Metastatic Colorectal Cancer

Britt to edit Master subtitle style Click MacArthur Dietetic Intern: Case Study Presentation Spring 2012

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What I learned in MSS with Susan & Leah

Senna Colace Miralax Suppositor y Enema CoLyte

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Outline

Colorectal Cancer Review

Statistics Function of Colon Understanding Cancer Causes & Risk Factors Screenings/Tests How Cancer Spreads Treatments

Case

Study

Pt. Profile Past Medical Hx. Background Research Nutritional Status Prognosis
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Colorectal Cancer
Definition & Statistics

Cancer that begins in the colon is called colon cancer, and cancer that begins in the rectum is called rectal cancer Cancer that starts in either of these organs may also be called colorectal cancer In 2012, more than 143,000 people in the United States will be diagnosed with colorectal cancer It is the 4th most common cancer in men, after skin, prostate, and lung cancer It is also the 4th most common cancer in women, after skin, breast, and lung cancer

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Colorectal Cancer
Function of Colon

Mayo Clinic. The Colon and Small intestine page. Available at http://www.mayoclinic.com/health/medical/IM00028. Accessed on June 12, 2012.

The colon is the first 4 to 5 feet of the large intestine, and the rectum is the last several inches7/22/12

Colorectal Cancer
Understanding Cancer

Normally, cells grow and divide to form new cells as the body needs them When this process goes wrong, is when a mass of tissue called a growth or tumor forms Tumors can be benign or malignant

Pat Kenny. Superstock. Cell Division page. Available at http://www.superstock.com/stock-photos-images/4102-20295. Accessed on June 12, 2012

Benign (not cancer):

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Colorectal Cancer
Causes & Risk Factors

Causes

Unknown? Begins as a polyp > 50 yrs African American/Black Eat a diet high in red or processed meats Have cancer elsewhere in the body Have cororectal polyps Have inflammatory bowel disease (Chrons or ulcerative colities) Family history of colon cancer Personal history of breast cancer 7/22/12 Inherited gene mutations (rare)

Risks Factors

Colorectal Cancer
Signs/Symptoms

Abdominal pain & tenderness in the lower abdomen Blood in the stool Diarrhea, constipation, or other change in bowel habits Narrow stools Weight loss with no known reason

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Colorectal Cancer
Screenings/Tests

Fecal occult blood test (FOBT)

Cancers or polyps bleed, and the FOBT can detect tiny amounts of blood in the stool
Sigmoidoscopy

Lower rectum examined

Colon and Rectal Cancer Basic Information. Available at http://www.aboutcance r.com/colon1.htm. Accessed on June 12, 2012.

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Colorectal Cancer
How Colorectal Cancer Spreads & Staging

How colorectal cancer spreads

Colorectal cancer cells most often spread to the liver, where the disease is dx. as metastatic colorectal cancer, not liver cancer Stage 0: Polyp, localized to colon Stage 1: Spread to inner linings of colon Stage 2: Extends through Mayo Clinic. Staging of Colon Cancer.7/22/12 http://www. Available at mayoclinic.com/health/medical/IM01892. Accessed on June 12, the muscular wall of

Staging

Colorectal Cancer
Treatments

Surgery (most often a colectomy)- removes cancer cells Chemotherapy-kills cancer cells Radiation therapy-destroys cancerous tissue

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Case Study

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I. Patient Profile
Demographics Age, Gender, Marital Status Race-Nationality Religion Household-number, composition, occupations, ages Occupation Economic Level Educational Attainment Recreational Activities, Measures 60 yo., Male, married? Black, Non-Hispanic or Latino Catholic N/A

Technical, full-time N/A N/A 7/22/12 N/A

II. Past Medical History( Hx)

Medical Condition Cardiac: Respiratory: GI: Surgical Hx.: Family Hx.: Social Hx.: Symptoms of Condition HTN, CHF, Hyperlipidemia COPD GERD Herniorrhaphy CAD, HTN ETOH use: Occasionally; Tobacco use: Regular; Drug use: Denies N/A

Allergies:

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III. Background Research

Course of Hospitalization 5/7: OSH Pt. presented to OSH with N/V, and abdominal pain, had a cholecystectomy 5/14: OSH Pt presented back to OSH shortly after with intense N/V and abdominal pain. CT scan was ordered, pt. was dx. to have an ileus and large liver mass on rt. lobe A liver biopsy was performed, pt was started on TPN and then sent to UTMCK Biopsy + for cancer (CA), 5/21/12; ICU At UTMCK, pt presented with +BMs D/cs TPN 7/22/12 Waited 36 hrs, gave pt. Reglan, with clears, and then

III. Background Research

Course of Hospitalization

5/25/12: ICU

Pt. was unable to tolerate the colonoscopy prep, pt. became very distended, NGT to suction and KUB ordered KUB revealed a GI obstruction PICC ordered for TPN Pt sent to surgery
5 L removed from sm. bowel, distended ~6cm Tumor on liver 17.1cm X 13.8 cm Metastatic cecal CA identified and a Rt. hemicoloctemy and end ileostomy were performed Rt. Lung tumor? CVL placed for TPN

5/26/12: ICU

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Right hemicolectomy

Right Hemicoloctemy

Mayo Clinic. Colectomy. Available at http://www.mayoclinic.com/health/medical/IM00231. Accessed on June 12,

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End Ileostomy

End Ileostomy

Irish Stoma Care and Colrectal Nurses Association. Available at http://www.isccna.org/ileostomy.htm. Accessed on June 12, 2012.

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III. Background Research

Course of Hospitalization

5/31-6/6: Floor

S/P colonic resection and end ileostomy, has developed PNA, Resp. Failure, COPD, now on BiPAP, edema, pulmonary effusion with mucus plugging, but unable to tolerate thoracentesis as yet. Metabolic acidosis 2 to acute kidney failure, nephrology consulted, pt. given Bumex + Albumen + ostomy output,+ UOP Pt. voices no complaints, denies pain Pt. is DNR/DNI Prognosis poor Nutrition: TFs

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III. Background Research

Labs Lab Na K Cl CO2 BUN Cr eGFR Glu Ca PO4 Mg 6/5 149 4.9 115 18 124 7.36 13.44 150 9.1 4.6 2.3 6/6 148 5.0 115 17 124 7.53 13.13 154 9.1 4.1 2.1 6/7 6/8 147 151 5.1 5.9 115 118 16 16 127 130 7.57 7.59 13.06 13.03 175 142 9.1 9.2 4.1 --High; Low --2.1 7/22/12

III. Background Research

Labs Lab Urine (mL) Ostomy(m L) 6/5 1905 1650 6/6 1850 875 6/7 800 225 6/8 1900 350

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III. Background Research

Course of Hospitalization

6/6-6/8: Floor

S/P colonic resection and end ileostomy, PNA, Resp. Failure, COPD, off BiPAP only PRN, edema, pulmonary effusion with mucus plugging Metabolic acidosis 2 to acute kidney failure, nephrology consulted, + ostomy output,+ UOP Pt. voices no complaints, depressed, wants to go home, Pallative Care discussed with family re: SNF and/or Hospice options Pt. is DNR/DNI Prognosis poor Nutrition: Soft FT d/cd, Renal diet, Megace and Boost ordered d/cd Bumex + Albumen
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6/10:

IV. Nutritional Status

Anthropometrics

Measurements Values Height (in.) 77 Weight (kg.) 76 Usual/Ideal Weight (kg.) 67 %Ideal Weight (%) 113 BMI (kg/m2) 25 NTR Goals: 2280 kcals (30kcal/kg);115g Protein (1.5g/kg)

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IV. Nutritional Status

PES PES (TFs): Inadequate protein-energy intake RT abdominal pain, N/V AEB ileus and large liver mass

PES (TPN): Inappropriate use of enteral nutrition RT distended bowel and copious NGT residuals AEB sm. obstruction PES(TFs): Inappropriate use of parenteral nutrition RT functioning gut AEB s/p right hemicolectomy and end ilostomy

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IV. Nutritional Status:

Nutrition Care Goals

Prevent Malnutrition pt.s est. needs are always met pt. is tolerating chosen TF formula

Ensure Ensure

Practicing

evidenced-based guidelines to better ensure pt. receives the most up-to date care as practiced in the field

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IV. Nutritional Status

Nutrition Intervention

No past diet history obtained No drug-nutrient (formula) interactions noted 5/21:

Formula with Goal: Peptamen AF @ 20ml/hr Formula with Goal: TPN 100
Macronutrient/ Mineral Amino Acids Dextrose Lipids 20% NaCl KCl Amount 115g/day 367g 57g 150g 25g Macronutrient/ Mineral KPO4 Ca Gluconate Magnesium Sulfate MVI Trace Element Amount 30mmol/day 12mEq/day 15MEQ/day 10mL/day 1mL/day

5/26:

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IV. Nutritional Statues:

Nutrition Intervention

5/28:

TPN at 100ml/hr decreased rate to 85 ml/hr 2 to volume overload Formula with Goal: Peptamen AF @ 20ml/hr D/cd Peptmen AF changed to Peptamen 1.5@ 65 ml/hr

5/31:

6/5:

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IV. Nutritional Status:

Nutrition Intervention

6/6:

Novasource Renal @ 40ml/hr was suggested d/t pts renal status Despite pts AFR and related lab values, I do not feel as if Novasource Renal is an appropriate formula for the following reasons: Protein needs will not be met Electrolytes are stable-not dehydrated + UOP and ostomy output Pt is tolerating current formula Looking at the pt as a whole, very sick. No escalading measures are to be taken; therefore, best leave pt on formula that can tolerate TFs d/cd on Renal diet Pt. d/cd with Hospice

6/8:

6/10:

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IV. Nutritional Status:

Evaluation of Nutrition Intervention
Prevent Ensure Ensure

Malnutrition

pt.s est. needs are always met pt. is tolerating chosen TF formula

Practicing

evidenced-based guidelines to ensure the pt. receives the most up-to date care as practiced within the field

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IV. Nutritional Status:

Medications for D/C Medication
Acetaminophen-oxyCodone-1 tab Asprin-81mg 1x/d Bumetanide (Bumex) -2mg- 1x/d Carvedilol-12.5mg-2x/d Lansoprazole-30mg-1x/d Omeprazole-20mg-1x/d Ondansetron-(zofran)-4mg-1tab1x/d OxyCodone-15mg q 4 hrs PRN Spirenolotone-25mg-2x/d

Function/Purpose Pain relief

Antiplatelet Loop diuretic for heart failure & volume overload No selective beta 1/alpha blocker used to treat heart failure Proton pump inhibitor Proton pump inhibitor Antiemetic Narcotic Sparing diuretic 7/22/12

IV. Nutritional Status:

Effects of Disease on Nutritional Status

Looking just at the pt.s surgery re: the right hemicoloctomy and end ileostomy

Cancer treatments will not be initiated on the patient

Greatest Concern: blockage of stoma & dehydration Foods to Avoid: f &v skins and seeds, raw veggies, nuts, popcorn, corn, salads and dried fruit Diet Alterations: refined breads, cereals and pastas are recommended over whole grains due to extra fiber in unrefined grains can cause digestion problems or stoma blockage Diet Modifications: eat smaller, more frequent meals on a consistent schedule to promote regular digestion and stool output
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Pt. Prognosis
Pts overall prognosis is poor Went home on Hospice care NSG d/c note: Appears pt may have component of depression, does not wish to participate in exam, keeps eyes closed, wants to go home [. . .] wife reports he is not wanting to eat much and does not want to interact and not happy when he woke up and saw a bag attached to him. . .

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References
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Schluter K, Gassmann P, Enns A, Korb T, Hemping-Bovenkerk A, Holzen J, Haier J. Organ-specific metastic tumor cell ahesion extravasation of colon arcinoma cells with different metastatic potential. American Journal of Pathology. 2006;69: 10641073. Mayo Clinic. The Colon and Small intestine page. Available at http://www.mayoclinic.com/health/medical/IM00028. Accessed on June 12, 2012. Pat Kenny. Superstock. Cell Division page. Available at http://www.superstock.com/stock-photos-images/4102-20295. Accessed on June 12, 2012. Colon and Rectal Cancer Basic Information. Available at http://www.aboutcancer.com/colon1.htm. Accessed on June 12, 2012. Mayo Clinic. Staging of Colon Cancer. Available at http://www. mayoclinic.com/health/medical/IM01892. Accessed on June 12, 2012. Mayo Clinic. Colectomy. Available at http://www.mayoclinic.com/health/medical/IM00231. Accessed on June 12, 2012. Irish Stoma Care and Colrectal Nurses Association. Available at http://www.isccna.org/ileostomy.htm. Accessed on June 12, 2012. National Cancer Institue: Colon and rectal cancer page. Available at http://cancer.gov/cancertopics/types/colon-and-rectal. Accessed on June 12, 2012.

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Who has the first question?

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