INTRODUCTION

Rectal cancer is a disease in which malignant (cancer) cells form in the

tissues of the rectum. Almost all rectal cancers are primary adenocarcinomas.
Adenocarcinoma of the rectum is a major cause of mortality and morbidity in
North America and Western Europe. Rectal cancers are, after colon cancers,
the second most common gastrointestinal (GI) carcinoma, and have the best
prognosis. The 5-year survival rate is approximately 50%. Screening for and
removing adenomatous polyps may improve survival rates.
The American Cancer Society has estimated that in 2008, over 148,000
people will have been diagnosed with colorectal cancer and that close to
50,000 people will die of colorectal cancer. Colon cancers will number 108,070
(53,760 men; 54,310 women), and 40,740 will be rectal cancers (23,490 men,
17,250 in women

Colorectal cancer is the second leading cause of cancer death for men
and women combined (third leading cause when men and women are
considered separately). About 49,960 deaths (24,260 men; 25,700
women) are expected to have occurred in 2008. The highest GI cancer rates
are in the Northeast and North Central states, and the lowest rates are in the
southern and western states (except for the San Francisco Bay area and
Hawaii, which have the highest incidences in the United States).

More than 940,000 new cases of colorectal cancer and nearly 500,000
related deaths are reported each year worldwide (World Health Organization,
2003). The incidence rate of rectal cancer is highest in the westernized
countries of North America, northern Europe, Australia, and New Zealand.
Intermediate rates are found in southern Europe, and there are low rates in
Africa, Asia, and South America. Rectal cancer shows less international
variation than colon cancer. Although there is a 60-fold difference in the
incidence rates of colon cancer between countries with the highest incidence
and those with the lowest incidence, there is only an 18-fold difference in the
incidence rates for rectal cancer. High colon-to-rectal cancer ratios (3-4:1)
prevail in North America, northern Europe, Australia, and New Zealand. Ratios
equalling less than 1 are typical in Asia and Africa.

The incidence of colorectal adenomas in Filipinos is low compared with

that in age-adjusted Western populations. This finding coincides with a low
incidence of colorectal carcinoma. The documentation of a low risk for
adenomatous polyps and colorectal cancer indicates that it would be difficult
for massive screening programs to demonstrate a significant positive impact
on the early detection of colorectal neoplasias in the Filipino general
population.
 BACKGROUND KNOWLEDGE

ETIOLOGY:

Rectal cancer usually develops over several years, first growing as

a precancerous growth called a polyp. Some polyps have the ability to turn
into cancer and begin to grow and penetrate the wall of the rectum.

The actual cause of rectal cancer is unclear. However, the following are risk
factors for developing rectal cancer:

• Increasing age
•
• Smoking
•
• Family history of colon or rectal cancer
•
• High-fat diet and/or a diet mostly from animal sources
•
• Personal or family history of polyps orcolorectal cancer

Family history is a factor in determining the risk of rectal cancer. If a family

history of colorectal cancer is present in a first-degree relative (a parent or
a sibling), then endoscopy of the colon and rectum should begin 10 years
before the age of the relative's diagnosis or at age 50 years, whichever comes
first.

An often forgotten risk factor, but perhaps the most important, is the lack of
screening for rectal cancer. Routine cancer screening of the colon and rectum
is the best way to prevent rectal cancer.

TREATMENT

Several healthcare professionals works together to help manage rectal

cancer. Among them are the general surgeon or cancer surgeon, radiation
oncologist, medical oncologist, and a primary care physician.

Rectal cancer is primarily treated with surgery. The surgeon removes the
entire tumor, if possible. Often, this means part of it must be removed. If
cancer has spread to the lymph nodes, the risk of a recurrence is higher.
Usually, surgery is combined with radiation and chemotherapy. A person
with rectal cancer may be given radiation before, during, or after surgery.
The purpose of the radiation is to decrease the risk of tumor recurrence.
Sometimes the cancer has spread too far to be removed surgically. While
a number of chemotherapy medications are used at this point, none offer
a cure. Treatment mostly relieves symptoms, such as swelling and
jaundice. Rectal cancer responds to chemotherapy in less than 50% of
cases. Research into treatment options for rectal cancer continues, in the
hope of producing better response rates than are seen currently.

NURSING MANAGEMENT

1. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk

for
infection; Social isolation; Imbalanced nutrition: less than body requirements

2. Client Education
Avoid close contact with others until treatment is completed
Maintain daily activities unless contraindicated, allowing for extra rest periods
as needed Maintain balanced diet; may tolerate food better if consumes
small, frequent meals

Maintain fluid intake ensure adequate hydration (2-3 liters/day)

Excreted body fluids may be radioactive; double-flush toilets after use

Place client in private room
Ensure proper handling and disposal of body fluids, assuring the containers
are marked appropriately
Ensure proper handling of bed linens and clothing
Educate client in all safety measures

•
•
MEDICAL MANAGEMENT

Despite significant advances in surgical therapy for rectal cancer,

recurrence and metastases still occur in a significant number of patients.
Radiotherapy has resulted in better local control while chemotherapy has been
used to eradicate micro-metastases. Many large studies have shown that the
addition of chemo-radiation increases eradication of tumor locally compared to
radiotherapy alone. No significant improvement was seen in distant
metastases or survival. In general, T3 and T4 (Stage II) tumors along with all
stage III and IV disease are definite indications for chemo-radiation which may
be given pre- or post-operatively.
 Pre-operative (neoadjuvant) treatment is often used for patients with
locally advanced or fixed rectal cancers. It can reduce tumor size and increase
respectability. Post-operative (adjuvant) radiation is also used when either
resection was grossly or microscopic incomplete, with the former having worse
results. Radiotherapy without surgery is not indicated unless only palliation is
expected.

Radiation without chemotherapy is not widely practiced. The evidence

supports the addition of combined chemo-radiation with better sphincter
preservation, better lower control and similar long-term survival. Newer
approaches include 5-FU in combination with oxaliplatin, irinotecan and
capecitabine with oxaliplatin. Newer chemotherapeutics such as the
epidermal growth factor and vascular endothelial growth factor inhibitors,
though commonly used as second-line treatments, are still undergoing
investigation to determine their most appropriate role.

Intraoperative electron beam radiation has been used in conjunction with

pre-operative radiation and/or chemotherapy for tumors that have gross
margins after resection or significant fixation. High-risk areas are determined
to establish the field of radiation by the surgeon and in cooperation with the
oncologist.

Finally, recurrent rectal cancer remains a significant challenge. The choice

of therapy can include all those discussed above and depend in part on prior
therapy modalities used and the extent of recurrence: local or metastatic.
Thus extensive evaluation, often including CT and PET, to determine the
extent of disease is imperative. Palliation is offered if the tumor is found to be
unresectable and/or significant metastases have occurred. Therapies include
stenting, bowel bypass surgery or palliative tumor resection. As with colon
cancer, isolated liver and lung metastasis should be considered for resection.

Although medical therapy is widely available in developed countries, its

availability is limited in under-developed countries. Cancer centers where
radio-and chemotherapy are available are being established, but are scarce
and still in the developing stage. This is one area where improvement can
have a significant impact on this disease.

PATHOPHYSIOLOGY

over 70% of rectal cancers, regardless of etiology, arise

from adenomatous polyps
 point mutations in the K-ras proto-oncogene

hypomethylation of DNA

leading to gene activation

loss of tumor-suppressor gene (the adenomatous polyposis coli (APC) gene on

5q21 and colorectal cancer (DCC) gene on 18q) and mutations in the p53
tumor-suppressor gene

in mucosal proliferation

polyp

carcinoma

ANATOMY AND PHYSIOLOGY

 The rectum lies anterior to the sacrum and coccyx and is approximately
15 cm long. The rectosigmoid junction is located at the end of the sigmoid
mesocolon. Its upper third is covered almost completely by peritoneum. Below
this level, the peritoneum is reflected anteriorly onto the posterior surface of
the uterus and vagina in females and onto the posterior surface of the bladder
in males. The peritoneal recesses, the pouch of Douglas (rectouterine), and
the rectovesical pouch lie between these organs.

The lower half of the rectum is entirely extraperitoneal. The rectum ends
just below the level of the coccyx. It turns posteriorly, through the puborectal
sling of the levator ani muscles, to become the anal canal. The rectum is
supplied by the superior rectal branch of the inferior mesenteric artery and by
branches of the internal iliac arteries. The rectal lymphatics drain superiorly
into the superior rectal nodes, then through the inferior mesenteric nodes, and
laterally into the internal iliac nodes.

The rectal wall is composed of 5 layers: the mucosa (lined with columnar
epithelium), the muscularis mucosa, the submucosa, the muscularis propria
(an inner circular layer and an outer longitudinal layer, comprising 3 narrow
bands), and the serosa.

Findings
Double-contrast barium enema:

• Most rectal cancers are 3-4 cm in diameter at diagnosis.

• Polypoid lesions vary from small smooth tumors to larger, lobulated
masses with an irregular surface and associated contour deformity along
one margin of the bowel wall

Polypoid carcinoma of the upper rectum.

• Annular lesions result from irregular circumferential masses that

severely constrict the bowel lumen.
• Margins of the carcinoma show overhanging edges, which are the tumor
shelf or shoulder
 PRE-OPERATIVE MEDICATIONS
ACTION DOSAGE
antihistamine mainly 25–50 mg
DIPHENHYDRAMIN(BENADR used to treat allergies. EVERY 4-6
YL) Like most other first HOURS
generation
antihistamines, the drug
also has a
powerfulhypnotic effect,
and for this reason is
often used as a non-
prescription sleep aid
and a mildanxiolytic.
The drug also acts as
an antiemetic.

BUPIVACANE local anaesthetic drug

belonging to
theamino amide group.

POST-OPERATIVE MEDICATIONS
ACTION DOSAGE
Mefenamic acid is 500mg
MEFENAMIC ACID a non-steroidal anti- 1 cap TID
inflammatory drug used
to treat pain.

CEFALEXIN Cephalexin (cefalexin) is 500mg

a cephalosporin 1mL TID
antibiotic used to treat
bacterial infections of
the upper respiratory
tract, the middle ear, the
bones, the skin, and the
 reproductive and urinary
systems. Cephalexin
(cefalexin) works by
interfering with the
bacteria's cell wall
formation.

DRUG STUDY

Cefalexin Mefenamic Acid

Action Inhibits bacterial cell Aspirin like that analgesic,
wall synthesis, thus antipyretic and anti-
promoting osmotic inflammatory activities these
instability which activities appear to be due to its
eventually leads to the ability to inhibit cyclooxygenase
bacterial cell death. and also antagonize certain
effects of prostaglandins.
Mefenamic acid displays central
and peripheral activities.
Indication Infections caused by Relief of pain including muscular,
staphylococcus, and rheumatic, traumatic, dental,
other susceptible post-operative and post parum
microorganism. pain, headache, fever and
dysmenorrhea.
Dosage 500 mg 1ml 3x/day 500mg (1 cap) 3x/day
Contraindicatio Allergy to penicillins and Pregnancy and lactation,
n cephalosporins. hypersensitivity, active
ulceration of either the upper or
lower GIT. If diarrhea or skin rash
appears, the drug should be
stopped at once.
Precaution Impaired renal function. If biliuria is suspected, Harrison
Pregnancy, prematures spot test should be performed
and infant less than 1 history of GI inflammatory
mo. Monitor renal and disease. Monitoring of
hematological status, prothrombim time when the drug
bronchial asthma and is administered to patient
poor oral nutrition. receiving oral anti-coaggulation.
Adverse Signs of allergy and GI discomfort, diarrhea or
Reaction digestive disorders. constipation, gas pain, nausea,
vomiting, drowsiness and
dizziness have been observed.
Peptic ulceration, nervousness.
Visual disturbances,
 bronchoconstriction. Signs of
hemolytic anemia should be
watched in case when the drug is
taken for prolonged period of
time.

THEORETICAL FRAMEWORK

When cells that are not normal grow in the rectum or in the colon,
colorectal cancer occurs. This is also called cancer of the colon or rectal
cancer. It forms tumors as it grows. This type of cancer usually occurs in the
life of people above 50 years of age and is one of the most common types of
cancer in today. It is the second leading cancer deaths in America today and
what makes it to be complex is that it is not detected easily.

Usually, it starts as polyps which are little growths inside the colon or the
rectum. Colon polyps are very common though not all of them turn out to
become cancer. However, it is very difficult to tell ahead which polyp will
graduate to cancer and which one will not. This is why it is very important for
people over 50 years old to go for test and ascertain if they have any polyps
and if there is, it is necessary that they be removed.

What makes this particular type of cancer to be very dangerous is that it

does not have any known symptom or the symptom may hide until it begins to
spread. But while observing your body, which is a normal thing to do, if you
notice the following symptoms in your body, you should try to see a doctor,
because probably, colon cancer might be in place.

It is no surprise perhaps that people sometimes wonder if they may have

colon cancer symptoms and need to know more about this variant of cancer
that continues to affect more and more people every year.

Colon cancer symptoms indicating likely diagnosis of what is more

generally referred to as colorectal cancer, because it may affect the colon and
or the rectal areas, is the third most common form of cancer in developed
countries such as the US and Canada. It is also the third leading cause of
cancer-related death. Figures indicate that there are approximately three
times as many colon cancer cases as there are incidences of cancer of the
rectum.

In real terms, taking the United States as an example, more people will be
suffering colon cancer symptoms with about 150,000 new cases of colorectal
cancer being diagnosed in the last year (2008 at the time of writing) and
about 50,000 will have died from the disease during the same time
period.Well on the way to US$300 million will be being poured into colon
cancer and rectal cancer research this coming year. Yet, as with so many
'traditionally researched' medical topics it is commonly reported that 'no one
really understands the causes of the disease'.

Of course there are plenty of theories about what may trigger the
development of colon cancer and consequently cause colon cancer symptoms,
and there is some useful advice that everyone should consider following to
reduce the risk of becoming a colorectal cancer statistic. But for many people
around the globe, their progress towards suffering the symptoms of colon
cancer or rectal cancer will already be to advanced to stop them from
receiving the damning diagnosis in this coming year.

Terrible though this diagnosis will be, or may have recently been for you,
as any news that you have any kind of cancer is a traumatic event in itself and
takes time to 'get your head around' and realize that in most cases there are
many vital things you can and should do to preserve and remedy your health
as quickly as possible

A recent Australian study found that the incidence of rectal cancer in men is
rising significantly plus how our genes and the environment can influence the
occurrence of cancer.

According to Dr. James Semmens from the Centre for Health Services
Research at University of Western Australia, colorectal cancer is the most
commonly occurring internal cancer affecting both men and women, and the
second most common cause of cancer-related death in Australia. What is
interesting about this finding of the increase in rectal cancer in males is that
this hasn't been seen in international studies. The increase was about 1.6%
per year, since 1982 up until 1995.

DISCHARGE PLANNING

Patient education and discharge planning require the combined effort of

the physician, nurse, enterostomal therapist, social worker, and dietitian. The
patient was given specific information, individualized to his needs about signs
and symptoms of potential complications. Dietary instructions essential to
help him identify and eliminate irritating foods that can cause diarrhea or
constipation were also specified. The importance of teaching about their
prescribed medications {ie,action ,purpose, and possible side and toxic
effect} were also emphasized. The nurse reviewed the
treament{ eg,irrigations, wound cleansing} and dressing changes and
encouraged the family to participate. The home environment was assessed
for adequacy of resources that will allow the patient to manage self care
activity. A family member had assumed responsibility for purchasing the
equipments and supplies needed at home. Patient was given specific
instruction as to when to call the physician.

The patient was advised to comply with the following:

 Check-ups every 6 months for the first 2 years after surgery, then annually
for up to 5 years after surgery, followed by colonoscopy every 6 years.
 Physical examination only as indicated; for rectal carcinoma, digital rectal
examination every 6 months.
 Routine carcinoembryonic antigen (CEA) assessment and diagnostic
imaging are not indicated due to their low diagnostic yield.