Cancer of the rectum symptoms

Straight or large bowel cancer is a common type of cancer, which is the growth of malignant cells in the rectum or large intestine. Tumors in the colon grow slowly, but can eventually become large enough to block the digestive tract. Cancer can spread to the liver, lymph nodes or other organs;symptoms may not appear until the cancer reaches a significant stage of development. However, with early detection and timely treatment, the prospects are very optimistic. How to treat tumors with folk remedies look here.

Clinic

The clinical picture of obstructive obstruction in colon cancer depends on the combination of two serious diseases and is due to the stage of each of these processes.

Many authors distinguish two forms of obstructive colonic obstruction: acute and chronic. VI Matveev( 1965), IB Rozanov and co-authors.(1975) distinguish between acute and intermittent intestinal obstruction, Yu. M. Ushakov et al. .( 1981), GE Efimov et al.(1984) - acute and partial, AI Bogatov and co-authors.(1976) - complete and partial, RT Panchenkov et al.(1985) - complete and growing.

We support the opinion of NM Ostrovsky( 1929), NN Alexandrov et al.(1980), KI Myshkin et al.(1981) on the advisability of isolating three forms of colonic obstructive obstruction - acute, subacute and chronic.

Acute colonic obstruction begins suddenly, with acute pain in the abdomen, which, like other symptoms, is increasing rapidly. Such an attack occurs among the overall health of people who previously did not consider themselves sick. Pain initially moderate to diffuse throughout the abdomen, after a few hours become paroxysmal, intense, localized in a specific place of the abdomen.

According to F. Dombal et al.(1980), of 5675 patients who had consulted about acute abdominal pain lasting up to 1 week, cancer was detected in 106( 1.9%), including 57( 1%) had colon cancer. The author believes that all patients with abdominal pain of unknown origin should be examined for the exclusion of colon cancer.

A characteristic sign of acute colonic obstruction is the retention of gases and stools. This symptom can occur in people who previously had a normal stool, but more often it is observed in patients with persistent constipation. For acute obstruction is characteristic, in addition to the delay of gases and stools, rapid bloating. Within a few hours the stomach becomes sharply swollen, spherical, there is a desire to release gases, but this does not work. However, in some cases there is a stool at the beginning of an acute attack, but it is usually meager and does not bring relief, since only the distal parts of the colon are emptied.

In some cases, acute development of intestinal obstruction is accompanied by vomiting. It has a reflex character. Vomit consists of gastric mucus and food debris. Only in the later stages, when the small intestine is attached, vomiting becomes abundant, with intestinal contents.

Rapid growth of these signs causes a clinical picture of acute colonic obstruction. According to our data, such a course of the disease is observed in 25% of patients with colon obturation, and somewhat more often when the tumor is localized in the right half and less often - with left-sided tumors. Thus, out of 50 patients with obstructive obstruction in cancer of the right half of the colon, 20( 40%) had an acute form, and out of 142 patients with lesion of the left half only in 33( 23.23%).This is explained by several reasons. A tumor, even small in size, located in the area of ​​the ileocecal valve, can cause obturation, which is manifested by signs of small intestinal obstruction, which, as is known, develops rapidly.

The intensity of the clinical picture is also determined by the condition of the ileocecal valve. It can be functionally complete, that is, do not let the contents of the colon into the small intestine, and the incomplete, when such a reflux is possible. In the first case, a closed cavity forms between the stenosing tumor and the ileocecal valve, the pressure in which rapidly builds up, its walls stretch, which is manifested by the acute development of the clinical picture. With a defective ileocecal valve, the contents from the large intestine can return to a thin one and, thus, the "tight" loop does not form, which is clinically manifested by a less pronounced obstruction pattern.

In addition to the anatomical inferiority of the ileocecal valve, which occurs in 10% of people, functional inferiority can develop. This is observed with a significant stretching of the cecum, when the lips of the valve diverge and can not retain the colonic contents.

The acute form of intestinal obstruction with left-sided tumors, according to our data, is less common. This is due to the slower growth of cancer in the left half of the colon, as well as the large volume of the colon segment between the stenosing tumor and the ileocecal valve.

In case of rectal cancer, the acute form of intestinal obstruction is rare. Most tumors are located in the ampoule of the rectum, and it has a fairly large diameter and its obturation is slow. An exception may be cancer of the rectosigmoid part of the rectum, the narrowest place of the colon, which quickly leads to stenosis and, consequently, intestinal obstruction is acute. According to the data, out of 101 patients with rectal obturation only in 16 the obstruction developed sharply.

Subacute form of colonic obstructive obstruction increases more slowly, but its main difference from acute form is that conservative measures are effective. After the application of cleansing enemas, an abundant stool is marked, pains pass, but this period of remission does not last long. After a few hours, sometimes an episode of intestinal obstruction develops again, requiring medical conservative measures. Intensity of attacks in these cases is less than in acute forms. At subacute current, patients sometimes at home stop an attack of obstruction. However, over time, the severity and duration of colonic obstruction symptoms increase and at the height of one of the attacks the patients enter the hospital. This course of the disease is observed in 30% of patients with colonic obstructive obstruction.

The chronic form is most typical for tumor colon obturation. In these cases, the obstruction develops gradually, without pronounced acute signs, usually against the background of long-term constipation. Up to a certain point, the decrease in the lumen of the gut is compensated by increased intestinal peristalsis. Passage of intestinal contents through the narrowed space also contributes to the mushy nature of the contents, especially in the right side of the colon. However, in the future, with the growth of constriction, subcompensation and decompensation develop and signs of intestinal obstruction progress very quickly. Constipation becomes more stubborn, more forced to take large doses of laxatives, resort to cleansing enemas. Along with constipation, a very important sign of bloating appears. Initially, it is unstable, but over time the stomach remains bloated for an extended period of time. There is a heaviness in the abdomen. The pains initially have a constant aching character, and later become cramping. During this period, patients, as a rule, seek medical help. It is characteristic that therapeutic conservative measures have a positive effect. Pain, and sometimes bloating after a cleansing enema disappear or are much reduced. Experienced doctors release such patients from the reception room home, which is a mistake. After 5-7 days, they again develop an attack of pain with bloating, which is the reason for hospitalization. However, with such a slow development of the disease with a weak intensity of symptoms, the diagnosis is delayed by 2-3 months.

According to our data, a chronic form of intestinal obstruction occurs in 36% of patients with tumor obturation, with damage to the right side of the colon in 17.3%, with cancer of the left half - in 40.2%, with rectal obstruction in 48,3% of patients.

The clinical course of obstructive colonic obstruction may be complicated by the development of peritonitis. The source of inflammation of the peritoneum in these cases is perforation of the tumor, the diastatic perforation of the colon above the tumor, as well as the penetration of microbes through the dilated wall of the colon. According to IA Eryukhin et al.(1981), violations of hemocirculation in the intestinal wall, ulceration and inflammatory processes in the area of ​​the tumor and above it play an important role in the occurrence of peritonitis in patients with colon cancer. The development of peritonitis significantly worsens the condition of patients, and the picture of intestinal obstruction is supplemented with symptoms of peritonitis, signs of irritation of the peritoneum appear, the peristalsis of the intestine subsides, and inflammatory changes in the peripheral blood grow.

The clinical course of obstructive colonic obstruction can simulate acute appendicitis. The mechanism of this phenomenon is different for cancers of the right and left half of the colon. Pain in the right ileal region is a characteristic sign of cancer of the cecum and proximal part of the ascending colon. This is explained by the peculiarities of the growth of tumors of the right half of the colon. They grow rapidly, increase in volume, quickly become infected, and the inflammation passes to the visceral, and then to the parietal peritoneum, which is manifested by the characteristic signs of acute appendicitis.

Another mechanism of pain in the right iliac region is observed with a more distal location of tumors in the large intestine. Gut obturation in these cases leads to stretching of the overlying parts of the colon and, above all, blind. In itself, the stretching of the wall, much less the inflamed and dystrophic changes in the cecal wall, simulate acute appendicitis. According to our data, 2.4% of patients with uncomplicated colon cancer and 10.9% of patients with obstructive intestinal obstruction are diagnosed with acute appendicitis, and more often with lesion of the right side of the colon.

Despite the pronounced clinical picture and great opportunities for detecting intestinal obstruction in colon cancer, these patients are admitted to the hospitals at a later date. Later, 24 to 75 hours after the onset of the disease, 75-90% of these patients are hospitalized, whereas in other forms of acute ileal obstruction later 8.8-29% of patients are hospitalized. This is due primarily to the slower development of obstructive colonic obstruction, as well as to the older age of patients in this group. According to Yu. A. Nesterenko et al.(1977), patients older than 60 years account for 65%, and according to RT Panchenkov et al.(1985), 68% of patients with colon cancer with obturation obstruction were older than 70 years. Among the patients we observed, over 60 years of age were 56.5%.As you know, elderly and elderly people are more reluctant to consult a doctor. However, in some cases, the main reason for the delay in providing adequate care is the differential diagnostic difficulties experienced by doctors in both the polyclinic and in a hospital setting.

Obstruction of the colon's lumen develops as the tumor grows. In itself, the size of the tumor does not have a self-sufficient value. In some cases, gut obturation is observed with small formations. For example, an obstruction in the area of ​​the ileocecal valve can cause small tumors. And yet the larger the tumor, the more opportunities for the development of obstruction;The faster the tumor grows, the sooner comes the obturation.

Recently, researchers have been actively studying the rate of growth of various malignant tumors. M. Nis-Senblatt( 1981) believes that the time of doubling the majority of malignant tumors is 50-80 days and in order to reach a clinically detectable tumor volume of 1 cm in diameter, at least 30 doublings, that is, about 5 years, are necessary. S. Bolin et al.(1983) found that cancers of the colon grow even slower and the doubling time for them is an average of 13Q days. A. V. Chaklin( 1983) writes that from the appearance of the first cancer cell to the development of a clinically manifested tumor passes from 2 to 7 years.

However, complete closure of the gut lumen at the tumor level, even in the clinical picture of obstruction, is rare. Symptoms of colon obturation may appear with preservation of the lumen to 0.6-1.0 cm. In these cases, the development of an obstruction may be promoted by rigidity of the intestinal wall due to a cancer or inflammatory process above and below the site of constriction.

Quite often, the development of complete obstruction is facilitated by foreign bodies that are stuck in a narrow place at the level of the tumor. These can be fruit bones, meat or fish bones, undigested chunks of food. The stopper material may be barium, taken through the mouth for examination of the large intestine. This method of research should not be used even if there is a suspicion of a large intestine. Of 18 patients with initial signs of intestinal obstruction, which were given barium suspension inwards, 7 developed full colon obstruction at the level of the tumor, which required an emergency operation.

An anatomical growth of the tumor is important for the development of colon obturation. Exophyte neoplasms rarely lead to the development of colonic obstruction. Such tumors usually occupy part of the intestinal wall, they are rarely circular, they are located more often in the right side of the colon, where the lumen is wide enough and the contents are semi-liquid. Conversely, endophytic tumors are more often circular, growing as if pulling the lumen of the intestine, narrowing it. They are located in the left side of the colon, where the lumen is already narrow and, moreover, the contents here are already solid. All this contributes to the more frequent development of intestinal obstruction in endophytic, especially infiltrative growth of the tumor. According to NN Alexandrov et al.(1980), of 224 patients with exophytic cancer, intestinal obstruction developed in 14( 6.25%), of 86 with ulcer form-3( 3.52%) and 551 patients with infiltrative tumor growth in 116( 21,05%).

Circular tumor growth, which is more common in the left half of the colon, also contributes to the development of gut obturation. Among 390 patients with a circular tumor, obstruction occurred in 111( 28.46%), and out of 436 patients with noncircular growth - only in 14( 3.21%).

The frequency of development of intestinal obstruction also depends on the location of the tumor. Cancer of the left side of the colon often causes obturation of the lumen. This is due to many reasons, among which the important is the anatomical growth of the tumor, the diameter of the lumen and the nature of the contents of the gut. All these indicators in the left side of the colon contribute to the occurrence of intestinal obstruction.

NN Aleksandrov et al.(1980) with cancer of the left half of the colon observed obturation obstruction in almost half of patients, and in cancer of the right half - 2 times less( Table).

Table. The incidence of obstructive obstruction in colon cancer

According to our data, out of 513 patients, obturation obstruction was detected in 49( 9.55%), most often when the tumor was localized in the left and right side of the colon( Table).

Table. The incidence of obstructive obstruction in colon cancer

The development of a large bowel obstruction also depends on the stage of the disease. The stage of colon cancer is determined by the totality of such signs as the size of the tumor, its spread to the depth of the intestinal wall, to surrounding organs and tissues, the damage to regional and distant lymph nodes and other organs. The development of intestinal obstruction in patients with colon cancer testifies, as a rule, to the neglect of the underlying disease.

According to GA Efimov and Yu. M. Ushakov( 1984), F. Kh. Kutusheva et al.(1984), in 90-100% of patients with complicated colorectal cancer, stage III and IV stages of the disease are identified, with the IV stage being noted in 65-76% of cases [Esperov BN et al., 1979;Panchenkov RT, et al., 1985;Klempert A.Ya. et al., 1986].Of the 306 patients operated in our clinic with signs of tumor colon obturation, radical surgery was performed only in 138( 45.09%), among uncomplicated forms of colon cancer resectiveness was 71%.

It should be noted that in some cases, the obstruction develops not in the place of the primary tumor, but in the other parts of the colon and is caused by compression by metastases or by the spread of the primary tumor.

Conservative treatment of

The task of conservative treatment is the elimination of obstruction of the intestine at the level of the tumor. Expect a positive result only in cases when the tumor does not completely cover the lumen of the intestine, and the obstruction is caused by caloric content, barium, foreign bodies, spasm of the intestine. Opening the lumen of the intestine at least temporarily eliminates the obstruction and improves the patient's condition. The main method of conservative treatment is cleansing enemas. They allow you to clean the distal parts of the colon, and in some cases, the upper segments. If there is no effect, you can repeat the cleansing enema in 20-30 minutes.

Siphon enemas are more effective. If the tumor is low, a small amount of water enters the intestine. It must be ensured that the amount of liquid injected corresponds to the amount of liquid administered. If the water is taken out less than is injected, then it passes above the tumor, but does not return. In these cases, the obstruction clinic will increase and, in addition, there is a risk of a gut rupture in the suprastenotics department. In the same way, the enema should be stopped if there is no calorie content in the washing waters. By the amount of injected fluid, it is possible to approximately determine the localization of the colon's obturation( the symptom of Tsege-Manteuffel).Sometimes the effect of the enema does not appear immediately, but after 20-30 minutes, when a large amount of stool and gases is released.

With low-lying tumors, you can try to pass through a narrowed place a rubber tube and through it to launder the contents. Sometimes the tube can be carried through the rectoscope. When the tumor is located above 30 cm, you can use a fibro colonoscope, which widens the site of constriction. Gut flushing through the biopsy channel is ineffective, although at a width of 5 mm it is possible to remove liquid contents and gases.

Recently, various methods of expanding the narrowing site have been used to increase the effectiveness of washing the suprastenotic part of the colon. For this purpose, electrocoagulation is used through a fibrocolonoscope or laser photocoagulation with a neodymium laser.

The complex of conservative treatment includes also neonatal neocaine blockades. Although some surgeons abandoned them, we observed a positive effect of the blockade. To relieve the spasm apply atropine, platifilin, no-shpu. The introduction of fluid, electrolytes is necessary for the elimination of dehydration, disturbance of the electrolyte and acid-base state. Detoxification of the body helps the introduction of haemodesis, polydesis, enterodesis and as a consequence - an increase in diuresis. Obligatory procedure is gastric lavage.

Conservative treatment should be recognized as effective if:

1) during the enema or immediately after it a large amount of stool and gases has departed;

2) pains in the abdomen completely disappeared;

3) the bloating has clearly decreased;

4) vomiting stopped.

Continue conservative treatment should not be more than 2 hours. If during this time the positive result is not obtained, the patient's condition does not improve, it is necessary to do the operation. In favor of surgical intervention is also evidenced by continuing pain in the abdomen, even if they are permanent, and not cramping. The operation is indicated also in those cases when the improvement of the patient's condition turned out to be short-lived and in a few hours signs of intestinal obstruction appear again. Such a short improvement sometimes deceives young surgeons who, once the signs of obstruction recur, again carry out "successful" conservative measures and postpone the operation. For this very reason, as V.P. Zinevich and co-authors write.(1985).Only 20% of patients operate within the first 6 hours after hospitalization.

According to GL Aleksandrovich et al( 1984), 30% of colon cancer patients admitted with signs of intestinal insufficiency were operated 24-72 hours with repeated cramping abdominal pains.

According to different authors, the number of patients operated on the first day of hospitalization varies widely. Thus, VI Kukosh and co-workers.(1984) only 10.3% of patients operated in the first 24 hours, S. Solonsky and A. S. Sorokin( 1984) - 35.3%, and GA Ivanov et al.(1984), LL Petushkov and co-authors.(1984) - 75-78%.

It is necessary to distinguish between emergency, urgent and early surgery for obstructive obstruction in colon cancer. Emergency surgical interventions are performed within 1 day of observation and treatment of patients in the hospital. This group accounted for 41.9% of all operations. Urgent operations are performed on the 2nd-7th day after the admission of patients. In these cases, conservative treatment led to a temporary improvement in the condition of the patients, but a few days later the attacks of obstruction repeated. In our series there were 21.3% of urgent operations. Operations that perform on the 8-14 day are classified as early, but in about 1/3 of patients, these operations are belated.

According to many authors, a stable positive effect of conservative treatment is observed in 10-25% of cases. II Zatevakhin et al.(1984) observed a positive result from conservative treatment in 34.7% of patients, and VI Kukosh et al.(1984) - in 41.2%.However, it should be remembered that the improvement in patients with colon cancer can not be final and this period should be used to prepare for surgery.

The choice of the right way to treat patients with obstructive colonic obstruction presents certain difficulties, which is due to many reasons. These patients enter the hospital, usually in serious condition, in the presence of two serious diseases( malignant tumor and intestinal obstruction), both diseases in the advanced stage. The severity of the condition of patients is due, in addition, to the old age and concomitant diseases.

In this regard, the natural desire of surgeons with the diagnosis is the desire to help the patient conservative means. Contraindication to the use of conservative methods is the presence of peritonitis. In these cases, surgical intervention should be performed immediately after a short-term preparation of the patient.