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+ Colon cancer: A major case study By: Emily Macieiski, Dietetic Intern + Introduction Patient: J.W. 53 year-old Caucasian male Height: 5’11” Weight upon Admission February 19, 2014- 183 lbs (~83 kg) BMI: 26.42 kg/m2 Weight upon Discharge February 26, 2014- 178 lbs (~81 kg) BMI: 25.65 kg/m2 Admitting diagnosis: anemia and abdominal pain Past Medical Hx: None + Social history Homeless Used to fly planes, but turned down a pilot job d/t ailing health Used to study to become a nurse Has no health insurance Not married Brother visited during his stay Does not smoke or drink alcohol Food is a daily struggle + GI tract Stomach and small intestine make up first part Where food is processed for energy Colon and rectum make up the last part Where solid waste is passed out of the body Small intestine 20 ft & Large Intestine 5 ft Rectum last 6 inches of the digestive system Colon has 4 parts: ascending, transverse, sigmoid, descending + Colon cancer Third most common cancer (excluding skin) diagnosed in the U.S. The risk of developing is 1 in 20 (5%) Risk factors: > 50 years old Hx of colorectal polyps Hx of DM IBD (Crohn’s and Ulcerative Colitis) 1st degree relatives with the dx Eating a high-fat diet Red/processed meats Smoking/ heavy alcohol abuse Obesity Physical inactivity + Colon cancer diagnosis Begins when healthy cells that make up the lining of colon or rectum change and grow uncontrollably They can form a mass/tumor and be benign or malignant Colorectal cancer usually begins as a polyp Non-cancerous growth Most form a mound in wall of colon About 10% require a special dye to be seen during a colonoscopy If metastasizes, cancer cells can develop new tumors + Symptoms Change in bowel habits: diarrhea, constipation Pain without a bowel movement Feeling like the bowel does not empty completely Rectal bleeding Dark/bloody stools Cramping/abdominal pain Weakness/fatigue Unintended wt loss + Tests to diagnose Many develop symptoms after it has already developed If symptoms occur, a doctor will do a physical exam and review medical hx Blood tests: CBC, liver enzymes, or tumor markers (CEA) Sometimes colorectal CA will bleed into large intestine or rectum Can cause anemia Tests and procedures to detect: colonoscopy, biopsy, molecular testing of the tumor, CT scan, MRI, ultrasound, chest x-ray, and PET scan. + Treatment- Colon Colon: Colectomy (sometimes called hemicolectomy, partial, or segmental resection) removes part of the colon and nearby lymph nodes Polypectomy removal of the polyp through a colonoscope + Treatment- Rectal Rectal: Polypectomy Transanal resection instrument is inserted thru the anus & cuts thru all the layers of the rectum to remove any cancerous tissues Low anterior resections part of the rectum containing the tumor is removed and then the colon attached to remaining rectum. Proctectomy entire rectum is removed and then the colon is attached to the anus (colo-anal anastomosis) Abdominoperineal resection (APR) removal of anus, sphincter muscle, and tissues. Pelvic exenteration rectum will be removed, along with the bladder, prostate in men, or uterus in women, if the cancer has spread + Radiation therapy Radiation therapy Can be used with colon CA that has spread to the lining of the abdomen or other organs For rectal CA, can be used before or after sx Chemoradiation radiation given with chemo Side Effects: skin irritation at the site of radiation; nausea; rectal irritation causing diarrhea, painful bowel movements, or blood in the stool; bowel incontinence; bladder irritation; fatigue/tiredness + Chemotherapy Systemic uses drugs that are injected into a vein or given by mouth; travel to difference parts of the body Regional drugs are injected directly into an artery leading to a part of the body containing a tumor; less side effects Drugs: FOLFOX (a type of combination chemotherapy used to treat colorectal cancer) Camptosar (used when colon cancer has metastasized or returned) Avastin (used when colorectal cancer has spread, it starves tumors of blood and oxygen) Erbitux (it helps to stop cancer cells from reproducing) Vectibix (used when colorectal cancer has spread despite chemotherapy) Side Effects + Stages Stage 0: cancer cells found only in inner lining of colon/rectum Stage I: grown through the mucosa and invaded mucosa layer Stage 2A: grown into outermost layers of colon/rectum Stage 2B: grown into the layers of the muscle to the visceral peritoneum Stage 2C: spread through the wall of the colon/rectum and grown into or attached to nearby tissues or organs + Stages Continued Stage 3A: grown through the inner lining/the muscle layers of the intestine; 1-3 lymph nodes Stage 3B: grown thru bowel wall or into surrounding organs; 1-3 lymph nodes Stage 3C: 3-4 lymph nodes Stage 4A: spread to one part of the body (such as liver/lungs) Stage 4B: spread to more than one organ/set of lymph nodes + + J.W.’s sx/procedures 2/19 GI consult. US showed mass in abdominal area. 2/20 EGD/colonoscopy with small bowel biopsy; rectal polypectomy Post-op diagnosis: diverticulosis, mass in colon, rectal polyp Mid to proximal transverse colon mass most likely cancer 2/21 Right hemicolectomy Post-op diagnosis: proximal transverse colon CA Await pathology results Oncology consult 2/24Pathology results showed stage 3B colon CA + Medications Cefotan- antibiotic Protonix- antigerd Heparin- anticoagulant Zofranantiemetic/antinauseant Decadron- corticosteroid, antiinflammatory, immunosuppressant Lantus Humalog- diabetic Toradol- pain Sennagen- laxative/stimulant Venofer- antianemic to treat iron deficiency + Important Labs HgA1c: 9.0%- 2/21 Glucose: 358 mg/dl- 2/21 Serum albumin: 2.3 gm/dl- 2/21 H/H: 5.6 gm/dl/22.3%- 2/21 CRP: 9.37 mg/dl + Dietary treatment J.W. was NPO on 2/19 Advanced to full liquids on 2/22 Regular diet on 2/24 Glucerna shake TID Recommended to switch to Diabetic High left Dear Doctor note Estimated needs: 25-30 kcal/kg 2,075-2,490 kcals/day Protein: 1.0-1.2 g/kg 86-100 grams PRO/day Needs increased once confirmed he had stage 3B colon CA 30-35 kcal/kg 2,430- 2,835 kcals/day Protein: 1.2-1.5 g/kg 97- 122 grams PRO/day + Dietary treatment continued The Diabetic high diet was recommended d/t his newly dx DM and for his increased needs J.W. was also constipated since 2/20, which delayed his discharge He lost 5 lbs during his stay of 1 week. NPO x 3 days. He consumed 100% of most meals and drank every Glucerna that was sent to him Glucerna coupons provided Academy of Nutrition and Dietetics handouts: Carbohydrate Counting for People with Diabetes, Fat Content of Foods List, and Fiber Content of Foods List provided. + Nutritional guidelines Low-fat, high-fiber diet to prevent future polyps Limit fiber post sx until bowels return to normal Tobacco and alcohol are discouraged Drinking 6-8 glasses water/day & exercise 30 min, 5 days/wk Fish oil can help inflammation Rich in vegetables (cruciferous), fruits, whole grains Consume less red meat intake of poultry, fish, beans, and tofu Multi-vitamin- especially folic acid, vitamins B6 and D3 Omit trans fatty acids unsaturated fats- salmon, flaxseed, canola and olive oils Dairy products encouraged for calcium and vitamin D + Nutrition diagnosis and Goals Unintended weight loss related to malabsorption as evidenced by 75 pounds weight loss (29%) over 6 months. Altered nutrition-related lab values related to newly diagnosed DM as evidenced by HgA1c of 9.0%. Increased calorie and protein needs related to newly diagnosed colon cancer stage IIIB as evidenced by biopsy results. Altered GI function related to changes in motility as evidenced by constipation x 5 days. Goal- Provide adequate kcal and protein to meet estimated needs Pt will maintain po intake of 75% or more of meals, including supplement Prevent further wt loss, maintain lean body mass Improvement with blood sugars Start solid foods by day 5-7 + Prognosis MD set him up with free class at Diabetes Wellness Center in April Free meter and glucose test strips Sent home with Metformin Port to be placed for chemo in a few weeks J.W. is very intelligent and driven Will be staying with family friends in Mason His stage of colon cancer hasn’t spread to other organs yet Doctors have a lot of faith in him + References "Colorectal Cancer." Welcome to the Johns Hopkins Colon Cancer Center. N.p., 2001-2014. Web. 21 Apr. 2014. Mahan, L. Kathleen., and Sylvia Escott-Stump. "Medical Nutrition Therapy in Cardiovascular Disease." Krause's Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia: Saunders, 2004. 730-731. Print. Pronsky ZM, Crowe JP. Food Medication Interactions. 17th edition. Birchrunville, PA: Food-Medication Interactions; 2012 "Colon Cancer Treatment." Treatment for Colon Cancer. N.p., 2014. Web. 21 Apr. 2014. "Colorectal Cancer." University of Maryland Medical Center. N.p., 2014. Web. 21 Apr. 2014. + References "Colorectal Cancer." Cancer.net. American Society of Clinical Oncology, 2014. Web. 21 Apr. 2014. http://www.cancer.net/sites/cancer.net/files/asco_answers_guide_colorectal.pdf "Colon Cancer Nutrition." EMedTV: Health Information Brought To Life. Clinaero, Inc, 2006-2014. Web. 21 Apr. 2014. "Colorectal Cancer." American Cancer Society, 2013. Web. 21 Apr. 2014. <http://www.cancer.org/acs/groups/cid/documents/webcontent/003096pdf.pdf>. Escott-Stump, Sylvia. "Colorectal Cancer." Nutrition and Diagnosis- Related Care. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2012. 759-62. Print. "SuperTracker." ChooseMyPlate.gov. United States Department of Agriculture, 2014. Web. 21 Apr. 2014.