Ms. Jonas is a 50-year-old woman who was recently arrested by the Federal Marshalls and is housed at your facility. She initiated a Sick Call Request yesterday complaining of rectal bleeding. Today you are the nurse triaging sick call slips, and you see Ms. Jonas in a face-to-face encounter. You learn that she has a history of hypothyroidism and is obese, despite attempting multiple diets over the years. She states that the bleeding began approximately 4 months ago while she was in the free world. It was intermittent and occurred with a bowel movement, perhaps once a week, but since arriving at the facility, it has occurred with every bowel movement. When she was seen in the free world, her primary care provider referred her for a colonoscopy, but she did not have the money to get one. She reports a history of internal hemorrhoids about 30 years ago after childbirth, but they have not been troublesome. She initially thought this was a flare-up and has been using her cellmate’s hemorrhoidal cream without improvement.
You obtain a set of vital signs: T 99.0°F, P 98, R 18, BP 110/62, SPo2 97%, HT 5’ 2”, WT 201 lbs, BMI 36.0 and place Ms. Jonas on the provider list for the next day.
Ms. Jonas is seen by the Provider the Next Day.
PROVIDER ACTIONS
Review of Systems
The patient states she has great fatigue and a weight loss of 12 lbs in the last four months, which she attributes to dieting; and occasional night sweats, which she attributes to menopause. She denies fever and chills. She reports increasing shortness of breath when walking up stairs for the past month but denies chest pain, palpitations, and syncope. She has dizziness when standing up quickly but denies headache, weakness, and paresthesia; denies cough, wheezing, and hemoptysis; denies anorexia, heartburn, nausea/ vomiting, and diarrhea; denies dysuria, hematuria, vaginal bleeding or discharge, and pelvic pain; denies any increased bruising and swollen lymph nodes; denies skin rashes, lesions, and itching; and denies insomnia, anxiety,and depression.
Relevant History
Ms. Jonas reports struggling with obesity since her pregnancy at age 32, after which she was diagnosed with hypothyroidism. She has taken levothyroxine 112 mcg daily for 20 years but takes no other medications or supplements. She has no prior history of heart, lung, GI, or bleeding disorders, and she has no prior surgeries or hospitalizations. Her parents are alive and healthy in their late 70s; she believes her maternal grandmother died in her 60s of “some kind of stomach cancer.” There is no family history of heart disease, diabetes, or bleeding disorder. She denies tobacco use and recreational drug use. She states she was a “social” drinker in the free world, having one-two glasses of wine most evenings.
Provider Physical Examination
Allergies: None.
Medications: Levothyroxine 112 mcg QD.
Vitals: T 98.7°F, P 100, R 18, BP 112/64, SPo2 98%, HT 5’ 2”, WT 201 lbs, BMI 36.0.
General: Well-developed, obese female; A&O x 4; all vital signs within expected parameters
Psychiatric: Broad affect, euthymic mood, fluent speech, average insight.
Skin, Hair, and Nails: Warm and dry, pallor of skin, nail beds, and conjunctivae noted. No jaundice or rashes present. No unexpected findings with hair or nails.
Lungs: Clear to auscultation bilaterally without adventitious sounds. Good respiratory effort with no accessory muscle use.
Heart: S1 S2, RRR with no murmurs, gallops, or rubs.
Abdomen: Normoactive bowel sounds in all quadrants. Soft, non-tender, non-distended; obese; no masses, organomegaly, or hernia present.
Genital/Rectal: Genital exam deferred; rectal exam shows normal sphincter tone, no fissures noted, visible small non-tender non-thrombosed external hemorrhoid visible at 3 o’ clock, and a small non-tender internal hemorrhoid at 9 o’ clock. Brown hard stool and gross blood noted in vault, which is guaiac occult blood test positive.
Extremities: No edema, clubbing, or cyanosis. Radial and dorsalis pedis pulses 2+ bilaterally.
Neurologic: Gait steady; no tremors, no focal deficits; CN II – XII intact.
Differential Diagnoses for Ms. Jonas
Colorectal cancer is high on the differential. Chronic intermittent hematochezia in an adult should always trigger investigation for colorectal neoplasm, particularly in patients over age 45, when associated with a change in bowel movements or when there is unintentional weight loss. This patient has never had baseline colon cancer screening as recommended, and though she has no known family history of colon polyps/cancer, a family history of “stomach cancer” is concerning. Additionally, her obesity and moderate alcohol intake place her at increased risk for several types of cancer, including colon cancer.
Inflammatory Bowel Disease (IBD) is on the differential. Crohn disease and ulcerative colitis, the most common forms of IBD, should be considered in patients with chronic hematochezia. IBD is often associated with weight loss, a change in bowel movements, and anemia as well. However, IBD typically presents with abdominal and/or rectal pain, diarrhea, and a positive family history of IBD. Peak incidence of diagnosis occurs between ages 15 and 30.
Hemorrhoidal bleeding is likely from the patient’s history of hemorrhoids and was confirmed on rectal exam. However, hemorrhoids should never be presumed to be the only cause of chronic rectal bleeding, nor iron deficiency anemia, especially in patients who are not up to date on colon cancer screening. Additionally, hemorrhoidal bleeding does not typically cause severe anemia, which was found when Ms. Jonas’ lab results were reported.
Diverticular bleeding should be considered, as 50% of patients over age 50 have diverticulosis found upon colonoscopy, and the most common cause of lower GI bleeding requiring in-patient hospitalization is diverticular bleeding. Obesity is also a risk factor for diverticular disease.
Ischemic colitis can cause lower GI bleeding, but the presentation is typically acute, associated with significant abdominal pain, and in a patient with underlying diabetes or cardiovascular risk factors.
Most likely diagnosis: Colorectal Cancer
When someone presents with blood in the stool, colorectal cancer must be on the top of the differential diagnosis list. Ms. Jonas did not have the recommended colonoscopy at the age of 50. Additionally, the “some kind of stomach cancer,” which her grandmother died from, along with her history of moderate alcohol intake and obesity puts her at increased risk for several types of cancer, including colon cancer. Chronic GI bleeding with likely iron-deficiency anemia should also be considered as a secondary diagnosis.
PATHOPHYSIOLOGY
Colorectal cancer is the third most common cancer diagnosed worldwide. Ninety-six percent of colorectal cancers are adenocarcinomas; 90% occur in patients over age 50, and 70% occur in the left side colon. When aberrant stem cells mutate, two types of precancerous colon polyps may occur. Although only 10% of these polyps will progress to cancer, approximately 25% of screened patients harbor adenomatous polyps, and prevalence increases with age. Transformation of polyps from adenoma to invasive adenocarcinoma typically occurs over 10 to 20 years. “Sidedness” is an important consideration in the diagnosis of colon cancer due to its impact on treatment and prognosis. Right-sided cancers, particularly when metastatic, exhibit a poor response to chemotherapy and a poorer prognosis than left-sided cancers.
PLAN
CBC with differential to assess for anemia
Referral for an urgent GI consult/ diagnostic colonoscopy
**That evening, the nurse at the facility received a call from the lab, with critical low lab results:
WBC 4.0; Differential – within expected parameters.
RBC 2.6 (low); Hgb 5.8 (critical low); Hct 24 (critical low); MCV 60 (low); PLT 490 (high); RDW 20 (high)
After consultation with the provider, Ms. Jonas was sent to the emergency department for further evaluation and blood transfusion.
AT THE HOSPITAL
After receiving two units of packed cells transfused at the hospital, a colorectal surgery consult was completed. A cat scan (CT) of the abdomen/pelvis revealed two peri-rectal and two peri-hepatic nodes; two hepatic masses and a proximal rectal mass.
Ms. Jonas returned to the facility. An endoscopy and diagnostic colonoscopy were performed later that week in an outpatient setting to biopsy the rectal mass and confirm the source of the bleeding. Her bleeding increased such that bleeding occurred even when she was not having a bowel movement. Because she was experiencing continuous rectal bleeding and the providers had difficulty stabilizing her anemia, Ms. Jonas underwent surgery and had an ileostomy. She returned to the facility and chemotherapy was initiated.
PATIENT EDUCATION TOPICS
Treatment plan and chemotherapy, including potential side effects and strategies to adddress
Self-care regarding her new ileostomy
Red flag signs and symptoms that should be reported immediately to healthcare staff
OUTCOME
Although Ms. Jonas tolerated the therapy well and maintained a positive attitude, the tumor did not respond to the treatments. Ms. Jonas was home on furlough when she passed away 3 months later.
REFERENCES
American Cancer Society. Colorectal cancer facts & figures. https://www.cancer.org/research/cancer-facts-statistics/colorectal-cancer-facts-figures.html
Baran B, Mert Ozupek N, Yerli Tetik N, et al. Difference between left-sided and right-sided colorectal cancer: a focused review of literature. Gastroenterology Res. 2018;11(4):264–273. doi:10.14740/gr1062w
Dekker E, Tanis P, Vleugels JLA, et al. Colorectal cancer. Lancet. 2019;394:1467–1480. doi:10.1016/S0140-6736(19)32319-0
Kim BSM, Li BT, Engel A, et al. Diagnosis of gastrointestinal bleeding: a practical guide for clinicians. World J Gastrointest Pathophysiol. November 15, 2014;5(4):467–478. doi:10.4291/wjgp.v5.i4.467
LoConte NK, Brewster AM, Kaur JS, et al. Alcohol and cancer: a statement of the American Society of Clinical Oncology. J Clin Oncol. 2018;36(1):83–93. doi:10.1200/JCO.2017.76.1155
US Preventive Services Task Force. Recommendation statement: screening for colon cancer. JAMA. June 21, 2016;315(23):2564–2575. doi:10.1001/jama.2016.5989
Wolf A, Fontham E, Church T, et al. Colorectal cancer screening for average risk adults: 2018 update from the American Cancer Society. CA Cancer J Clin. 2018;68:250–281. doi:10.3322/caac.21457
Wijesinghe, Sampath. (2021). 101 Primary care case studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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