CLINIC OPATHOLOGICAL STUDY OF COLORECTAL MALIGNANCY IN TERTIARY CARE HOSPITAL

Background: Colorectal carcinoma is one of the most frequent malignancies in the world. It is the second foremost cause of cancer mortality in the United States. Methods: The present study was carried out on 25 patients, being admitted to the various surgical wards ofM.B. Govt. Hospital, attached to the R.N.T. Medical College Hospital, Udaipur between the period July 2017 to November 2019 Results: The presenting symptoms in the present study were change in bowel habit (92%), bleeding per rectum (32%), and loss of weight in 60% of cases. A lump abdomen was noticed in 48% of cases, pain abdomen in 36% of cases. 16% presented with acute bowel obstruction. Conclusion: The common symptoms of constipation or constipation with diarrhoea are neglected and treated with simple laxative without elaborate investigation. Bleeding from malignant growth in the rectum is thought to be from piles and mistreated accordingly, without doing a simple digital examination. It is emphasized that a thorough history taking, proper physical examination is must. To arrive in a correct diagnosis and plan a definite treatment. Also health education to the public in the forms of lectures, posters and audio-visual presentations will help the patient to seek medical advise at an earliest time.


Introduction
Colorectal carcinoma is one of the most frequent malignancies in the world. It is the second foremost cause of cancer mortality in the United States. Hence, colorectal cancer poses a severe concern to public health 1 Compared to the western world, the incidence rates of colorectal cancer are low in India; but apart from geographical variations, the incidences are rising rapidly in India. Incidence rate in different subsides varies for age, gender, and race 2 Colorectal cancer is the third most common cancer in men (746,000 cases, 10.0% of the total) and the second in women (614,000 cases, 9.2% of the total) worldwide. Almost 55% of the cases occur in more developed regions. There is wide geographical variation in incidence across the world and the geographical patterns are very similar in men and women 3

Materials and Methods
Cases of colorectal carcinoma were collected from July 2017 to November 2019 for this study. A total of 25 cases were studied of which 8 cases presented as emergencies.
Detailed history was elicited from each patient with special reference to family history, habitations and early symptomatology. Thorough physical examination of the patient was performed for evaluation of general condition, detection of signs and per-rectal examination.
Thorough laboratory investigations were done in all patients and majority of underwent USG abdomen. Luminal contrast radiographic studies were done in selected cases. Colonoscopy and CT scan abdomen and pelvis was done in majority of cases. Chest skiagram taken for all patients for preoperative evaluation as well as detection of secondaries. Liver function test was done as routine investigation in all patients.
For all possible cases, preoperative biopsy taken via proctoscopic, colono scopic guidance and histologic type made out before planning treatment. Detailed histopathological reports were available for staging of tumour and assessing the grade of differentiation.

Results
The present study was carried out on 25 patients, being Most of the cases were from older age group. Maximum incidence was in the sixth decade, but even below the age of 30, 5cases were reported. The tendency to develop colorectal carcinoma is considered to increase progressively with advancing age. But incidence is also increasing in adults younger than 40 years. Incidence was relatively more in females. M: F ratio in this series was 0.92:1 .
Majority of the patients though had symptoms for some time, tend to ignore them and presented at latest ages.
Eight out of 25 cases (32%) in this series are presented as acute emergencies. Twelve cases presented with obstructive features, Out of them 4 were presented in emergency setting with acute bowel obstruction Majority of the cases (84%) had symptoms of altered bowel habits and anaemia (84%). Weight loss was present in 60% cases, lump abdomen was present in 12 patients 48% cases,3 cases of recto sigmoid growth, 3 cases of ascending colon,2 cases of hepatic flexure growth, 2 cases of sigmoid colon,1 case of descending colon and 1 case of caecum, and pain abdomen was present in 36% cases. Bleeding per rectum were seen32% cases. Altered bowel habits, anaemia and weight loss were the significant symptoms in our series. 84% of the patients presented with altered bowel habits and anemia while 60% of the patients gave history of significant weight loss.
Most of the recto sigmoid and left sided growth were either annular and stenosing or ulcerative with infiltration type. Almost all cases of carcinoma rectum were of ulcerative type. 3 sigmoid growths showed infiltration into surrounding viscera. One case of anorectal carcinoma presented within filtration of prostate. One patient presented with B/L hydronephrosis due to ureteric compression. Majority of right sided growths were polypoidal or cauliflower like growths. One hepatic flexure growth was found to infiltrate into abdominal wall. Two cases of synchronous tumour found, one was synchronous carcinoma of caecum and sigmoid colon growth. While the other was carcinoma of second part of duodenum and carcinoma of hepatic flexure. 5 patients presented with distant metastasis. Out of them 3 had multiple liver metastasis, one had dorsolumbar spine metastasis. One patient present with peritoneal metastasis in the form of nodules.

Discussion
Malignancy of the large bowel form one of the common types of cancer, whichpresent with different clinical symptoms and signs. In our country because of ignorance, illiteracy, low socio-economic status and feeling of fear of colostomy, most of the patient present late in the advanced stage, where only palliative treatment can be offered. Also these cases presenting with bleeding per-rectum were treated as piles by general family practitioner, till no relief was obtained by conventional method and then referred to teaching institute. Also the incidence of malignancy in general and malignancy of large bowel particular is becoming more due to increasing life span of the people.
The commonest presenting symptom in the present study was change in bowel habit (84%) and anaemia (84%), followed by loss of weight (60%).

Conclusion
It is concluded from the present study that patients suffering from malignancy of large bowel, particularly of rectum and rectosigmoid region present for radical treatment in an advanced stages, where possibility of medical resection are very little. The common symptoms of constipation or constipation with diarrhoea are neglected and treated with simple laxative without elaborate investigation. Bleeding from malignant growth in the rectum is thought to be from piles and mis-treated accordingly, without doing a simple digital examination. It is emphasized that a thorough history taking, proper physical examination is must. To arrive in a correct diagnosis and plan a definite treatment. Also health education to the public in the forms of lectures, posters and audio-visual presentations will help the patient to seek medical advise at an earliest time.