General
Cancer of the Bowel or Colorectal Cancer is one of the commonest cancers in
Europe and the Western societies. In the UK it is the second commonest cancer
for both men and women. Approximately 30,000 people get colorectal cancer in
the UK every year. One quarter of those people are already beyond treatment
at the time of the diagnosis because the cancer is too advanced. Although
there are many effective treatments for colorectal cancer today, it still causes
10,000 deaths per year in the UK.
All treatments are more efficient at the early stages and this is why it so
important to discover colorectal cancer as early as possible after its onset. In
the very near future a Screening Programme for colorectal cancer among the
general population is about to start in the UK. Until then, it is important that any
adult over the age of 40 with unusual symptoms from their bowels seeks advice
from their doctor.
In most cases Colorectal Cancer begins as a polyp. A polyp is a benign growth
which takes years to grow. Some, but not all, polyps will become cancers if left
for a number of years to grow. If a polyp is discovered and removed before it
becomes malignant then the risk of bowel cancer is eliminated. Polyps are
found and removed during colonoscopy.
The importance of Age and Family History
About 95% of cases of colorectal cancer occur above the age of 40. The
majority of the cases occur after the age of 60. One may get colorectal cancer
under the age of 40 only if there is a genetic condition in their family. This is
why an important factor when enquiring about the above symptoms is the
“Family History”.
Because colorectal cancer is such a common condition anyone can have a
relative who has suffered it just by pure chance. This is particularly true if that
relative had colorectal cancer at an advanced age because cancer that
happens at an advanced age is unlikely to be caused predominantly by genetic
factors. Also, distant relatives do not put someone at risk because the genes
get very diluted after each generation.
There may be risk of genetically caused colorectal cancer only if there is a
“First Degree Relative –FDR” or more. By FDR we mean parents or siblings
only. The chance of a genetic cause of colorectal cancer is higher if the FDR
had colorectal cancer at a relatively young age. If there is one or more FDR
with colorectal cancer at an age younger than 40 then there may be a genetic
condition in the family: Familial Adenomatous Polyposis (FAP) or
Hereditary Non Polyposis Colorectal Cancer (HNPCC). When a suspicion
of those conditions arises then a full genetic testing is indicated by specialist
geneticists. Preventive investigations of several members of the family may be
indicated. It is emphasized that both FAP and HNPCC are rare conditions and
account for less than 5% of cases of colorectal cancer.
Symptoms
The symptoms of Colo-Rectal Cancer are unfortunately very subtle and can
often be mistaken for those of common conditions such as gastroenteritis,
irritable bowel, haemorrhoids etc. Although an experienced physician can easily
distinguish on questioning between cancer and those benign conditions, this is
not always easy for the patient.
The main symptoms that are suspicious for Colo-Rectal Cancer are:
1. Bleeding from the Rectum (Per Rectum or PR Bleeding).
2. Change of Bowel Habits (for more than 6 weeks).
3. Abdominal Pain
4. Anaemia (Low Blood Count that results in paleness)
It is emphasized that all of the above symptoms can be caused by benign
conditions and the presence of one or more of those DOES NOT mean that
patient has cancer.
Symptoms: 1. Bleeding from the Rectum
This is a very common symptom and in over 95% of cases results from
haemorrhoids or anal fissures, particularly if the patient is younger than 40.
Bleeding can be in the form of a bright red spot on the toilet paper (usually
caused by haemorrhoids) or in the form of dripping bright blood either in the
beginning or in the end of the bowel movement (also usually caused by
haemorrhoids).
The most suspicious kind of blood is the one which is of darker colour and is
mixed with the stools. This means that it may originate from higher up in the
bowel and therefore requires investigation.
Sometimes bleeding is so minimal that it is “occult” and the patient is unaware
of its presence. The suspicion of bleeding is raised when the patient is found to
suffer from iron-deficiency anaemia without any other obvious cause. It is
confirmed with the aid of “Faecal Occult Blood” test (FOB). The presence of
unexplained iron-deficiency anaemia and positive FOB is an indication for
investigations for bleeding from the bowel and stomach.
Rectal bleeding may be caused by a polyp or CRC.
Symptoms: 2. Change of Bowel Habits
Each individual has a slightly different pattern of bowel movements or “bowel
habits”. Bowel habits may be inherent to the particular individual but also
depend on dietary factors, lifestyle, even psychological factors.
There are great variations and, apart from extreme cases or pathological
syndromes, in most cases it is not easy to define what is “normal” or “abnormal”
bowel habit. However bowel habits tend to be a long term thing. Of course
anyone may have a temporary change of bowel habits because of
gastroenteritis, change of diet, travelling, stress etc, however most such
changes tend to restore themselves to the previous habits within a few weeks.
Persistent change of bowel habits for more than six weeks may be an indication
of a bowel condition.
The change of bowel habits can take 3 forms:
Constipation (or decreased frequency with or without straining of bowel
movements)
Diarrhea (or increased frequency)
Alternating Constipation –Diarrhea.
Of the above changes constipation is the less suspicious one and does not
always require immediate investigation if there is a reasonable explanation for
its onset. A trial of high fibre diet and mild laxatives may first be tried before
invasive investigations.
Diarrhea (or just increased frequency with non formed stools) is more
suspicious. This may be true diarrhea, i.e. watery motions, or just increased
frequency of bowel movements with non formed stools. Sometimes there might
be a symptom of incomplete evacuation that makes the patient to go to the
toilet repeatedly although there is little result (this is called tenesmus). Apart
from CRC other common causes may be Inflammatory Bowel Disease or colitis
of other origin, Diverticular Disease etc. Investigations will almost always be
required for persistent diarrhea.
Alternating Constipation – Diarrhea is particularly suspicious when it is a new
pattern on a person over 50. On the contrary it is often caused by Irritable
Bowel Syndrome if the patient is younger than 40. Usually investigations are
required.
Symptoms: 3. Abdominal Pain
Abdominal pain has been experienced by every individual at some point in their
life. There are many kinds of abdominal pain and not only it can arise from any
organ inside the abdomen but it can also arise from problems outside the
abdomen such as chest, spine etc. Obviously there are numerous causes of
abdominal pain, most of them benign, and in order to put a diagnosis a
thorough consultation and several investigations are often required.
Abdominal pain is suspicious for CRC only when associated with one of the
other symptoms above or in the presence of a palpable abdominal mass.
Symptoms: 4. Anaemia
Unexplained iron-deficiency anaemia (low blood count) needs investigation
of both the bowel and the stomach. This is because it may signify slow blood
loss from minimal bleeding which may be caused by cancer (although there are
other causes).
The Consultation and Clinical Examination
During the consultation the physician will take the history and establish the
nature of symptoms through a number of questions which aim to clarify many
important details. A personal health history and a brief family history are also
taken.
The abdomen is then clinically examined in order to detect any abnormal
distension, the presence of tenderness, enlarged organs or glands or the
presence of abnormal masses.
Cancer of the Rectum can often be found on clinical examination therefore the
physician examines the rectum in three ways: with a finger examination (per
rectum examination), proctoscopy (inspection of the anus with a short
hollow scope-this reveals the presence of haemorrhoids etc.) and Rigid
Sigmoidoscopy.
Rigid Sigmoidoscopy is performed with an instrument which is approximately 20
cms long and is connected to a light source and an insufflator. This instrument
allows the inspection of most of the rectum.
Usually none of the above examinations is particularly painful although some
discomfort may occur in the presence of an inflamed or diseased anus/ rectum.
Although some patients find those examinations slightly embarrassing their
importance for a correct clinical assessment cannot be stated too strongly.
For a description of the diagnostic investigations please click on the link.
Surgery for Colorectal Cancer
Treatment of Recurrent Colorectal Cancer
Follow Up after Colorectal Cancer surgery
©COPYRIGHT OF www.bowel-health.com contents by Dr. Savvas
Papagrigoriadis. All rights reserved.
Rectal cancer
obstructing the
lumen, as seen on
colonoscopy.
obstructing the
lumen, as seen on
colonoscopy.
Rectal cancer with Total
Mesorectal excision
specimen (courtesy of
www.proctosite.com)
Mesorectal excision
specimen (courtesy of
www.proctosite.com)
Cancer of the Colon and Rectum (Colorectal Cancer)
 | |  | |  | |  | |  | |  |
Right Colon Cancer (Courtesy
of www.proctosite.com)
of www.proctosite.com)
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |