Joseph Mizrahi, MD1, Yunseok Namn, MD1, Jonathan M. Buscaglia, MD2
1Stony Brook Medicine, Stony Brook, NY; 2Stony Brook University Medicine, Stony Brook, NY
Introduction: Colorectal cancer (CRC) often presents with gastrointestinal complaints such as changes in bowel habits or rectal bleeding. We present here an unusual case of CRC diagnosed in the setting of respiratory distress.
Case Description/Methods: A 78-year-old female with no prior history of lung disease but a long smoking history presented with acute dyspnea, with an oxygen saturation of 86%. The physical exam revealed bilateral wheezing and a soft non-distended abdomen. There were no biochemical lab abnormalities and her chest radiograph demonstrated an elevated right hemidiaphragm, a chronic finding for the patient (Figure 1). Given her longstanding smoking history, she was started on steroids and nebulizers for a suspected COPD exacerbation. However, her respiratory status worsened and she was upgraded to the medical intensive care unit. A pulmonary function test was subsequently performed which showed a reduced FEV1 (0.48) and FVC (0.63), but a normal FEV1/FVC ratio (77%) – denoting a restrictive lung disease pattern, inconsistent with the original diagnosis of a COPD exacerbation. This prompted further imaging which revealed a severely dilated colon (maximum dilation of 8.4 cm) with a transition point at the proximal sigmoid colon (Figure 2). As the patient previously never had a colonoscopy, one was performed which revealed a 3 cm, circumferential, fungating, nearly lumen obstructing mass 30 cm from the anal verge, concerning for adenocarcinoma (Figure 3). A colonic stent was therefore placed with improvement in the patient’s work of breathing. Biopsies later confirmed adenocarcinoma for which she underwent a left hemicolectomy.
Discussion: CRC is rarely diagnosed as a result of non-gastrointestinal related symptoms. In this case, the patient presented with wheezing and dyspnea as a result of a large colonic mass causing upstream dilation and severe compressive atelectasis. Based on the patient’s smoking history and wheezing on exam, the physicians anchored on the diagnosis of a COPD exacerbation despite the lack of a COPD history or radiographic findings to suggest an obstructive pulmonary pathology. Anchoring bias is a common source of diagnostic error among physicians and it is important to always establish a broad differential diagnosis – especially when patients fail the first line of treatment. In addition, this case underscores the importance of CRC screening in patients, as she herself had no prior screening and unfortunately developed CRC.
Citation: Joseph Mizrahi, MD; Yunseok Namn, MD; Jonathan M. Buscaglia, MD. P1059 - COLORECTAL CANCER: AN UNCOMMON CAUSE FOR RESTRICTIVE LUNG DISEASE. Program No. P1059. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.