DI Case Study

Metastatic Colorectal Cancer

Britt MacArthurDietetic Intern: Case Study Presentation Spring 2012

What I learned in MSS with Susan & Leah

SennaColaceMiralax

SuppositoryEnemaCoLyte

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

Outline

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

Colorectal CancerDefinition & Statistics

Colorectal CancerFunction of Colon

The colon is the first 4 to 5 feet of the large intestine, and the rectum is the last several inches

The colon removes water and nutrients from the food and turns the rest into waste (stool)

The waste passes from the colon into the rectum and then out of the body through the anus

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

Colorectal CancerUnderstanding 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 malignantBenign (not cancer):◦ No invasion of surrounding tissue◦ Cells do not spread to other parts

of the body Malignant (cancer):

◦ Invade tissues/organs◦ Spread (metastasis) via

bloodstream (lymphatic)

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

Causes◦ Unknown?◦ Begins as a polyp

Risks Factors◦ > 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 (Chron’s or ulcerative colities)◦ Family history of colon cancer◦ Personal history of breast cancer◦ Inherited gene mutations (rare)

Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC)

◦ Smoking◦ Sedentary life-style◦ Obesity

Colorectal CancerCauses & Risk Factors

◦ 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

Colorectal CancerSigns/Symptoms

Colorectal CancerScreenings/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 Colonoscopy Rectum & entire colon is

examined Double-contrast

barium enema An enema with a barium

solution is given and X-rays are taken of colon and recum

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

Colorectal CancerHow 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

Staging◦ Stage 0: Polyp, localized to

colon◦ Stage 1: Spread to inner linings

of colon◦ Stage 2: Extends through the

muscular wall of colon◦ Stage 3: Spread outside colon

to lymph nodes◦ Stage 4: Other organs such as

liver or lungs

Mayo Clinic. Staging of Colon Cancer. Available at http://www.mayoclinic.com/health/medical/IM01892. Accessed on June 12, 2012.

◦ Surgery (most often a colectomy)- removes cancer cells

◦ Chemotherapy-kills cancer cells◦ Radiation therapy-destroys cancerous tissue

Colorectal CancerTreatments

Case Study

Demographics Measures

Age, Gender, Marital Status 60 yo., Male, married?

Race-Nationality Black, Non-Hispanic or Latino

Religion Catholic

Household-number, composition, occupations, ages

N/A

Occupation Technical, full-time

Economic Level N/A

Educational Attainment N/A

Recreational Activities, Hobbies N/A

I. Patient Profile

Medical Condition Symptoms of Condition

Cardiac: HTN, CHF, Hyperlipidemia

Respiratory: COPD

GI: GERD

Surgical Hx.: Herniorrhaphy

Family Hx.: CAD, HTN

Social Hx.: ETOH use: Occasionally; Tobacco use: Regular; Drug use: Denies

Allergies: N/A

II. Past Medical History( Hx)

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/c’s TPN◦ Waited 36 hrs, gave pt. Reglan, with clears, and then initiated TFs

with NGT to suction◦ Since + biopsy for liver CA, was decided to scope pt. via colonoscopy

to determine 1° CA site to determine if the liver mass was 2° to colorectal CA

III. Background ResearchCourse 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

5/26/12: ICU◦ 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

III. Background Research Course of Hospitalization

Right Hemicoloctemy

Right hemicolectomy

Mayo Clinic. Colectomy. Available at http://www.mayoclinic.com/health/medical/IM00231. Accessed on June 12, 2012.

End Ileostomy

End Ileostomy

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

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

III. Background ResearchCourse of Hospitalization

III. Background ResearchLabs

Lab 6/5 6/6 6/7 6/8

Na 149 148 147 151

K 4.9 5.0 5.1 5.9

Cl 115 115 115 118

CO2 18 17 16 16

BUN 124 124 127 130

Cr 7.36 7.53 7.57 7.59

eGFR 13.44 13.13 13.06 13.03

Glu 150 154 175 142

Ca 9.1 9.1 9.1 9.2

PO4 4.6 4.1 4.1 ---

Mg 2.3 2.1 2.1 ---

Alb. 2.1 2.1 2.0 2.1

High; Low

III. Background ResearchLabs

Lab 6/5 6/6 6/7 6/8

Urine (mL) 1905 1850 800 1900

Ostomy(mL)

1650 875 225 350

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/c’d, Renal diet, Megace and Boost ordered◦ d/c’d Bumex + Albumen

6/10:◦ Pt. d/c’d with Hospice◦ LOS: 20.0 days

III. Background ResearchCourse of Hospitalization

Measurements Values

Height (in.) 77

Weight (kg.) 76

Usual/Ideal Weight (kg.) 67

%Ideal Weight (%) 113

BMI (kg/m2) 25

IV. Nutritional Status Anthropometrics

NTR Goals: 2280 kcals (30kcal/kg);115g Protein (1.5g/kg)

IV. Nutritional StatusPES

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

Prevent Malnutrition

Ensure pt.’s est. needs are always met

Ensure pt. is tolerating chosen TF formula

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

IV. Nutritional Status: Nutrition Care Goals

IV. Nutritional StatusNutrition Intervention

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

◦ Formula with Goal: Peptamen AF @ 20ml/hr 5/26:

◦ Formula with Goal: TPN 100

Macronutrient/Mineral

AmountMacronutrient/Mineral

Amount

Amino Acids 115g/day KPO4 30mmol/day

Dextrose 367g Ca Gluconate 12mEq/day

Lipids 20%57g

Magnesium Sulfate

15MEQ/day

NaCl 150g MVI 10mL/day

KCl 25g Trace Element 1mL/day

IV. Nutritional Statues:Nutrition Intervention

5/28: ◦ TPN at 100ml/hr decreased rate to 85 ml/hr 2° to volume overload

5/31:◦ Formula with Goal: Peptamen AF @ 20ml/hr

6/5:◦ D/c’d Peptmen AF changed to Peptamen 1.5@ 65 ml/hr

IV. Nutritional Status:Nutrition Intervention

6/6:◦ Novasource Renal @ 40ml/hr was suggested d/t pt’s renal status

Despite pt’s 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 6/8:

◦ TFs d/c’d on Renal diet 6/10:

◦ Pt. d/c’d with Hospice

IV. Nutritional Status:Evaluation of Nutrition Intervention

Prevent Malnutrition

Ensure pt.’s est. needs are always met

Ensure 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

Medication Function/Purpose

Acetaminophen-oxyCodone-1 tab Pain relief

Asprin-81mg 1x/d Antiplatelet

Bumetanide (Bumex) -2mg- 1x/d Loop diuretic for heart failure & volume overload

Carvedilol-12.5mg-2x/d No selective beta 1/alpha blocker used to treat heart failure

Lansoprazole-30mg-1x/d Proton pump inhibitor

Omeprazole-20mg-1x/d Proton pump inhibitor

Ondansetron-(zofran)-4mg-1tab-1x/d

Antiemetic

OxyCodone-15mg q 4 hrs PRN Narcotic

Spirenolotone-25mg-2x/d Sparing diuretic

IV. Nutritional Status:Medications for D/C

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

Pt’s 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. . .

Pt. Prognosis

1. 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: 1064-1073.

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

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

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

5. Mayo Clinic. Staging of Colon Cancer. Available at http://www. mayoclinic.com/health/medical/IM01892. Accessed on June 12, 2012.

6. Mayo Clinic. Colectomy. Available at http://www.mayoclinic.com/health/medical/IM00231. Accessed on June 12, 2012.

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

8. National Cancer Institue: Colon and rectal cancer page. Available at http://cancer.gov/cancertopics/types/colon-and-rectal. Accessed on June 12, 2012.

References

Who has the first question?