Introduction
Colorectal cancer was, in 2020, the third most prevalent cancer worldwide, the second leading cause of cancer death1 and accounted for 11% of cancer diagnoses and deaths in Australia.2 Haemorrhoidal bleeding is not uncommon in pregnancy. We present a case of a 29-year-old multiparous woman who presented at 35+4 weeks gestation with rectal bleeding.
Case
A 29 year old female in her third trimester presented with 4 months of worsening rectal bleeding on a background of 8 years of intermittent bleeding associated with haemorrhoids. She was otherwise fit. She had been scheduled for colonoscopy which was delayed due to pregnancy. She presented to the Emergency Department three times in two weeks with worsening rectal bleeding. She was admitted on her third presentation with a haemoglobin of 98g/L, no bowel motion for 6 days and 3kg weight loss in 1 month. Decision for delivery by caesarean section was made due to persistent bleeding necessitating transfusion. A male infant was delivered at 36+5 in good condition. An intraoperative flexible sigmoidoscopy demonstrated a rectal mass 8cm from the anorectal line which was biopsied.
The patient showed no clinical signs of bowel obstruction immediately postpartum. A postpartum showed a 14cm segment of sigmoidorectal intussusception with upstream large bowel dilatation and focal soft tissue thickening within the rectum without evidence of metastatic disease. She underwent an open high anterior that day. Histopathological examination of the 34cm specimen confirmed moderately differentiated adenocarcinoma of the sigmoid colon.
The immediate postoperative recovery period was uncomplicated and the patient was discharged home 5 days following anterior resection. A follow-up genetic assessment was undertaken and testing for hereditary forms of colorectal cancer is underway.
Discussion
This case highlights the potential difficulties in diagnosis and investigation of colorectal cancer in pregnancy. It is pertinent that recurrent presentations and red flag symptoms not be ignored and that a multidisciplinary approach be utilised to appropriately investigate and manage these women.
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