Things not to miss - Carcinoma of colon

A 64 years old male patient admitted with worsening shortness of breath for 2 days duration. He had cough and wheezing. He had a history of cigarette smoking for more than 30 years.

On examination he was thin built and was dyspneic. He was mildly pale. Lungs were hyperinflated with widespread ronchi. Cardiac and liver dullness were impaired.



Clinical Diagnosis?

• Exacerbation of COPD

Management?

• Stop smoking
• Nebulized/ Inhaled bronchodilators +/- steroids
• Antibiotics

Investigation reports were as follows.

WBC - 13.5 (N - 70% L - 30%)

Hb - 10.5

Plt - 350

MCV - 76

AST - 35
ALT - 40

S. Cr - 78

CXR

What are the abnormalities in this Xray?

The patient improved with treatment and was discharged 2 days later.

About three weeks later patient readmitted with similar symptoms. Examination findings were again compatible with an exacerbation of COPD. His inhaler technique was good and he was compliant with the medications. He had also quitted smoking.

Investigation reports were as follows.

WBC - 12.5 (N - 70% L - 30%)
Hb - 9.9
Plt - 380
MCV - 73

AST - 30
ALT - 35

S. Cr - 80

This time he had to stay 3 days in the ward but made a good recovery.

One month later he again admitted with cough, but this time he had hemoptysis.

Ultrasound of the abdomen showed multiple liver metastasis. Colonoscopy revealed a malignant growth in the cecum.

Did we go wrong somewhere??

• YES!

Where exactly?

• Check the Hb and MCV !
• In patients with COPD even a normal value is abnormal! They are supposed to be polycythemic.

Anemia, particularly in elderly people is something that you should never overlook.

What to do when you detect anemia?

• There are about a million causes for anemia!
• FBC itself has more than enough clues to guide you through the path.

Let's quickly recall few important facts. I have absolutely no intention to repeat what's there in 'Essential Hematology'. You better read it!

Other cell lines

• Leukopenia and/ or thrombocytopenia may indicate marrow pathology.
• Elevated platelets may be an indicator of bleeding! (Like in this patient), or presence of chronic inflammation.

MCV

• High - Think about B12/ Folate deficiency, It can also be high in hemolytic anemias.
• Low - Fe deficiency, Thalassemia minor/intermedia or other hemoglobinopathies.
• Normal - Anemia of chronic disease, Marrow pathologies.

RDW

• If high, favors Fe deficiency

What other investigations would you consider?

• Blood picture - Probably the most informative investigation. Can diagnose almost all diseases.
• Fe studies
• In Fe deficinecy
• Low ferritin
• Low S. Fe
• Low Transferrin saturation
• High Total Iron Binding Capacity (TIBC)
• S. B12 level and Red cell Folate level
• Not freely available
• Retic count/ Bilirubin/ Coombs test/ S. Haptoglobin/ LDH
• Hemolytic anemia
• We can discuss this on another day!

NEVER TREAT ANEMIA BY GUESSWORK! ALWAYS CONFIRM IT!

What if it's iron deficiency

• Nutritional deficiency is not that common! We are a fairly developed country :-P
• In premenopausal women, it's most often due to heavy menstrual bleeding.
• In the absence of an obvious bleeding source look for
• Dyspepsia
• Loss of weight/ appetite
• Hematuria
• In all patients the bleeding source should be identified.

In young patients 

• UGIE/LGIE - if symptoms +
• Stool occult blood is a good screening investigation

In elderly people

• All need to undergo UGIE+/-LGIE
• In fact, it is recommended to scope people above 60 years of age, and those who have red flag symptoms
• WITHIN TWO WEEKS
• Reason? 
• In west, they've found that 8-15% of patients over 60 years of age with Fe deficiency have GI tract malignancies!

So next time, never miss a CA COLON on a FBC!