is associated with cancers throughout the colon and increased incidence of synchronous lesions, total colonic imaging is required for any patient presenting with this symptom. In patients undergoing emergency colonic resection it is essential that colonoscopy should be performed following post-operative recovery.40
Multiple studies have shown that abdominal pain cannot be used to predict the site of colorectal cancer.20,22
Overall abdominal pain,
unrelated to colonic obstruction or perforation, is one of the most common reasons for referral for lower GI endoscopy41 has a low PPV.23
Some studies have suggested that weight loss is more common in right-sided cancers,8
sided cancers are likely to be more advanced6
which may be a reflection of the fact that right- or have metastases.37
In practice it is felt that weight loss requires total colonic evaluation, as patients presenting with this symptom are unlikely to have a statistically different incidence in right- or left-sided cancers.20
Studies have shown the presence of an abdominal mass to be greater with right-sided cancers,6–8,24
which is felt to be related to right-sided
cancers presenting at a more advanced stage. This feature is not borne out by all studies,20
imaging required for patients with this symptom.24
1. CRUK, UK cancer incidence statistics, 2008. 2. Freedman AN, Slattery ML, Ballard-Barbash R, et al., Colorectal cancer risk prediction tool for white men and women without known susceptibility, J Clin Oncol, 2009;27(5):686–93.
3. Parkin DM, Olsen AH, Sasieni P, The potential for prevention of colorectal cancer in the UK, Eur J Cancer Prev, 2009;18(3):179-90.
4. Rosato FE, Marks G, Changing site distribution patterns of colorectal cancer at Thomas Jefferson University Hospital, Dis Colon Rectum, 1981;24(2):93–5.
5. Kee F, Wilson RH, Gilliland R, et al., Changing site distribution of colorectal cancer, BMJ, 1992;305(6846):158.
6. Nawa T, Kato J, Kawamoto H, et al., Differences between right- and left-sided colon cancer in patient characteristics, cancer morphology and histology, J Gastroenterol Hepatol, 2008;23(3):418–23.
7. McSherry CK, Cornell GN, Glenn F, Carcinoma of the colon and rectum, Ann Surg, 1969;169(4):502–9.
8. Shallow TA, Wagner FB Jr, Colcher RE, Clinical evaluation of 750 patients with colon cancer; diagnostic survey and follow-up covering a fifteen-year period, Ann Surg, 1955;142(2):164–75.
9. Thompson MR, ACPGBI Referral guidelines for colorectal cancer, Colorectal Dis, 2002;4(4):287–97.
10. Marderstein EL, Church JM, Classic “outlet” rectal bleeding does not require full colonoscopy to exclude significant pathology, Dis Colon Rectum, 2008;51(2):202–6.
11. Spinzi G, Fante MD, Masci E, et al., Lack of colonic neoplastic lesions in patients under 50 yr of age with hematochezia: a multicenter prospective study, Am J Gastroenterol, 2007;102(9):2011–5.
12. Saidi HS, Karuri D, Nyaim EO, Correlation of clinical data, anatomical site and disease stage in colorectal cancer, East Afr Med J, 2008;85(6):259SE1 7P62.
13. Nikpour S, Ali Asgari A, Colonoscopic evaluation of minimal rectal bleeding in average-risk patients for colorectal cancer, World J Gastroenterol, 2008;14(42):6536–40.
14. Robertson R, Campbell C, Weller DP, et al., Predicting colorectal cancer risk in patients with rectal bleeding, Br J Gen Pract, 2006;56(531):763–7.
15. Ford AC, Veldhuyzen van Zanten SJ, Rodgers CC, et al., Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis, Gut, 2008;57(11):1545–53.
16. Chapuis PH, Goulston KJ, Dent OF, Tait AD, Predictive value of rectal bleeding in screening for rectal and sigmoid polyps,
but re-affirms the need for total colonic Summary and, as such,
Overall, it is clear that rectal bleeding and change in bowel habit are specific symptoms that can be classified as ‘distal’ symptoms, being closely correlated with cancer in the distal colon. Majumdar et al. has described a “proximal cluster” and “distal cluster” of symptoms that can be easily applied to the clinical setting.22
The distal cluster includes
rectal bleeding, altered stool, tenesmus, rectal mucus or rectal pain. Thompson et al. collected an impressive volume of data, and clearly demonstrated that patients with “distal” symptoms alone could be investigated with a flexible sigmoidoscopy. Furthermore, they showed that colonoscopies performed in patients after a sigmoidoscopy had a low diagnostic yield.24
The proximal cluster includes anorexia, nausea,
vomiting, abdominal pain and fatigue. Anaemia is more closely associated with a right-sided lesion, and should be included in this ‘cluster’. This group of symptoms require total colonic examination to exclude colorectal cancer.20,24
Figure 1 clearly shows the pathway for
appropriate investigations of colorectal cancer, based on the patients’ presenting symptoms, and thus likely cancer site. n
Br Med J (Clin Res Ed), 1985;290(6481):1546–8.
17. Thompson MR, Heath I, Ellis BG, et al., Identifying and managing patients at low risk of bowel cancer in general practice, BMJ, 2003;327(7409):263–5.
18. Thompson MR, Perera R, Senapati A, Dodds S, Predictive value of common symptom combinations in diagnosing colorectal cancer, Br J Surg, 2007;94(10):1260–65.
19. NICE, Guidance on cancer services. Improving outcomes in colorectal cancers, Manual update, National Institutute for Clinical Excellence, 2004.
20. Kent AJ, Woolf D, McCue J, Greenfield SM, The use of symptoms to predict colorectal cancer site. Can we reduce the pressure on our endoscopy services?, Colorectal Dis, 2010;12:114–8.
21. Pepin C, Ladabaum U, The yield of lower endoscopy in patients with constipation: survey of a university hospital, a public county hospital, and a Veterans Administration medical center, Gastrointest Endosc, 2002;56(3):325–32.
22. Majumdar SR, Fletcher RH, Evans AT, How does colorectal cancer present? Symptoms, duration, and clues to location, Am J Gastroenterol, 1999;94(10):3039–45.
23. Puente Gutierrez JJ, Dominguez Jimenez JL, Marin Moreno MA, Bernal Blanco E, Diagnostic value of colonoscopy indication as predictor of colorectal cancer: is it possible to design a fast track diagnosis?, Gastroenterol Hepatol, 2008;31(7):413–20.
24. Thompson MR, Flashman KG, Wooldrage K, et al., Flexible sigmoidoscopy and whole colonic imaging in the diagnosis of cancer in patients with colorectal symptoms, Br J Surg, 2008;95(9):1140–6.
25. Hamilton W, Lancashire R, Sharp D, et al., The importance of anaemia in diagnosing colorectal cancer: a case-control study using electronic primary care records, Br J Cancer, 2008;98(2):323–7.
26. Beale AL, Penney MD, Allison MC, The prevalence of iron deficiency among patients presenting with colorectal cancer, Colorectal Dis, 2005;7(4):398–402.
27. Powell N, McNair A, Gastrointestinal evaluation of anaemic patients without evidence of iron deficiency, Eur J Gastroenterol Hepatol, 2008;20(11):1094–1100.
28. Acher PL, Al-Mishlab T, Rahman M, Bates T, Iron-deficiency anaemia and delay in the diagnosis of colorectal cancer, Colorectal Dis, 2003;5(2):145–8.
29. Li F, Kishida T, Kobayashi M, Serum iron and ferritin levels in patients with colorectal cancer in relation to the size, site,
and disease stage of cancer, J Gastroenterol, 1999;34(2):195–9.
30. Stephens MR, Hopper AN, White SR, et al., Colonoscopy first for iron-deficiency anaemia: a Numbers Needed to Investigate approach, QJM, 2006;99(6):389–95.
31. Knight K, Wade S, Balducci L, Prevalence and outcomes of anemia in cancer: a systematic review of the literature, Am J Med, 2004;116(Suppl. 7A):11S–26S.
32. Stapley S, Peters TJ, Sharp D, Hamilton W, The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: a cohort study using medical records, Br J Cancer, 2006;95(10):1321–5.
33. Rae LC, Community screening for colorectal cancer in north- eastern New South Wales, 1987–1996, Med J Aust, 1998;168(8):382–5.
34. Harmston C, Akwei S, Barnes R, Goodyear S, Wong L, Are screen detected colorectal cancers asymptomatic?, Colorectal Dis, 2010;12(5):416 9.
35. Ammaturo C, Cirillo F, Imperatore F, et al., Colorectal obstruction caused by cancer, Minerva Chir, 1996;51(6):433–8.
36. Turunen MJ, Colorectal cancer obstruction: a challenge to improve prognosis, Ann Chir Gynaecol, 1983;72(6):317–23.
37. Rabeneck L, Paszat LF, Li C, Risk factors for obstruction, perforation, or emergency admission at presentation in patients with colorectal cancer: a population-based study, Am J Gastroenterol, 2006;101(5):1098–1103.
38. Chen HS, Sheen-Chen SM, Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends, Surgery, 2000;127(4):370–6.
39. Wolmark N, Wieand HS, Rockette HE, et al., The prognostic significance of tumor location and bowel obstruction in Dukes B and C colorectal cancer. Findings from the NSABP clinical trials, Ann Surg, 1983;198(6):743–52.
40. Bat L, Neumann G, Shemesh E, The association of synchronous neoplasms with occluding colorectal cancer, Dis Colon Rectum, 1985;28(3):149–51.
41. Panzuto F, Chiriatti A, Bevilacqua S, et al., Symptom-based approach to colorectal cancer: survey of primary care physicians in Italy, Dig Liver Dis, 2003;35(12):869–75.
42. Okamoto M, Shiratori Y, Yamaji Y, et al., Relationship between age and site of colorectal cancer based on colonoscopy findings, Gastrointest Endosc, 2002;55(4):548–51.
43. Tomiyama R, Kinjo F, Hokama A, Saito A, Relationship between diabetes mellitus and the site of colorectal cancer, Am J Gastroenterol, 2003;98(4):944–5.
Other Factors Influencing Colorectal Cancer Site
The frequency of right-sided colon cancer increases with patient age,42
although patients ≤40 years of age also have a relatively high incidence of right-sided lesions.6
Hence, total colonoscopy should be
implemented for all age groups undergoing colorectal cancer screening. Diabetes has also been associated with right-sided colonic lesions.43
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