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1. Kenapa pada obstruksi kobisa terjadi dehidrasi?

Gambaran pertama dalam memeriksa pasien dengan kecurigaan obstruksi


usus merupakan adanya tanda generalisata dehidrasi, yang mencakup
kehilangan turgor kuJit maupun mulut dan lidah kering. Karena
lebih banyak cairan. disekuestrasi ke dalam lumen usus, maka bisa
timbul demam, takikardia dan penurunan dalam tekanan darah.

2. Instruksi post opnya apa?


a. Pertahankan masa gastrik tube 1-3 hari
b. Diet peroral diberikan segera setelah saluran pencernaan berfungsi,
dimulai dengan diet cair dan bertahap diberikan makanan lunak dan padat
c. Mobilisasi sedini mungkin
d. Kontrol rasa sakit seminimal mungkin

3. Apakah ca sigmoid selalu menyebabkan ileus obstruktif?


Tidak
We identified 1004 patients with stage IV colon cancer subsequently hospitalized with
BO (8.0%). In multivariable analysis, proximal tumor site (hazard ratio, 1.22 [95% CI,
1.07-1.40]), high tumor grade (1.34 [1.16-1.55]), mucinous histological type (1.27 [1.08-
1.50]), and nodal stage N2 (1.52 [1.26-1.84]) were associated with increased risk of BO,
as was the presence of obstruction at cancer diagnosis (1.75 [1.47-2.04]). A more recent
diagnosis was associated with decreased risk of subsequent obstruction

In this large population of patients with stage IV colon cancer, BO after diagnosis was
less common (8.0%) than previously reported. Risk was associated with site and
histological type of the primary tumor. Future studies will explore management and
outcomes in this serious, common complication.

Incidence and Predictors of Bowel Obstruction in Elderly Patients With Stage IV Colon
CancerA Population-Based Cohort Study
Megan Winner, MD, MS1,4; Stephen J. Mooney, MS4; Dawn L. Hershman, MD2,4; et alDaniel
L. Feingold, MD1; John D. Allendorf, MD1; Jason D. Wright, MD3; Alfred I. Neugut, MD, PhD2,4
Author Affiliations Article Information
JAMA Surg. 2013;148(8):715-722. doi:10.1001/jamasurg.2013.1
4. Jadi utk screeningnya gimana?
Barium enema dan rektosigmoidekopi, Kalo ada lesi yg mencurigakan baru
kolonoskopi.

Fecal occult blood test (FOBT) untuk mendeteksi adanya darah dalam tinja.
Pembuluh darah di permukaan polip atau usus besar seringkali rapuh dan mudah
rusak karena dilalui oleh feses/kotoran.
Digital rectal exam 1-2th.

Pilihan pemeriksaan skrining ditentukan berdasarkan risiko individual,


pilihan individual dan akses. Pada orang dewasa dengan risiko
sedang, skrining harus dimulai pada individu berusia 50 tahun
dengan pilihan berikut:11
1. Colok dubur
2. FOBT atau FIT setiap 1 tahun
3. Sigmoidoskopi fleksibel setiap 5 tahun
4. Kolonoskopi setiap 10 tahun
5. Barium enema dengan kontras ganda setiap 5tahun
6. CT kolonografi setiap 5 tahun

5. Kapan diperlukan terapi ajuvan seperti kemo?


Kalo udah stage 3 biasanya dilakukan kolektomi sampe ke lymph node trs
dilanjutkan dgn kemo.

But your doctor may recommend adjuvant chemotherapy (chemo after surgery) if
your cancer has a higher risk of coming back (recurring) because of certain
factors, such as:

 The cancer looks very abnormal (is high grade) when viewed under a
microscope.

 The cancer has grown into nearby blood or lymph vessels.


 The surgeon did not remove at least 12 lymph nodes.

 Cancer was found in or near the margin (edge) of the removed tissue,
meaning that some cancer may have been left behind.

 The cancer had blocked off (obstructed) the colon.

 The cancer caused a perforation (hole) in the wall of the colon.

6. Jadi kalo udah ketauan polip hrs diapain biar dia gak berkembang jd crc?

Lakukan polipektomi kolonoskopi. Jd pas kolonoskopi si polip yg kecil < 2 cm


bisa dibuang dgn jepitan kauter pd kolonoskopi. Kalo > 2cm, dpt di eksisi
segmental pake kolonoskopi cuma tidak ideal krn telah bersifat kanker dan resiko
komplikasi lebih besat.
Abis di polipektomi hrs periksa secara periodic, biasanya 1 tahun kemudian
kolonos lagi dan kemudian tiap 3 th buat nyari ada ato ga lesi baru.

Bisa juga dilakukan laparoptomi utk eksisi buat polipekyomi. Kolektomi


segmental jarang dilakukan kecuali kalo emg dia ganas.

7. Kalo ca sigmoid itu ada nyeri perut yg khas gak?


Ca sigmoid kan masuknya ke kanker kolorektal kiri, biasanya nyerinya itu…
Kolon dipersarafi oleh serabut simpatis yang berasal dari n. splanknikus
dan pleksus presakralis serta serabut parasimpatis yang berasal dari n. vagus.
Karena distribusi persarafan usus tengah dan usus belakang, nyeri alih pada kedua
bagian kolon kiri dan kanan berbeda. Lesi pada kolon bagian kanan yang berasal
dari usus tengah terasa mula-mula pada epigastrium atau di atas pusat. Nyeri dari
lesi pada kolon desendens atau sigmoid yang berasal dari usus belakang terasa
mula-mula di hipogastrium atau di bawah pusat dan nyeri perut

8. Paling sering metastasisnya kemana? Kobisa emg penyebarannya gimana?


In summary, we provide reliable figures on the metastatic spread from colon and rectal cancer.
Anatomical location and histological subtype profoundly affected the patterns of metastasis when
considering organs beyond the liver: rectal cancer metastasized to the thorax, nervous system and
bone, whereas colon cancer and mucinous and signet ring adenocarcinomas metastasized within
the peritoneum. Prognosis in CRC patients with solitary metastases was worst in nervous system
(4 months) and bone (5.5 months) metastases, intermediary in liver metastases (9 months) and
most favorable with thoracic metastases (14 months)

Recent research on the immunology of cancer has provided intriguing insight into the metastatic
process, and may help us further understand the difference between thoracic and liver metastases.
In the present study, many CRC patients presented with extrahepatic metastases and without
detectable liver metastases. As discussed above, anatomical factors may be an explanation.
However, one could hypothesize that liver metastases have indeed been present, but have been
eliminated or entered a dormant phase, rendering treatment ineffective.
At lower stages, thoracic metastases were almost as frequent as liver metastases,
and also in stage IV patients with multiple metastases. The only group where liver
metastases were clearly more common was in stage IV patients with single
metastases. Similar findings were reported in a recent Japanese hospital study,
where lung metastases were more frequent in CRC patients who underwent
curative surgery, compared with stage IV patients.
Therefore, it seems that lung metastases need a longer time to grow, compared
with liver metastases. an unaccustomed thought, because the liver is considered an
immunosuppressive organ29 and survival in liver metastases was indeed poor, only 9 months. If
the metastasis succeeds in escaping the immune system, the milieu of the liver will promote the
growth of liver metastases, which thus will become clinically apparent. Metastases to other sites
have yet not occurred, at least at a clinically detectable rate. The relatively better prognosis in
thoracic metastases implies a slower growth rate, which is compatible with retained activity of
anti-tumor immune responses. Improvements in radiological methods have enabled detection of
event smaller tumor growths, e.g. lung metastases

It appears that CRC spreads via the portal circulation to the liver, and from there to the lungs. It
may also reach the lungs directly, perhaps using lymphatics, or directly from the distal rectum.
However, in the present data there were clear indications that the lungs seem to be an important
waypoint toward further spread: nervous system metastases occurred more frequently together
with respiratory metastases than with liver metastases

9. Kenapa banyaknya kok metastasis ke hati?


The liver is the most common site of metastasis in patients with colorectal cancer due to
its anatomical situation regarding its portal circulation

Pembuluh darah vena mengikuti pembuluh darah arteri


untuk menuju ke vena mesenterica superior dan arteri
mesenterica inferior yang bermuara ke dalam vena porta

10. Seberapa bsr kemungkinan polip jd crc?

Although most colorectal polyps do not


become cancer, virtually all colon and rectal
cancers start from these growths. People may
inherit diseases in which the risk of colon
polyps and cancer is very high.

The vast majority of polyps are NOT cancerous or even pre-cancerous. The polyps without the
potential to turn into cancer include small hyperplastic polyps, inflammatory polyps, and
hamartomatous polyps which are not part of an inherited polyp syndrome. The precancerous
polyp which can turn into a cancer is called an adenoma. The two most common types of
colorectal polyps are hyperplastic polyps and adenomas. Usually, the larger the size of the
adenoma, the greater the chance that there may be cancer or pre-cancerous cells present in the
polyp. Since it is hard to determine the exact nature of a polyp, polyps found during colonoscopy
are removed and sent to the lab for a microscopic analysis.

Current theories propose it will take about 10 years for a small adenoma to transform into a
cancer. That is why the standard interval for screening colonoscopy is 10 years. However, the
time interval may be shorter for patients with a hereditary form of colon cancer (like familial
adenomatous polyposis or hereditary non polyposis colorectal cancer) or inflammatory bowel
disease. The recommended intervals are general guidelines and may not apply to every patient.
11. Apa hubungannya red meat sm crc?

The International Agency for Research on Cancer (IARC) has classified


processed meat as a carcinogen, something that causes cancer. And it
has classified red meat as a probable carcinogen, something that
probably causes cancer. They found that eating 50 grams of processed
meat every day increased the risk of colorectal cancer by 18%.

Scientists have offered a number of explanations for the link between red meat
and colon cancer. One theory blames heterocyclic amines (HCAs), chemicals
produced when meat is cooked at high temperatures. HCAs may play a role, but
since high levels can also be present in cooked chicken, they are unlikely to be
the whole explanation. Preservatives have also been implicated in the case of
processed meats; nitrates are a particular worry, since the body converts them
to nitrosamines, which are carcinogenic. But since fresh meat is also linked to
colon cancer, preservatives can't be the whole answer.

These results are interesting enough on their own, but Dr. Michelle Lewin and
her colleagues went one step further. They were able to retrieve cells from the
lining of the colon that are shed into the stool with every bowel movement as a
normal event. The cells from people eating the high-meat diet contained a large
number of cells that had NOC-induced DNA changes; the stools of vegetarians
had the lowest number of cells with damaged genetic material, and the people
who ate high-meat, high-fiber diets produced intermediate numbers of damaged
cells.

Did you ever wonder what puts the red into red meat? The short answer
is myoglobin, a protein that looks red when it binds with oxygen. But after a few
days in the refrigerator, myoglobin gives up its oxygen and the meat turns brown.
To keep meat looking rosy, manufacturers may pump in some carbon monoxide,
which sticks to myoglobin like glue, keeping it red for weeks. Carbon monoxide is
also used to keep tuna looking fresh, and a variety of additives are used to
improve the appearance of other foods. The moral: Don't judge a food by its
color.

Where's the beef?

The study from England showed that large amounts of red meat can produce
genetic damage to colon cells in just a few weeks. It's an important finding, but it
does not prove that red meat causes cancer. None of the cells were malignant,
and the body has a series of mechanisms to repair damaged DNA. In most
cases, the repairs are successful, but when they fail, cells can undergo malignant
transformation.

12. Jadi kalo ada ileus obstruktif pada crc itu tatalaksananya hrs diapain?
One such problem is bowel obstruction (BO), which occurs when a cancerous growth or adhesions
block intestinal flow; the resulting nausea, vomiting, pain, and dehydration usually require
inpatient hospitalization.2,3 Although untreated BO can be fatal,4 most patients receive treatment
because onset is typically progressive rather than acute,5,6 and symptoms are too severe to be
ignored.7 The prognosis of patients with BO is poor; life expectancy is typically measured in
weeks to months,8,9 in part because the circumstances that typically give rise to BOs herald the
end of life

13. Kemungkinan recurrence gak sih?


From a total of 446 patients who were been treated for colon carcinoma
with curative intent, 74 developed recurrent disease (17%). In 43 of those
patients (58%), recurrent disease was detected during a scheduled follow-up
visit, with 41 (95%) being asymptomatic. Tumor marker testing, imaging, and
colonoscopy identified all of these recurrences. In the remaining 31 patients with
recurrent disease (42%), recurrence was found during non-scheduled interval visits;
26 (84%) of these patients were symptomatic. The most prevalent symptoms
were abdominal pain, altered defecation, and weight loss. Patients with asymptomatic
recurrences had a significantly higher overall survival compared with
patients with symptomatic recurrences.

Kalo dari penelitian ncbi, dilakukan selama 10 tahun.

Surveillance for recurrences, particularly for relapses in the liver and lung, should be
performed for at least 4 years in colon cancer patients. Patients with rectal cancer should
be followed for a longer period than those with colon cancer, focusing on locoregional,
liver and lung recurrence. It is particularly noteworthy that adjuvant chemotherapy may
prolong the interval until recurrence and the interval until lung metastasis is relatively
longer.

Symptoms of recurrent colorectal cancer may include systematic changes that affect
the whole body, such as fatigue or weight loss. Other symptoms may be related to
lymph node swelling or lumps in the lymph nodes.

14. Ada gak kegawatdaruratan lain pd crc selain ileus obstruktif?


Perforasi, perdarahan

Insiden terjadinya perforasi kanker kolorektal 2,3-2,5%, ditandai dengan adanya peritonitis.Perforasi kolon
merupakan kegawatdaruratan dimana terjadi kebocoran kolon sehingga isi kolon masuk ke rongga
peritoneum dan menimbulkan peritonitis baik lokal maupun difus.
Pemeriksaan colok dubur dilakukan pada setiap pasien dengan gejala ano-rektal. Pemeriksaan ini bertujuan
untuk menetapkan keutuhan sfingter ani dan menetapkan ukuran dan derajat fiksasi tumor pada rektum 1/3
tengah dan distal. Pada pemeriksaan colok dubur ini yang harus dinilai adalah: Keadaan tumor: Ekstensi
lesi pada dinding rektum serta letak bagian terendah terhadap cincin anorektal, cervix uteri, bagian atas
kelenjar prostat atau ujung os coccygis. Mobilitas tumor: Hal ini sangat penting untuk mengetahui prospek
terapi pembedahan. Ekstensi dan ukuran tumor dengan menilai batas atas, bawah, dan sirkuler

1. Obstruksi akibat kanker kolorektal


Ileus obstruktif merupakan kegawatan yang paling tersering di jumpai pada kasus keganasan
kolorektal. Ileus obstruksi merupakan suatu penyumbatan mekanis baik total atau parsial pada
usus yang akan menganggu atau menghambat pasase cairan, gas maupun makanan. Penyumbatan
ini dapat terjadi pada setiap titik sepanjang traktus gastrointestinal dan gejala klinis yang muncul
tergantung pada tingkat obstruksi yang terjadi. Obstruksi menyebabkan dilatasi usus bagian
proksimal dan kolapsnya usus bagian distal. Obstruksi yang disebabkan oleh tumor umunya
adalah obstruksi sederhana yang jarang menyebabkan strangulasi.Total angka kejadian obstruksi
dari kanker kolorektal terjadi 8-10 %, 60 % terjadi pada usia tua. Duapertiga terjadi pada kolon
kiri dan sepertiga di kolon kanan.

a). Gambaran klinis


Gambaran klinis dapat berupa nyeri kolik abdomen, distensi, perubahan tingkat kesadaran,
kemudian baru diikuti dengan muntah feculent (muntahan kental dan berbau busuk bercampur
feses), pasien tampak dehidrasi dan sampai timbul syok/renjatan ditandai dengan akral dingin,
kulit kering dan tekanan darah menurun.Pada pemeriksaan auskultasi dapat ditemukan bising usus
meningkat atau tidak ditemukan bising usus pada kasus obstruksi lama. Pemeriksaan colok dubur
dapat dilakukan untuk mengetahui letak tumor, apakah di rektum atau di kolon.

b). Diagnosa62,63
Secara keseluruhan, pemeriksaan foto polos mempunyai sensitivitas 84 % dan spesifitas 73 %
dalam diagnosis ileus obstruksi .Standar pemeriksaan foto polos abdomen adalah serial yang
terdiri dari 3 jenis foto yaitu: foto abdomen supine AP, abdomen tegak AP dan foto toraks tegak.
Pada pasien yang tidak kooperatif, pemeriksaan foto polos abdominal minimal dilakukan dua
posisi yaitu pada posisi supine yaitu anteroposterior (AP) dan tegak (AP) hal hal yang harus
diperhatikan pada pemerisaan foto polos abdominal adalah adanya pelebaran usus, adanya fluid
level patologis, penebalan dinding usus dan distribusi udara Gambaran radiologis obstruksi usus
besar bergantung pada kompetensi katup ileosekal. Terdapat beberapa tipe obstruksi kolon yaitu
tipe obstruksi dimana katup ileosekal masih kompeten. Pada keadaan ini dapat terlihat berupa
dilatasi kolon tipis tanpa adanya distensi usus halus. Bila obstruksi terus berlangsung maka dapat
menyebabkan katup ileosekal tidak kompeten, sehingga akan terjadi distensi usus halus. Pada
keadaan awal dari inkompetensi katup ileosekal menunjukkan diameter sekum dan kolon asendens
terdistensi maksimal dibandingkan kolon bagian distal disertai adanya udara pada usus halus. Bila
obstruksi berlangsung lama udara pada sekum dan kolon asendens berangsur berkurang, dan udara
masuk ke dalam usus halus dan mengisi ke lebih banyak ke usus halus. Pada keadaan ini
menyerupai obstruksi usus halus Gambaran radiologis dari ileus obstruksi usus besar adalah kolon
yang terdistensi terletak pada abdomen bagian perifer dan dapat dibedakan dari usus halus yang
terletak pada sentral abdominal dengan adanya gambaran haustra. Dilatasi sekum yang melebihi 9
cm dan dilatasi bagian koloksin lain yang melebihi 6 cm dianggap abnormal yang Bagian usus
yang terletak distal dari obstruksi akan kolaps dan bagian rektum tidak terisi oleh udara.
Identifikasi kolon pada sonografi seringkali sulit karena kolon dipenuhi dengan gas dan feses.
Penyebab obstruksi kolon dapat diidentifikasi. Adanya massa kolon atau intususepsi ileosekal
dapat di perlihatkan pada pemeriksaan ultrasonografi. Gambaran yang dapat terlihat pada
intususepsi adalah adanya lingkaran konsentris seperti sosis. Diagnosa banding ileus obstruksi
adalah ileus paralitik Pada ileus paralitik biasanya gas tidak terkumpul (terlokalisir) disatu bagian
namun terdapat gambaran udara di seluruh bagian usus (baik usus halus maupun usus besar) atau
sama sekali tidak terdapat gambaran gas (gasless) di seluruh bagian usus. Namun demikian
gambaran ini tidak definitif. karena dapat disebabkan oleh obstruksi usus besar dengan
inkompetensi valve ileosekal atau juga didapatkan pada obstruksi usus halus pada tahap awal.
Pada ileus paralitik lumen usus berdilatasi sesuai dengan proporsinya masing-masing, sehingga
gambaran kolon tetap lebih besar dari pada gambaran usus halus. Pemeriksaan CT scan
mempunyai sensitivitas dan adalah 96 % dan 93 %. Penggunaan CT dinilai lebih menguntungkan
dibanding kontras enema terutama pada pasien usia tua dan pada pasien dengan keadaan umum
yang kurang baik. CT biasanya dilakukan dengan pemberian kontras intravena. Pemeriksaan CT
scan dapat menunjukkan level obstruksi, penyebab obstruksi dan adanya komplikasi yang dapat
terjadi seperti strangulasi, perforasi, pneumatosis intestinal. Gambaran dari CT scan Abdomen
menunjukan adanya obstruksi dan terdeteksi adanya tumor primer. Bila bukan merupakan
obstruksi total dan kondisi umum memungkinkan, dapat dilakukan kolonoskopi dan biopsi. Pasien
diperiksa laboratorium berupa ureum, kreatinin, elektrolit dan analisa gas darah. Gambaran foto
thorax memperlihatkan apakah ada metastase paru 27 Pasien biasanya dehidrasi, maka perlu
dilakukan penanganan preoperatif.

c). Penanganan preoperatif


Penilaian preoperatif dan penanganan harus hati-hati dan cepat untuk menghindari terlambatnya
penanganan intervensi operasi yang dapat menyebabkan perubahan status kesadaran atau
perubahan tanda-tanda vital. Pasien dipuasakan dilakukan pemasangan infus, nasogastrik tube
(NGT), kateter urin dan dilakukan pengawasan intake dan output cairan. Bila terdapat asidosis
metabolik, hipo- atau hiperglikemia,dan ketidakseimbangan elektrolit harus dikoreksi. Antibiotik
harus diberikan.