colonic polyps may occur in any part of the colon majority of them arise in the rectum and sigmoid...
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COLONIC POLYPSMay occur in any part of the colonMajority of them arise in the rectum and
sigmoid colonThey tend to cause rectal bleeding (visible
or occult) and may undergo malignant change
If rectal polyps are found, the entire colon must be investigated- total colonoscopy
The larger the lesion the more likely it is to be malignant
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COLORECTAL POLYPSHistopathologically- three patterns of growth:
tubular adenomas
villous adenomas
tubulo-villous adenomas
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PHYSICAL EXAMINATIONGeneral examination- features suggesting
malignant disease:Obvious weight lossPalor of the skinAbdominal distentionHepatomegalyAbdominal mass
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PHYSICAL EXAMINATIONRectal examination:
Finger can reach lesions as far as the its length 7-9 cm
Palpable fixed mass in Douglas pouch-sigmoid tumor dropped retrorectally
The glove inspected for blood and mucus
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Types of Colon Cancer Types of Colon Cancer
Familial15%
Hereditary4%
Sporadic80%
IBD1%
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Risk Factors
Nearly 90% of colon cancer patientsare over the age of 50.
Other risk factors include:
family or personal history of colon cancer or polyps
chronic inflammatory bowel disease hereditary colorectal syndromes use of cigarettes and other tobacco products high-fat/low fiber diet physical inactivity
Nearly 90% of colon cancer patientsare over the age of 50.
Other risk factors include:
family or personal history of colon cancer or polyps
chronic inflammatory bowel disease hereditary colorectal syndromes use of cigarettes and other tobacco products high-fat/low fiber diet physical inactivity
Risk increases with age
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Symptoms
Signs and symptoms typically occur only in advanced colon cancer. Symptoms may include:
Change in bowel habits lasting more than a few days
Bleeding from the rectum
Blood in the stool
Cramping or gnawing stomach pains
Weakness and fatigue
Jaundice (yellow-green color of the skin & white part of the eye)
Signs and symptoms typically occur only in advanced colon cancer. Symptoms may include:
Change in bowel habits lasting more than a few days
Bleeding from the rectum
Blood in the stool
Cramping or gnawing stomach pains
Weakness and fatigue
Jaundice (yellow-green color of the skin & white part of the eye)
Early colon cancer usually has no symptoms
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Colon Cancer TestsColon Cancer TestsFecal occult blood testing (FOBT)Barium enemaFlexible sigmoidoscopyColonoscopyVirtual Colonoscopy
Get the test. Get the polyp. Get the cure.
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ColonoscopyColonoscopy
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ColonoscopyColonoscopy
AdvantagesDetects >90%
polyps and cancerProvides diagnosis
and therapyMedicare covers
average-risk
LimitationsRisksAvailabilityCostCompliance
Get the polyp. Get the cure.
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Testing rates remain far too lowTesting rates remain far too low
Are people getting tested?Are people getting tested?
Fewer than half of Americans over age 50 report having had a recent colorectal cancer screening test
Because of low testing rates, only 39% of colorectal cancers are detected at the earliest, most treatable stage
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Ethnic/Racial differencesEthnic/Racial differencesPercentage who have never had
screening colonoscopyHispanics - 67%Black - 55.8%White, non-Hispanic – 47%Never married 60%Education less than high school diploma
58% vs 52% completed high school vs 46% with some college education
2005 data, AHRQ2005 data, AHRQ
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Virtual ColonoscopyVirtual Colonoscopy
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Virtual ColonoscopyVirtual Colonoscopy
Spiral CT to generate 3D imagesCleaning of bowel, distension with airNon invasive, no complicationsNot endorsed for CRC screening
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Virtual ColonoscopyVirtual Colonoscopy
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Limitations Virtual Colonoscopy Limitations Virtual Colonoscopy
Variable resultsNo screening studiesNo longitudinal studiesCostDoes not allow for therapy
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Stool DNAStool DNANow recommended by ACS and USMSTF for
average risk individualsMulti-target DNA stool assay required to
achieve adequate sensitivity and detect the various gene mutations
K-rasK-ras
APCAPC
P53P53
BAT-26BAT-26
21 separate point mutations21 separate point mutations
DIADIA
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Video Capsule ColonoscopyVideo Capsule ColonoscopyIn the process of development
Battery lifeNo clinical data availableAnticipate to see clinical trials
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Colon Cancer TestsColon Cancer TestsAverage RiskAverage Risk
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Average Risk IndividualsAverage Risk Individuals
No SymptomsAge 50No risk factors
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Current RecommendationsCurrent RecommendationsAverage RiskAverage Risk
*Preferred strategy by ACG*Preferred strategy by ACG
Test Interval (years)
FOBT Yearly
Sigmoidoscopy Every 5
FOBT + Sigmoidoscopy Yearly, every 5
Colonoscopy Every 10*
Barium enema Every 5
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Approach to Colon Cancer TestingApproach to Colon Cancer Testing
AsymptomaticMen and Women
Age < 50 yr
No family Hx
No Screening
HNPCC or FAP
Genetic Counseling
1 first-degree 60 yrs
Average-riskscreening,
starting age 40
YES family Hx
2 or more first-degree or 1 first-degree < 60 yrs
Colonoscopy every5 yrs, starting age 40
Age 50 yr
NO family Hx
Average Screening
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The flat polypThe flat polyp
Techniques to improve detectionNarrow-band imagingChromoendoscopyEndocytoscopy
Soitenko et al. JAMA Soitenko et al. JAMA March 2008March 2008
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Narrow Band ImagingNarrow Band Imaging
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Left sided ulcerative colitis Left sided ulcerative colitis
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Ulcerative colitis with extensive Ulcerative colitis with extensive pseudopolypspseudopolyps
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FAMILIAL POLIPOSIS COLIIt is a rare autosomal dominant disorderMultiple colorectal polypsRectal bleeding/ change in bowel habitThe treatment- colorectal removal with
ileoanal anastomosis, or panproctocolectomy with definitive ileostomy
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Peutz-Jeghers syndromeIt is an autosomal dominant inherited disorder
characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic macules.
Patients with Peutz-Jeghers syndrome (PJS) have a 15-fold increased risk of developing intestinal cancer compared with that of the general population.
Such cancer locations includes gastrointestinal and extraintestinal sites.
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