Gastroenterology Masterclass

Seema is a 44 year old Indian lady. She saw your partner about 6 months ago with rectal bleeding and was treated for haemorrhoids.

She has two children age 16 and 14 and during each pregnancy she had piles, which required local treatment but resolved after. She saw your partner with a history of reddish blood, which was on the surface of the motion, occasionally dripped into the pan and was on the paper. He treated her with Proctosedyl but did not examine her and told her to come back if the problem did not settle over the next 4 weeks.

It did improve a bit but she now she returns because it has not resolved and now the blood seems to be mixed up with the motion as well. Her bowels are open twice daily but she sometimes has the feeling she wants to go but then doesn’t pass anything.

She has a blameless life style, being a non-smoking, teetotal vegetarian. She works as a PA at a local chemical factory and has been very busy recently which is why she delayed her return, and because your partner didn’t seem very concerned she didn’t come back sooner.

She is now more anxious as a friend has bowel cancer and the diagnosis was delayed. She also wonders whether surgical treatment of her piles would be a good idea. She is less busy at work now and has private health insurance.

Her weight is steady and she is eating well.

Examination of her abdomen is normal. On rectal examination, as well as a small external haemorrhoid, you can feel a hard mass at the tip of your finger, which you are sure is abnormal and is probably a cancer.

Proctoscopy just shows some blood stained motion but you can’t get a better view.

Questions

a) What do you do next? What do you say to the patient and how would you manage the problem? How likely is a rectal cancer is with this story?

b) What is the significance of the haemorrhoids and why have they returned?

c) What do feel about the partner’s management? How would you discuss this with the patient, with the partner and within the practice.

d) The hospital confirms your fears and unfortunately she has a single liver secondary. She and her husband want to talk to you about her previous and future care. How do you approach this? Should she have all the treatment they are suggesting (pre-op radiotherapy, surgery for the primary, surgery for the secondary and chemotherapy)?