beware this sign

About a month ago a man in his 70s came with a classical sign: alternating constipation and diarrhoea. I first learned this sign as being a reliable indicator of bowel cancer in my third year at medical school. First as a junior house surgeon, then later as a GP, time after time, I learnt the grim significance of this sign. It implies that the lumen, or inner bore, of the large intestine is narrowed, and there are very few other things that do this.

I sent him for an ultrasound scan of his abdomen and today it has come back: not only a definite cancer in his lower colon but, much more ominously, a huge secondary growth in his liver. It is this latter that will kill him, by hepatic failure, which is not such a bad death; I saw my own wife die in precisely this way after her breast cancer spread to her liver. You just drift gently away, with a minimum of pain, finally lapsing into a "liver coma", as the toxins the liver usually filter from the blood gradually accumulate in the circulation. This is what will certainly be his fate, but how long will he last? Will he see Christmas, or fade away even quicker than that? Time, as they say, will tell...