It is not always possible to evaluate patients that present acutely with carcinoma of the colon and rectum for synchronous lesions. Patients that require emergent surgery necessitate urgent and efficient operation. Patients with lower gastrointestinal bleeding, perforation, or obstruction represent a challenging subset of patients with colorectal cancer. An organized approach to these patients in the effort not to overlook a synchronous carcinoma is important. The present paper provides an evidenced-based approach to this special situation. 1. Background Colorectal cancer is the third most common malignancy worldwide and the fourth most common in the United States, with estimated 146,970 new cases diagnosed in 2009. In the United States, approximately 49,920 cancer-related deaths were attributed to a colorectal malignancy in 2009, making it second only to mortality from lung cancer [1]. Despite the high incidence of colorectal carcinoma that is diagnosed yearly, the majority of lesions are resected with curative intent (70%–80%) and colorectal cancer-related deaths account for 20%–30% of those diagnosed and treated surgically, making it a highly curable malignancy if identified in its early-stages. Approximately, 55% of colorectal cancers diagnosed on screening are found to present with Stage I or II disease [2, 3]. Patients with Stage I or Stage II colon cancer have a greater than 60% 5-year survival, and for patients with Stage I or Stage II rectal cancer, there is a greater than 50% 5-year survival [4, 5]. Because of this, colorectal screening exams in asymptomatic patients have become the recommended standard of care for average risk patients at the age of 50 and at the age of 40 or younger for those in the moderate and high risk groups. Approximately, 70% of colorectal lesions occur distal to the splenic flexure, and looking at colon cancer alone, approximately 25% are found in the sigmoid, 10% at the rectosigmoid junction, and 4%–6% located in the descending colon [6]. Anatomically, the left colon has a smaller diameter than the right, and as a result, left-sided carcinomas can cause varying degrees of intraluminal occlusion and patients more frequently present with obstructive symptoms. Large bowel obstructions present a challenging clinical scenario for the physician in the diagnosis, operative management, and the timing of colonic surveillance. Patients presenting with advanced lesions causing partial or high-grade large bowel obstruction commonly have a distant history or no history of previous colonic surveillance. This fact is of clinical
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