canal and the rectum. Puborectalis relaxation allows the anorectal angle to approach
180 degrees which in combination with relaxation of the other components of the
external allows defecation.

Lymphatic drainage of the rectum travels along the internal iliac vessels as well
as the aorta. Lymphatic drainage of the anal canal can follow the internal iliac vessels
but also may travel through channels in the inguinal region.

IV.

OVERVIEW OF THE DISEASE

A. Definition
Bowel obstruction or Intestinal Obstruction is a partial or complete blockage
of the bowel that prevents the contents of the intestine from passing through.
Rectal cancer or the cancer of the rectum is the disease characterized by the
development of malignant cells in the lining or epithelium of the rectum. Malignant cells
have changed such that they lose normal control mechanisms governing growth. These
cells may invade surrounding local tissue or they may spread throughout the body and
invade other organ systems.
According to National Cancer Institute as cited at www.cancer.gov, rectal cancer is the
cancer that forms in the tissues of the rectum (the last several inches of the large
intestine closest to the anus).

B. Pathophysiology

Nearly all colorectal malignancies are adenocarcinoma that begins as

adenomatous polyps. Most tumors develop in the rectum and sigmoid colon, although
any portion of the colon may be affected. The tumor typically grows undetected,
producing few symptoms. By the time symptoms occur, the disease may have spread
into the deeper layers of the bowel tissue to adjacent organs. Cancer spreads by direct
extension to involve the entire bowel circumference, thesubmucosa, and the outer
bowel wall layers. Neighboring structures such as liver, greater curvature of the
stomach, duodenum, small intestine, pancreas, spleen, genitourinary tract, and
abdominal wall also may be involved by direct extension. Metastasis to regional lymph
nodes is the most common form of tumor spread. This is not always an orderly process;
distal nodes may contain cancer cells from the primary tumor may also spread by the
way lymphatic system or circulatory system to secondary sites such as liver, lungs,
brain, bones and kidneys. seeding, of the tumor to other areas of the peritoneal cavity
can occur when the tumor extends through the serosa or during surgical resection.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.

Lymph system. The cancer spreads from where it began by getting into the lymph
system. The cancer travels through the lymph vessels to other parts of the body.

Blood. The cancer spreads from where it began by getting into the blood. The cancer
travels through the blood vessels to other parts of the body.
Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis.
Cancer cells break away from where they began (the primary tumor) and travel through
the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through the lymph
vessels, and forms a tumor (metastatic tumor) in another part of the body.

Blood. The cancer gets into the blood, travels through the blood vessels, and forms a
tumor (metastatic tumor) in another part of the body.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if
rectal cancer spreads to the lung, the cancer cells in the lung are actually rectal cancer
cells. The disease is metastatic rectal cancer, not lung cancer.
The following stages are used for rectal cancer:
Stage 0 (Carcinoma in Situ)
Stage 0 (rectal carcinoma in situ). Abnormal cells are shown
in the mucosa of the rectum wall.
In stage

0, abnormal cells are

found

in

the mucosa (innermost layer) of the rectum wall. These

abnormal cells may become cancer and spread. Stage 0 is
also called carcinoma in situ.

Stage I

Stage I rectal cancer. Cancer has spread from the mucosa of

the rectum wall to the muscle layer.

In stage I, cancer has formed in the mucosa (innermost layer) of the rectum wall and
has spread to thesubmucosa (layer of tissue under the mucosa). Cancer may have
spread to the muscle layer of the rectum wall.

Stage II

Stage II rectal cancer. In stage IIA, cancer has spread through the muscle layer of the
rectum wall to the serosa. In stage IIB, cancer has spread through the serosa but has
not spread to nearby organs. In stage IIC, cancer has spread through the serosa to
nearby organs.
Stage II rectal cancer is divided into stage IIA, stage IIB, and stage IIC.
Stage IIA: Cancer has spread through the muscle layer of the rectum wall to
the serosa (outermost layer) of the rectum wall.
Stage IIB: Cancer has spread through the serosa (outermost layer) of the rectum wall
but has not spread to nearby organs.
Stage IIC: Cancer has spread through the serosa (outermost layer) of the rectum wall to
nearbyorgans.
Stage III
Stage III rectal cancer is divided into stage IIIA, stage IIIB, and stage IIIC.

Stage IIIA rectal cancer. Cancer may have spread through the mucosa of the rectum
wall to the submucosa and muscle layer, and has spread to one to three nearby lymph
nodes or tissues near the lymph nodes. OR, cancer has spread through the mucosa to
the submucosa and four to six nearby lymph nodes.
In stage IIIA:
Cancer may have spread through the mucosa (innermost layer) of the rectum wall to
thesubmucosa (layer of tissue under the mucosa) and may have spread to the muscle
layer of the rectum wall. Cancer has spread to at least one but not more than 3
nearby lymph nodes or cancercells have formed in tissues near the lymph nodes; or
Cancer has spread through the mucosa (innermost layer) of the rectum wall to the
submucosa (layer of tissue under the mucosa). Cancer has spread to at least 4 but not
more than 6 nearby lymph nodes.

Stage IIIB rectal cancer. Cancer has spread through the muscle layer of the rectum wall
to the serosa or has spread through the serosa but not to nearby organs; cancer has
spread to one to three nearby lymph nodes or to tissues near the lymph nodes. OR,
cancer has spread to the muscle layer or to the serosa, and to four to six nearby lymph
nodes. OR, cancer has spread through the mucosa to the submucosa and may have
spread to the muscle layer; cancer has spread to seven or more nearby lymph nodes.
In stage IIIB:
Cancer has spread through the muscle layer of the rectum wall to the serosa (outermost
layer) of the rectum wall or has spread through the serosa but not to nearby organs.
Cancer has spread to at least one but not more than 3 nearby lymph nodes or
cancer cells have formed in tissues near the lymph nodes; or
Cancer has spread to the muscle layer of the rectum wall or to the serosa (outermost
layer) of the rectum wall. Cancer has spread to at least 4 but not more than 6 nearby
lymph nodes; or

Cancer has spread through the mucosa (innermost layer) of the rectum wall to
the submucosa(layer of tissue under the mucosa) and may have spread to the muscle
layer of the rectum wall. Cancer has spread to 7 or more nearby lymph nodes.

Stage IIIC rectal cancer. Cancer has spread through the serosa of the rectum wall but
not to nearby organs; cancer has spread to four to six nearby lymph nodes. OR, cancer
has spread through the muscle layer to the serosa or has spread through the serosa but
not to nearby organs; cancer has spread to seven or more nearby lymph nodes. OR,
cancer has spread through the serosa to nearby organs and to one or more nearby
lymph nodes or to tissues near the lymph nodes.
In stage IIIC:
Cancer has spread through the serosa (outermost layer) of the rectum wall but has not
spread to nearby organs. Cancer has spread to at least 4 but not more than 6
nearby lymph nodes; or
Cancer has spread through the muscle layer of the rectum wall to the serosa (outermost
layer) of the rectum wall or has spread through the serosa but has not spread to nearby
organs. Cancer has spread to 7 or more nearby lymph nodes; or
Cancer has spread through the serosa (outermost layer) of the rectum wall and has
spread to nearby organs. Cancer has spread to one or more nearby lymph nodes or
cancer cells have formed in tissues near the lymph nodes.

Stage IV
Stage IV rectal cancer is divided into stage IVA and stage IVB.

Stage IV rectal cancer. The cancer has spread through the blood and lymph nodes to
other parts of the body, such as the lung, liver, abdominal wall, or ovary.
Stage IVA: Cancer may have spread through the rectum wall and may have spread to
nearbyorgans or lymph nodes. Cancer has spread to one organ that is not near the
rectum, such as theliver, lung, or ovary, or to a distant lymph node.
Stage IVB: Cancer may have spread through the rectum wall and may have spread to
nearbyorgans or lymph nodes. Cancer has spread to more than one organ that is not
near the rectum or into the lining of the abdominal wall.

C. Causes and Risk Factors

Causes of Intestinal Obstruction
Obstruction of the bowel may due to:

A mechanical cause, which means something is in the way

Ileus, a condition in which the bowel doesn't work correctly but there is no
structural problem

Paralytic ileus, also called pseudo-obstruction, is one of the major causes of intestinal
obstruction in infants and children. Causes of paralytic ileus may include:

Bacteria or viruses that cause intestinal infections (gastroenteritis)

Chemical, electrolyte, or mineral imbalances (such as decreased potassium
levels)
Complications of abdominal surgery
Decreased blood supply to the intestines (mesenteric ischemia)

Infections inside the abdomen, such as appendicitis

Kidney or lung disease
Use of certain medications, especially narcotics

Mechanical causes of intestinal obstruction may include:

Adhesions or scar tissue that forms after surgery

Foreign bodies (eaten materials that block the intestines)
Gallstones (rare)
Hernias
Impacted stool
Intussusception (telescoping of one segment of bowel into another)
Tumors blocking the intestines
Volvulus (twisted intestine)

Causes and Risk Factors of Rectal Cancer

The exact causes of rectal cancer are not known. However, studies show that the
following risk factors of rectal cancer increase a person's chances of developing this
disease:

Age. Colorectal cancer is more likely to occur as people get older. More than 90
percent of people with this disease are diagnosed after age 50. The average age at
diagnosis is in the mid-60s.

Diet. Studies suggest that diets high in fat (especially animal fat) and low in calcium,
folate, and fiber may increase the risk of colorectal cancer. Also, some studies
suggest that people who eat a diet very low in fruits and vegetables may have a
higher risk of colorectal cancer. More research is needed to better understand how
diet affects the risk of colorectal cancer.

Polyps. Polyps are benign growths on the inner wall of the colon and rectum. They
are fairly common in people over age 50. Some types of polyps increase a person's
risk of developing colorectal cancer.
A rare, inherited condition, called familial polyposis, causes hundreds of polyps to
form in the colon and rectum. Unless this condition is treated, familial polyposis is
almost certain to lead to rectal cancer.

Personal medical history. Research shows that women with a history of cancer of
the ovary, uterus, or breast have a somewhat increased chance of developing

colorectal cancer. Also, a person who has already had rectal cancer may develop
this disease a second time.

Family medical history. First-degree relatives (parents, siblings, children) of a

person who has had colorectal cancer are somewhat more likely to develop this type
of cancer themselves, especially if the relative had the cancer at a patientng age. If
many family members have had colorectal cancer, the chances increase even more.

Genetic alterations: Changes in certain genes increase the risk of colorectal cancer.

Hereditary nonpolyposis colon cancer (HNPCC) is the most common type

of inherited (genetic) colorectal cancer. It accounts for about 2 percent of all
colorectal cancer cases. It is caused by changes in an HNPCC gene. About 3 out
of 4 people with an altered HNPCC gene develop colon cancer, and the average
age at diagnosis of colon cancer is 44.

Familial adenomatous polyposis (FAP) is a rare, inherited condition in

which hundreds of polyps form in the colon and rectum. It is caused by a change
in a specific gene called APC. Unless familial adenomatous polyposis is treated,
it usually leads to colorectal cancer by age 40. FAP accounts for less than 1
percent of all colorectal cancer cases.

Family members of people who have HNPCC or FAP can have genetic
testing to check for specific genetic changes. For those who have changes in
their genes, health care providers may suggest ways to try to reduce the risk of
colorectal cancer, or to improve the detection of this disease. For adults with
FAP, the doctor may recommend an operation to remove all or part of the colon
and rectum.

Ulcerative colitis or Crohn's disease. A person who has had a condition that
causes inflammation of the colon (such as ulcerative colitis or Crohn's disease)
for many years is at increased risk of developing colorectal cancer.

Cigarette smoking. A person who smokes cigarettes may be at increased risk of

developing polyps and colorectal cancer.

D. Signs and Symptoms

Signs and Symptoms of Intestinal Obstruction

Abdominal swelling (distention)

Abdominal fullness, gas
Abdominal pain and cramping
Breath odor
Constipation
Diarrhea
Inability to pass gas
Vomiting

Signs and Symptoms of Rectal Cancer

The development of tumors in the rectum or anal canal may change the consistency,
shape or frequency of bowel movements. The severity of the symptoms may increase
or more symptoms might arise as the cancer spreads throughout the rectum or into the
colon. Rectal bleeding may make the stool bright red. A bleeding tumor may also
change the color of the stools, sometimes making the stool very dark or tarry looking.
Rectal cancer signs related to bowel habit changes may include:

Diarrhea

Constipation

Not being able to completely empty the bowel

Change in the size or shape of stools (narrower than usual)

Bloody stool (either bright red or very dark)

Bleeding
Seeing blood mixed with stool is a sign to seek immediate medical
care.Although many peoplebleed due tohemorrhoids, a doctor should still be notified in
the event of rectal bleeding.
Prolonged rectal bleeding (perhaps in small quantities that is not seen in the
stool) may lead to anemia, causing fatigue, shortness of breath, light-headedness, or a
fast heartbeat.
Obstruction
A rectal mass may grow so large that it prevents the normal passage of
stool.This blockage may lead to the feeling of severe constipation or pain when having

a bowel movement.In addition, abdominal pain or cramping may occur due to the
blockage.
The stool size may appear narrow so that it can be passed around the rectal
mass.Therefore, pencil-thin stool may be another signof an obstruction from rectal
cancer.
A person with rectal cancer may have a sensation that the stool cannot be
completely evacuated after a bowel movement.
Weight loss: Cancer may cause weight loss. Unexplained weight loss (in the absence
of dieting or a new exercise program) requires a medical evaluation.

General rectal cancer symptoms

Early stages of rectal cancer may have no symptoms. However, more systemic
(body-wide) changes may result as the tumor goes deeper into the layers of tissues
lining the rectum or if the cancer spreads (metastasizes) throughout the body.
Generalized symptoms of rectal cancer may include:

Pain in the rectum

Abdominal pain or discomfort

More frequent gas pains or stomach cramps

Feeling bloated or full

Change in appetite

Unintended weight loss

Fatigue or tiredness

E. Complications
Complications of Bowel Obstruction
Untreated, intestinal obstruction can cause serious, life-threatening complications,
including:

Tissue death. Intestinal obstruction can cut off the blood supply to part of intestine.
Lack of blood causes the intestinal wall to die. Tissue death can result in a tear
(perforation) in the intestinal wall, which can lead to infection.

Infection. Peritonitis is the medical term for infection in the abdominal cavity. It's a lifethreatening condition that requires immediate medical and often surgical attention.
Complications of Rectal Cancer
Primary complications associated with rectal cancer (1) bowel obstruction due to
narrowing of the bowel lumen by lesion; (2) perforation of the bowel wall by the tumor,
allowing contamination of the peritoneal cavity by bowel contents; (3) direct extension of
the tumor to involve adjacent organs.
F. Diagnostic Tests

Physical exam and history : An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything else
that seems unusual. A history of the patients health habits and past illnesses
and treatments will also be taken.

Digital rectal exam (DRE): An exam of the rectum. The doctor or nurse inserts
a lubricated, gloved finger into the lower part of the rectum to feel for lumps or
anything else that seems unusual. In women, the vagina may also be examined.

Colonoscopy : A procedure to look inside the rectum and colon for polyps
(small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a
thin, tube-like instrument with a light and alens for viewing. It may also have a
tool to remove polyps or tissue samples, which are checked under
a microscope for signs of cancer.

Colonoscopy. A thin, lighted tube is inserted through the anus and rectum and into
the colon to look for abnormal areas.

Biopsy : The removal of cells or tissues so they can be viewed under a

microscope to check for signs of cancer. Tumor tissue that is removed during
the biopsy may be checked to see if the patient is likely to have
the gene mutation that causes HNPCC. This may help to plan treatment. The
following tests may be used:

Reverse-transcription polymerase
A laboratory test in

which

cells

chain
in

reaction (RT-PCR)

sample

of

tissue

are

test:
studied

using chemicals to look for certain changes in the structure or function of genes.

Immunohistochemistry study: A laboratory test in which a substance such as

an antibody, dye, or radioisotope is added to a sample of tissue to test for
certain antigens. This type of study is used to tell the difference between
different types of cancer.

Carcinoembryonic antigen (CEA) assay : A test that measures the level of

CEA in the blood. CEA is released into the bloodstream from both cancer cells
and normal cells. When found in higher than normal amounts, it can be a sign of
rectal cancer or other conditions

CBC is ordered to detect anemia resulting from chronic blood loss and tumor
growth.

Fecal Occult blood (by guaic or hemoccult testing) is ordered to detect blood in
feces, because nearly all colorectal cancers bleed intermittently.

Chest x ray is obtained to detect tumor metastasis to the lungs

CT scan and MRI or ultrasonic examination may be used to access tumor

depth and involvement of other organs by direct extension or metastasis.

Positron emission tomography (PET)-a test that produces images showing the
amount of functional activity in tissue being studied; helps in finding out if the
disease has spread outside the pelvis to other organs

Transrectal ultrasound-an ultrasound probe that is inserted into the rectum

sends out sound waves to image the tumor

G. Surgery

Abdominoperineal Resection Surgery (APR)

APR is a common treatment for rectal cancer when the cancer is located close to
the anus. During an APR, the entire rectal cancer, adjacent normal rectum, rectal
sphincter or anus, and surrounding lymph nodes are removed through an incision in the
lower abdomen and the perineum (the skin around the anus). Following removal of the
cancer, the incision in the perineum is sewn shut. The cut end of the large intestine is

attached to an opening in the abdominal wall, called a colostomy. This opening is

covered with a bag, which serves to collect stool as it passes through the large intestine
and through the colostomy. In contrast to a LAR, the colostomy is permanent.
Many patients would like to avoid a permanent colostomy. When the rectal
cancer lies close to the sphincter or anus, an APR is typically recommended. In some
instances, a more limited surgery can be used to avoid a colostomy, or radiation therapy
can be used to shrink the rectal cancer prior to surgery allowing the patient to maintain
control of bowel function. Some small rectal cancers that lie close to the anus can be
removed with less extensive surgery called a local excision. Not all patients can
undergo a local excision
Patients undergoing an APR may experience lower abdominal pain after the
operation. Less common complications related to surgery include bleeding, infection,
slow wound healing and temporary difficulty with emptying the bladder. Some men may
experience sexual dysfunction after surgery. In-hospital death occurs after APR in less
than 5% of patients. Patients should ask the surgeon to explain the various surgical
complications and their frequency of occurrence at the hospital where the surgery will
be performed.
Disadvantages of APR

Need for permanent colostomy

Significantly higher short-term morbidity and mortality

Significantly higher long-term morbidities

Higher rate of sexual and urinary dysfunction

Laser photocoagulation

Laser photocoagulation uses a very small, intense beam of light to generate heat
in tissues toward which it is directed. The heat generated by the laser beam can be
used to destroy small tumors, it is also used for palliative surgery of advanced tumors to
remove obstruction. Laser photocoagulation can be performed endoscopically and is
useful for clients who cannot tolerate major surgery.

Colostomies

Surgical resection of the bowel may be accompanied by a colostomy for

diversion of fecal contents. A colostomy is an ostomy made in the colon. It may be
created if the bowel o\is obstructed by the tumor, as a temporary measure to promote
healing of anastomoses, or a permanent means of fecal evacuation when the distal
colon and rectum are removed.

1.

Sigmoid colostomy the most common permanent colostomy performed,

particularly for the cancer of the rectum. It is usually created during an
abdominoperineal resection. This procedure involves the removal of the
sigmoid colon, rectum, and anus through abdominal and perineal incisions.
The anal canal is closed, and a stoma formed from the proximal sigmoid
colon. The stoma usually is located on the left lower quadrant of the
abdomen.

2.

Double barrel colostomy two separate stomas are created. The distal
colon is not removed but bypassed. The proximal stoma, which is
functional, diverts feces to the abdominal wall. The distal stoma, also called
the mucus fistula, expels mucus from the distal colon.

3.

Transverse loop colostomy

4.

Hartmann procedure, a common temporary colostomy procedure, the distal

portion of the colon is left in place and is oversewn for closure. A temporary
colostomy may be done to allow bowel rest or healing, such as following
tumor resection or inflammation of the bowel. It is also created following
traumatic injury to the colon, such as gunshot wound. Anastomosis of the
severed portions of the colon is delayed because bacterial colonization of
the colon would prevent proper healing of the anastomosis.

NURSING CARE OF CLIENT WITH COLOSTOMY

Assess the location of the stoma and the type of colostomy performed.Stoma
location is an indicator of the section of bowel inwhich it is located and a predictor
of the type of fecal drainage toexpect.

Assess stoma appearance and surrounding skin condition frequentlyAssessment

of stoma and skin conditionis particularly important in the early postoperative
period, whencomplications are most likely to occur and most treatable.

Position a collection bag or drainable pouch over the stoma.Initial drainage may
contain more mucus and serosanguineousfluid than fecal material. As the bowel
starts to resume function,drainage becomes fecal in nature.The consistency of
drainage dependson the stoma location in the bowel.

In ordered irrigate the colostomy, instilling water into the colonsimilar to an

enema procedure. The water stimulates the colon toempty.

When a colostomy irrigation is ordered for a client with a double-barrel or loop

colostomy, irrigate the proximal stoma. Digitalassessment of the bowel direction
from the stoma can assist indetermining which is the proximal stoma. The distal
bowel carriesno fecal contents and does not need irrigation. It may be irrigatedfor
cleansing just prior to reanastomosis.

Empty a drainable pouch or replace the colostomy bag asneeded or when it is no

more than one-third full. If the pouch isallowed to over fill, its weight may impair
the seal and cause leakage.

Provide stomal and skin care for the client with a colostomy asfor the client with
an ileostomy Good skin andstoma care is important to maintain skin integrity and
function asthe first line of defense against infection.

Use caulking agents,such as Stomahesive or karaya paste, and askin barrier

wafer as needed to maintain a secure ostomypouch. This may be particularly
important for the client with aloop colostomy. The main challenge for a client with
a transverseloop colostomy is to maintain a secure ostomy pouch over theplastic
bridge.

A small needle hole high on the colostomy pouch will allow flatusto escape. This
hole may be closed with a Band-Aid andopened only while the client is in the
bathroom for odor control.Ostomy bags may balloon out, disrupting the skin
seal, ifexcess gas collects.

CLIENT AND FAMILY TEACHING

Prior to discharge, provide written, verbal, and psychomotor instruction on

colostomy care, pouch management, skin care, andirrigation for the client.
Whether the colostomy is temporary orpermanent, the client will be responsible
for its management.Goodunderstanding of procedures and care enhances the
ability to provideself-care, as well as self-esteem and control.

Allow ample time for the client (and family, if necessary) topractice changing the
pouch, either on the client or a model.

Practice of psychomotor skills improves learning and confidence.If an

abdominoperineal resection has been performed, emphasizethe importance of
using no rectal suppositories, rectaltemperatures, or enemas. Suggest that the
client carry medicalidentification or a MedicAlert tag or bracelet. These,
measuresare important to prevent trauma to the tissues when the rectumhas
been removed.

The diet for a client with a colostomy is individualized andmay require no

alteration from that consumed preoperatively.Dietary teaching should, however,
include information onfoods that cause stool odor and gas and foods that thicken

and loosen stools. Foods that cause these effects on ostompatienttput are listed
below.

Foods That Increase Stool Odor

Asparagus Fish
Beans Garlic
Cabbage Onions
Eggs Some spices

Foods That Thicken Stools

Applesauce Pasta
Bananas Pretzels
Bread Rice
Cheese Tapioca
Yogurt Creamy peanut butter

Foods That Increase Intestinal Gas

Beer Cucumbers
Broccoli Dairy products
Brussels sprouts Dried beans
Cabbage Peas
Carbonated drinks Radishes
Cauliflower Spinach
Corn

Foods That Loosen Stools

Chocolate Highly spiced foods
Dried beans Leafy green vegetables
Fried foods Raw fruits and juices
Greasy foods Raw vegetables
Foods That Color Stools
Beets Red gelatin

H. OTHER TREATMENTS

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other
types of radiation to kill cancer cells. There are two types of radiation therapy. External
radiation therapy uses a machine outside the body to send radiation toward the
cancer. Internal

radiation therapy

uses

a radioactive

substance

sealed

in

needles, seeds, wires, or catheters that are placed directly into or near the cancer. The
way the radiation therapy is given depends on the type and stage of the cancer being
treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer
cells, either by killing the cells or by stopping the cells from dividing. When
chemotherapy is taken by mouth or injected into avein or muscle, the drugs enter the
bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
When chemotherapy is placed directly in the cerebrospinal fluid, an organ, or a
body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas
(regional chemotherapy).

Chemoembolization of the hepatic artery is a type of regional chemotherapy that may

be used to treat cancer that has spread to the liver. This is done by blocking the hepatic
artery (the main artery that supplies blood to the liver) and injecting anticancer drugs

between the blockage and the liver. The livers arteries then carry the drugs into the
liver. Only a small amount of the drug reaches other parts of the body. The blockage
may be temporary or permanent, depending on what is used to block the artery. The
liver continues to receive some blood from the hepatic portal vein, which carries blood
from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being
treated.
Targeted drug therapy
Drugs that target specific defects that allow cancer cells to grow are available to
people with advanced colon cancer, including bevacizumab (Avastin), cetuximab
(Erbitux), panitumumab (Vectibix) and regorafenib (Stivarga). Targeted drugs can be
given along with chemotherapy or alone. Targeted drugs are typically reserved for
people with advanced colon cancer.

Some people are helped by targeted drugs, while others are not. Researchers
are working to determine who is most likely to benefit from targeted drugs. Until then,
doctors carefully weigh the limited benefit of targeted drugs against the risk of side
effects and the expensive cost when deciding whether to use these treatments.