colorectal polyps & cancer · why screen? • screening detects polyps and cancers 2 - 3 years...
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GUT CHECK:
Colorectal Polyps & Cancer,
Inflammatory Bowel, &
Gluten-Related Issues
Martin S. Walko, MD, FACS
General Surgery
Androscoggin Valley Hospital
Berlin, NH
OVERVIEW
• Colorectal polyps and colorectal cancer
– Screening Options, Treatment &
Prevention
• Inflammatory Bowel Disease
– Symptoms & Treatment
• Gluten-Related GI Problems
– Symptoms & Treatment
• Polyp - Neoplasms
– Neo, “ New ”
– Plasm, “ Something Formed ”
• Types
– Benign
– Pre-malignant
– Atypical (Dysplastic Features)
– Malignant
COLON POLYPS & CANCER
WHAT DO THEY COME
FROM?
• Genetics: These start as our own cells
– Tumor Suppressor Genes
– Oncogenes
– Mis-match Repair
• Environmental
– Diet: Fats, fiber, Calcium, other substances
• Obesity
– Sedentary Life-style
WHY DOES THIS HAPPEN?
• Not sure
• Genetic predisposition
• Environmental
– Diet, fat, fiber, obesity, alcohol
• LIKELY MULTI-FACTORIAL
WHY ARE POLYPS
IMPORTANT?
• Polyp progression
– 90% of colorectal cancers start as polyps
– Size matters
• Increasing size = increase risk of cancer
• < 1cm = ~1%
• 1 - 2cm = 10%
• > 2cm = 20 - 50%
– Exceptions : HNPCC, FAP, atypia
WHERE DO THEY FORM?
HOW LONG DOES IT TAKE
FOR THIS TO HAPPEN?
• Polyp to cancer progression takes roughly 10 years BUT CAN be variable
• This is an important consideration regarding follow up and ACS Colorectal Cancer Screening Guidelines.
• USA: Average age of person with colon cancer is around 65 years old
WHY ARE THEY
IMPORTANT?
• Number 2 cancer killer of both men and
women
• Number 3 cancer in incidence in men and
women
• ~ 5% Lifetime Risk = 1 in 20 people at risk
• Approximately 136,800 cases in 2014
• MAJORITY ARE PREVENTABLE
WHO’S AT RISK?
• About 15 - 30% of People > 50 yrs have
precancerous polyps
• Personal Medical History
– Cancer, Polyps, Inflammatory Bowel Disease
• Family History
– First degree relative
– Colorectal cancer at Age < 50 vs < 60
• African-Americans
WHAT ARE THE
SYMPTOMS?
• Blood per rectum
• Change in Bowel Habit
– Constipation, diarrhea, irregularity, mucous,
tenesmus
• Change in Stool Caliber
• Dark Black Stool
• Unexplained Weight Loss
• Signs or symptoms of Jaundice
MOST COMMON
SYMPTOM?
NONE
WHAT IS SCREENING?
• Screening is Used to Evaluate a Population
WITHOUT Symptoms for a Common
Disease/Illness That Can be Treated Once
Identified Early
• Needed: ID an Important Health Problem,
Test, Latent Phase, Inexpensive &
Economic (Ideally), Treatment
ACS SCREENING CRC
SCREENING GUIDELINES
• Average Risk
– Age 50 y
– Annual DRE/FOBT
– BE, Virtual Colonoscopy, FIT, Cologuard, Flex
Sig, or Colonoscopy
• Increased Risk
– Personal or Family h/o Polyps or Colorectal
cancer—Talk to your Doctor
– Inflammatory Bowel Disease
– Typically, Colonoscopy Recommended
SCREENING OPTIONS
• Annual Fecal Occult Blood Test
(FOBT)/Digital Rectal Exam (DRE)-
controversial, but simple
• Barium Enema
• Flexible Sigmoidoscopy
• “Pill Camera”
• “Virtual Colonoscopy”
• “Cologuard”
• Colonoscopy
WHY SCREEN?
• Screening Detects Polyps and Cancers 2 - 3
YEARS Before They Cause Symptoms
• Colorectal Cancers Can Grow At Different
Rates
• 2 - 3 Years Often Means the Difference
Between Cure and Palliation
• Notifies First-Degree Relatives of Risk
BARIUM ENEMA
• Safe
– Risks
• Visualizes Polyps about 1 - 2cm in size
• Diagnostic only—Uncomfortable—Requires Air & Barium (DCBE)
• Screening Guidelines
– FOBT/DRE
– Variable – typically, every 5 years
• If Positive Colonoscopy
FLEXIBLE
SIGMOIDOSCOPY
• Safe
– Risks
• Indications for screening
• Limitations
• Screening Guidelines:
– Annual FOBT/DRE
– Asymptomatic: every 5 years
• If Positive Colonoscopy
VIRTUAL COLONOSCOPY
• AKA, CT Colonography
• Some are similar to Barium Enema
• Detects abnormalities > 1cm+ in size
• Approved for Congress, et al., but Coverage
Typically Varies with Insurance
• Diagnostic only
• Positives Colonoscopy
• Other uses: Completion colonoscopy, other
Extra-colonic Pathology
COLOGUARD • Recently Approved by FDA
• Not Recommended by the USPSTF – US Preventative Services Task Force
• Exact Science Corporation
• Low Risk—Tests Stool
• Positives Colonoscopy
• Biochemical Multi-Test – Blood
– Gene & DNA Mutatution Markers
• Sensitive, but NOT Specific
CAPSULE ENDOSCOPY
“PILL CAMERA”
• Not approved for colon screening, yet….
• Used for small intestine disorders
• Being Studied as a Possible Colon Screen
• If Positive Colonoscopy
• Larger Diameter of the Colon Limits
Usefulness
• Stay Tuned…..
COLONOSCOPY
• Considered to be the “Gold Standard”
• Bowel Preparation, aka “The Prep”
– Varies from doctor to doctor
– Basic: Clear Liquids x 24hrs & Laxatives
• Diagnostic & Therapeutic
– Identify & Treat Problem
• Relatively Safe
– Risks: Next Slide
COLONOSCOPY RISKS • Bleeding
– tearing, polypectomy, biopsy, spleen
– rarely requires transfusion
• Infection
• Perforation
• Delayed Recognition of complication
• Missed Cancer
• Risk of Need for Operation
• Incomplete Study
POLYP TREATMENT
OPTIONS
• Colonoscopic polypectomy or biopsy
– Done at the same time
– Biopsy Results take 5 - 7 days to 2 weeks for a
letter
• Operative resection
– For large polyps
– For cancers
– Prophylactically
COLONOSCOPY ACTION
SHOTS
The following contains scenes from actual
colonoscopies—viewer discretion is
advised.
FOLLOW-UP
COLONOSCOPY
• Discuss with your doctor
• Guidelines:
– No Polyps - 5 - 10 years
– Pre-cancerous Polyps – 2 - 5 years (usually 3)
– Aggressive, Large or Multiple Polyps
Months vs. Operative Resection (Surgery)
SURGERY
• NOT a Failure
• Cancer operation for polyps and cancer
– Open vs. Laparoscopic/Minimally Invasive
• Risks
– Bleeding, infection, anastamotic complications,
– ileus, transfusion, re-operation, etc.
• GOAL -- CURE
• Alternative -- Palliation
POLYP/CANCER
PREVENTION
• Personal & Family History
– Risk Factors: polyps, cancer, IBD
– Discuss with your doctor
• Diet
– Fiber - Fruits & vegetables
– Cruciferous veggies may be better
– Limit fats to 25 - 30% of total calories
• Moderate Alcohol Use
• Maintain Ideal Body Weight & Be Active
• No Tobacco use
CANCER, DIET &
PREVENTION • Grilling & Deep Fat Frying & Frying
– Heterocyclic Amines
– Nitrosamines
• “Nitrated/Prepared Meats”
• Decrease Grilling Time
– Parboil/cook Meats Before Grilling
• Marinades
– Adds flavor & decreases toxic HCAs
• Leaner Meats
• Avoid Burning Meats & Fried Foods
CRC SURVIVAL RATES
• Stage I -- 90% at 5 years
– Cancer patients tend to be older, so other health
issues come into play (Relative Rate vs.
Observed Rate)
– This number is higher in younger/healthier
patients
• Stage IV -- about 10% at 5 years
ACS SCREENING RESULTS
• Over the Past ~Decade Increased Education
on CRC Screening Has Helped
• In the USA:
– 30% Decline in colorectal cancer rates in
patients over 50yrs
– BUT, Colorectal cancer rate on the rise in
patients under 50yrs.
CRC PREVENTION
SUMMARY
• Avoid Saturated Fat, HCA & Nitrosamines,
EtOH to Excess & Sedentary Life-Style
• Decrease Polyps:
– Calcium: 1,200mg/day
– Aspirin: 81mg/day
– NSAID’s ?
– Vitamins
• A, C, E, D, Folic acid
• No Tobacco Use is Safe
INFLAMMATORY
BOWEL
DISEASE
Crohn’s Disease
Ulcerative Colitis
Indeterminate Colitis
WHAT ARE IBDs? • Inflammatory Bowel Disease
– Spectrum of Auto-Immune Disorders
• Crohn’s—Mouth to Anus, typically small bowel
• Ulcerative Colitis—Rectum & Colon
• Indeterminate Colitis
– Unclear Trigger – T - cell Activation
– Familial Tendency, but can be Sporadic
– Increases Risk for Intestinal Cancer
– Life-long Monitoring (Colonoscopy & Blood
Work) Is Mandatory
IBD vs. IBS
• IBD = INFLAMMATORY Bowel Disease
• IBS = IRRITABLE Bowel Syndrome
IBD SYMPTOMS
• Diarrhea
• Rectal Bleeding
• Abdominal Pain
• Anemia
• Fatigue
• Weight-loss
• Failure to Thrive in children
• Extra-Intestinal: uveitis, arthritis, rashes
TREATMENT
• Immune Regulating Agents
– Sulfasalazine & Related Medications
– 6-mercaptopurine, Steroids
– Antibiotics
– Anti-TNF Agents, aka “Biologics”
• monoclonal antibody such as infliximab
(Remicade), adalimumab (Humira), certolizumab
pegol (Cimzia), and golimumab (Simponi), or with a
circulating receptor fusion protein such as etanercept
(Enbrel).
IBD & SURGERY
• NOT CURATIVE
• IBD is a Systemic disease
• Surgery is Reserved for Complications of
the Disease:
– Obstruction
– Perforation
– Hemorrhage
– Toxic Megacolon
GLUTEN-RELATED GI
ISSUES
• Celiac, aka Sprue
• Non-Celiac Gluten Sensitivity
GLUTEN
• A vegetable protein found in wheat, rye,
barley
• Actually composed of 2 smaller proteins:
– Gliadin
– Glutenin
• Can evoke Auto-Immune response in the
gut, leading to Celiac, aka Sprue
• Affects ~1% of Americans
CELIAC SYMPTOMS
• Mild: Gas, Bloating, Loose Stool
• Progressively more Severe: Diarrhea,
Vitamin Deficiency, Malnutrition, Iron-
Deficiency Anemia
• Cancer
CELIAC MANAGEMENT
• STRICT GLUTEN-FREE DIET
• Typically, Readily Managed with Diet
• Increased Risk for Cancer
– Small Bowel T - cell Lymphoma
CELIAC DIAGNOSIS
• History/Presentation
– Rarely “Textbook”
• Blood work
– Antibodies (IgA) for Tissue Trans-
Glutaminase, Endomysial Ag, Gliadin, etc.
– HLA Testing (DQ2 or DQ8)
• Endoscopy
– Biopsies of Duodenum
– Colonoscopy is rarely helpful
NON-CELIAC GLUTEN
SENSITIVITY
• Not Fully Understood & Hotly Debated
• Does NOT Increase the Risk for Cancer vs.
Celiac
• Symptoms Improve with Abstinence of
Wheat
THANK YOU!
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