Suggest treatment for periodic abdominal pain while treating metastatic colorectal cancer

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Posted on Thu, 11 Jun 2015 in Cancer
Question: In hospital with iv antibiotics while on chemo for met colon cancer .

WBC plus patlets counts low . Also on and off andominal pains especially around stoma area and belly button .

Liver mets and peritoneal mets . Can the peri mets b causing this ?
doctor
Answered by Dr. Anil Parth Desai 16 minutes later
Brief Answer:
Hi It could be peritoneal mets or infection

Detailed Answer:
Hi I did review your concern.
I can understand you are going through a rough phase.

As I can understand you are having periodic abdominal pain around stoma site and belly button. Have you noticed any fever or redness, swelling or pus around the stoma site?

Your pain can be due to
1)Metastasis which can impinge nearby nerves or structures or
2)it can be due to an infection due to low wbcs or
3)mild obstruction caused by twisting of bowel loops due to stoma procedure.
4) If recent stoma creation it can be stitches that can cause the pain.

My advice would be to consult your surgeon and evaluate your condition with stoma site examination, stoma material analysis and also imaging studies of your abdomen to rule out obstruction. also a test for C.difficle toxin in your fecal matter can be done to test for a possible C.diff infection as it can sometimes present as abdominal pain without much diarrhoea when a person has low wbc and is on antibiotics.
If after ruling everything out, and all test are negative and imaging studies have shown mets, then it is probably mets pain and the best way to relieve cancer mets pain is opioid analgesics which need to be taken under doctor guidance.
Please let me know if you have more questions or concerns. Also let me know feedback of your condition.
I hope this helps
Wish you all the best.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Anil Parth Desai 1 hour later
Yes fever 2 days and chills
Now having iv antibiotics in hospitals and fluids .
Bp was also low . Now fever and bp are ok.
But on and off pain near belly button areas and tenseness .

Stone created 16 months ago
WBC , Pallett count both low .
doctor
Answered by Dr. Anil Parth Desai 10 minutes later
Brief Answer:
I would recommend imaging studies and rule out infection

Detailed Answer:
Hi Thank you for your follow up query.

Feeling of tenseness and pain on and off near belly button can be a referred pain due to partial obstruction of bowel. Most of the time it reverses on its own. but it is better to get investigated in form of xray and CT scan for the first time around and confirm the diagnosis.

Also another possibility is infection although since now your fever is normal it is less chances. If there is fluid seen on CT scan in any of the pockets in abdominal cavity it can be aspirated to see the microbes present and then treated accordingly with special antibiotics.


These are the 2 main considerations now- partial bowel obstruction due to stoma loops and infection.If both are ruled out then probably your intermittent pain is due to metastasis irritating the peritoneum causing pain and you then requiring opioids analgesia.

About the platelet count, generally doctors do not worry until it goes below 30,000. Then they might need to transfuse you with some platelets to decrease the risk of bleeding from any body site.

I hope this helps.
Let me know if you have any more questions or concerns.
Also let me know feedback of your condition.
Wish you all the best my friend.
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Anil Parth Desai 24 minutes later
Pallett count was 37. That not too much concern . Fever since Friday and today on and off but more along 37 readings now and bp around 90.

Ok so bowel obstruction or infection .

When do peritonal mets start causing pain ? There were 4 nodules seen in march about 2 cm each .

Can this
Mean the chemo not working as the mets should have shrunk more or something right in Peri area ?
doctor
Answered by Dr. Anil Parth Desai 16 minutes later
Brief Answer:
I would advice you to review chemotherapy with your oncologist if persisten

Detailed Answer:
Hi , thank you for your followup query mam.
your fever is now receding so that is good news. hopefully if pain was due to infection irritating peritoneum it will also likely go away in 1-2 days time.

Peritoneal mets can cause pain when they irritate paerital peritoneum which is pain sensitive. It can be as small as 0.5cm to start causing nagging pain. However, important question here is we need to get rid of it anyhow-pain or no pain.

My advice would be to review your chemotherapy and latest PET scans with your treating oncologist. There are multiple chemotherapy options with colon cancer these days and it depends on resources in form of money, technique and availability. Generally recurrences in peritoneum can be treated with 2nd line treatment agents if the 1st line chemotherapy does not work. However, for that your oncologist needs to review when was the last dose of chemotherapy given to you and when will you schedule your next PET scan to see if there is a response or not.
the 2nd line chemo i am talking about and you can discuss with your doctor is EGFR antagonist drugs like cetuximab, which can be initiated after mutation testing of your colon cancer samples. Please discuss this option with your doctor.

I would not say yet that your chemo is working unless there has been few rounds of chemo given and PET and biopsies does not show any improvement in your cancer load status.
I hope this helps.
Let me know if you have any more questions or concerns. I will be more than happy to helps. Also let me know feedback of your condition.
Wish you all the very best.

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Anil Parth Desai 31 minutes later
Thanks very helpful .

Irinitecan failed that's when he had only 1 liver mets .

Now he's had three rounds of oxyplatin and raltitrexed . Then all these problems arose .

If this one failed then us avastin good ? He can't have cetuximvab as KRAS mutant .

Is prognosis poor without any chemo ?
doctor
Answered by Dr. Anil Parth Desai 14 minutes later
Brief Answer:
Avastin can be an option. do not loose hope.

Detailed Answer:
Hi, I did review your concern.
Oxyplatin and raltitrexed are platinum based drugs and antimetabolites respectively and they can get pretty nasty sometimes with normal body cells especially blood cells and hair cells. However, they do kill tumor cells also pretty well and hence we use them weighing the risk and benefits.

I would wait for the results of these drugs to take effect as they are a strong combination. Yes, even if then the PET scans and patients cancer related symptoms do not improve, I would recommend you to discuss Avastin which is a angiogenesis inhibitor to be added by your doctor. I am sorry to hear that KRAS is mutant as it limits an option of EGFR inhibitors.

But we should not think about the negatives and always think about positives.
Cancer is won half in mind and half by treatment. And my teaching says that if cancer attacks us we must attack the cancer with double strength.

Prognosis definately poor without chemotherapy, but we still have options left and must utilize all thats in our capacity.
I hope this helps.
Please let me know if you have any more questions or concerns my friend and i will be more than happy to help you with best of my ability.
Wish you all the super best. Stay firm!stay positive!
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Anil Parth Desai 47 minutes later
Thanks so much . First dr that made us feel better

U see he was stage 3 and tumor in bowel removed march 2014. After op probs started as mets appeared . I think maybe the surgery caused mets .

Anyway as irinotecan failed we got worried . This combo has had a effect on his body alot ie appetite complete loss , he hates food and so weight loss , plus fatigue and now poss infection and low platlet the counts and WBC counts .

So this combination is strong right ?

And avastin is more tolerable right ?
doctor
Answered by Dr. Anil Parth Desai 25 minutes later
Brief Answer:
The combination right now is good as of now.

Detailed Answer:
Hi I did review your follow up query mam.

I believe surgery at that time was the only option any doctor had. The problem with colon cancer stage 3 is that the doctor wants to treat it and best way to treat any cancer is remove it from the body as much as you can. Also, with bowel cancers there is risk of non cancer complications like perforation and obstruction and causing death without cancer mets. so surgery is a standard initial call for all ca colon patients. The data is controversial whether cancer is spread by surgery.

Anyways, The present combination is strong I believe. But the thing about cancer we need to understand is that every patient tumor is a different biology to certain extent and we as humans have not yet found out a way to treat exactly what everyone has. But yes, platinum based oxyplatin and other antimetabolite drug raltitrexed are good drugs to kill cancer cells. Obviously they will also then be strong to normal body cells and then there are these sad side effects of anorexia and weight loss and low blood counts and all.

But we need to fight with them at any cost.

If he hates food, i would recommend you to discuss this with your doctor and see if your center can use any medication for anorexia and increasing appetite like cyproheptadine, steroids for short time or progesterone analogues. some doctors have good experience with them and some not.
Avastin is a relatively new drug and we do not have much experience with it but it is more tolerable according to many oncologists. However, it causes certain complications like bleeding,thrombosis and rare cases of gastric perforations. But then every anticancer drug has certain risks and we need to weigh the benefits and risks.

As of now this combination seems right, in lieu of KRAS mutation. Let us wait and pray for best results and then take it from there on. Also please talk to doctor about his current complaints which are as important and discuss the possible options i suggested in my previous answer.

I hope this helps.
Let me know if you have any more questions and concerns and please give me feedback about his condition.
Wish you all the best! stay firm! stay positive!
Yours sincerely,
Dr Parth Desai.
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Anil Parth Desai 44 minutes later
I'm v worried re the appetite he just don't feel like eating or could it be cancer doing this to appetite ?

Appetite Picks up a bit towards end of cycle we noticed . I think we will ask
Something for appetite .

Can treatments for liver mets like tace help ?

Also these peritoneal mets would they cause pain near belly button area / tummy area?
doctor
Answered by Dr. Anil Parth Desai 19 minutes later
Brief Answer:
TACE is an option for liver mets. peritoneal mets can cause pain

Detailed Answer:
Hi i did review your follow up query.

TACE uses arterial methods to bring ischemia in a tumor in an organ. It has been used for hepatocellular carcinoma. But literature experience with it in mets of colon cancer is not much. however, theoretically it should reduce the tumor load allthough not 100% and provides palliative care. You can discuss it with the treating oncologist or oncosurgeon and they can refer to a doctor who specializes in this procedure. The potential adverse effects we need to consider are abnormalities in liver function that can occur transiently and a small risk of hemorrhage.

The peritoneal mets can cause pain near belly if they are irritating the parietal peritoneum. Also, if the tumor cells are dying due to cancer drugs and causing inflammation, it can cause pain for some days. But then thats a good thing. however, my advice would be to consult your doctor and rule out infection and or obstruction as that is more important first to rule out and be treated accordingly.

Appetite is a problem and it is due to both the cancer effects as well as due to chemotherapy. Healthy diet is the key. For the appetite there are few options. some doctors have even used medicinal marijuana and anabolic steroids but literature is very controversial. Cyproheptadine , short course of steroids and progesterone analogues are workable options to increase his appetite. You can discuss this with your doctor.

I hope this helps.
Let me know if you have any more questions and concerns and please give me feedback about his condition.
Wish you all the best! stay firm! stay positive!
Yours sincerely,
Dr Parth Desai.
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Anil Parth Desai 1 hour later
Ok il
Discuss the appetite options as these need to be sorted I think as he just not feeling like eating and losing lot weight .

With the issues so far .. Appetite loss, weight loss, poss infection , low WBC and low platlet count - shoukd chemo be stopped as seems to be going a lot if harm ?

Are there other options apart from chemo ?
doctor
Answered by Dr. Anil Parth Desai 17 minutes later
Brief Answer:
I would advice chemotherapy to continue

Detailed Answer:
Hi, i did review your concern.
That is a good idea mam. You can discuss the best way to bring about his diet and weight slightly back towards normal as best as we can.

About stopping the chemotherapy, I would believe it is entirely your family decision to take and it depends from person to person. The main factors are tolerance and will power. If the patient is ready to go through the grind and his family is ready to go through the support grind, my advice will be to go along with it unless the patient is in a vegetative state where he cannot be a regular part of the society.
If he can tolerate it to the maximum point, he should get the chemo till he can. But that is my advice and you can discuss this in detail with your family and the treating doctor.
Apart from chemotherapy, There is an option of radiotherapy, of which I am not a firm supporter of. I have seen radiotherapy cause severe morbidity in colon cancer patients. There is an option of stem cell transplant, but none have studied it much as it is used mostly for blood cancers. Few have tried it with mixed results in colon cancers and studies are going on around at this present regarding stem cell transplant. Also they are very costly and they themselves include super high dose chemotherapy before transplant.

I would infact suggest some other therapy options like learning yoga and meditation techniques to calm his mind and help him gain more control over his body ,acupunture for cancer pain,laughing clubs and so on. Meeting people with other and similar problems and talking to them helps a lot to many patients.

Also For his children I would advice to consult a gastroenterologist and get themselves checked from the age of 50 as some of the colon cancers are hereditary and can be prevented or stopped at an early stage.

I hope this helps.
Let me know if you have any more questions and concerns and please give me feedback about his condition.
Wish you all the best! stay firm! stay positive!
Yours sincerely,
Dr Parth Desai.
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
Answered by
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Dr. Anil Parth Desai

Pathologist and Microbiologist

Practicing since :2009

Answered : 593 Questions

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