By Tedler D. Depaynos, MD
The patient is from a northern province who settled at the hometown of his wife where the industry is digging for the evasive glittering yellow metal. They were lucky because what they were looking for was very cooperative so that whatever he was feeling was diverted to the success of their adventure. Because of the unlucky incidents which forced them to stop their underground adventures, the diversion of what he was feeling also stopped. The pain he was feeling worsened and he got worried with the enlarging tender bulging mass at the left lower side of his abdomen.
Initial impression of his attending surgeons was a simple abdominal wall abscess. Although the mass was firm and nodular, it was warm to touch and very tender. Routinely, an abdominal ultrasound (UTZ) was done to localize and visualize the extent of the mass before doing an incision and drainage or I and D. The ultrasonologist, however, gave an impression that it is probably an extension of a tumor from the lower colon or sigmoid area. In short, the superficial bulging mass may have originated from the colon.
An enlarging mass in the intestine especially in the lower colon usually protrudes into the lumen causing eventually intestinal obstruction. Initially, it may cause difficulty of moving one’s bowel and the patient may complain of chronic constipation. The proximal part may then become dilated result in a bloated abdominal feeling. This could easily be appreciated through abdominal x-rays. In this patient, he never had these manifestations and his abdominal x-rays were basically normal.
After further questioning, however, the patient recalled that there was one incident two or three weeks before when his stools were admixed with fresh blood. Fresh blood in the stools usually come from the distal part while “dinuguan-like” blood or black digested blood admixed with the stools usually come from the upper part like the duodenum or even the stomach. It is then possible that the bleeding came from the “colonic tumor”. A chest x-ray and a CT scan of the abdomen were then requested.
A CT scan is more precise in viewing the abdominal contents. It slices the abdominal cavity thinly like a “sliced loaf bread” and each slice could be seen and analyzed. Sadly in this patient, the CT scan confirmed that the superficial bulging abdominal mass that was felt apparently came from a mass in the sigmoid part of the large colon. There were various enlarged abdominal “lymhnodes” and some of them were even compressing the two ureters dilating their proximal parts. There were small “masses” seen also in the liver which were interpreted as hepatic “metastasis”. Likewise, the chest x-ray also revealed a small “metastatic” mass.
Even without a biopsy result, from the experience of the attending surgeons, the patient was diagnosed to have a 4th stage colonic cancer and this was explained to the patient and his close relatives. A biopsy could be done initially to confirm the diagnosis and likewise the colonic mass extending to the abdominal wall could be removed by resection but not all the “lymphnodes” and the other “metastatic” masses. The surgery would only relieve him of his pain and impending obstruction, but will not cure the disease. It would just be palliative.
In general, early stage malignancy does not cause any uncomfortable signs and symptoms. If ever they do, they are interpreted to be due to other diseases or often even neglected because of the “busyness” of the individual just like this patient. His case is non-classical because he did not experience the usual intestinal obstruction caused by a colonic tumor.
Basic key to treatment of this kind of malady is early diagnosis before any metastasis occurs. It is thus recommended that a routine gastro-endoscopy and colonoscopy should be done to all individuals before they reach their senior age. In individuals who have a family history of similar malignancy some MDs even recommend that they should undergo these diagnostic procedures when they reach their fourth and a half decades.
In these procedures, polyps may be seen and could easily be excised and biopsied. If a polyp has a great tendency to become malignant like an “adenomatous” one, a yearly examination through these procedures is strongly advised.
The patient consented to a simple biopsy of his masses and when it turned out to be malignant he insisted of going home.**
