Why Should I Be Concerned About Colon Cancer?

Colon and rectal cancer is the third most common cancer overall in the U.S. today. 

Only lung and breast cancer occur with a higher incidence in women, while lung and prostate cancer rank first and second in men.

Of particular importance to those of us living in the Tri-State area is the fact that colorectal cancer occurs at a higher incidence here than in other parts of the country.  Data accumulated over the past three years at both Deaconess Hospital and St. Mary’s Medical Center have shown a consistently higher rate of colon and rectal cancer in the Tri-State area as opposed to the national average.  The reason for this increase in incidence is unknown.

WHAT ARE POLYPS?  

Most, if not all colorectal cancers actually begin as a benign growth called a polyp.  These polyps are more common on the left side of the colon, although they can occur throughout the colon.  It is thought that these polyps require three to five years of growth to reach a size at which there is significant risk of changing to cancer.  It is during this benign phase that detection and removal can prevent the development of cancer.

WHAT ARE THE RISK FACTORS? 

 The most common risk factors for the development of cancer of the colon and rectum are advancing age or a family history of colorectal cancer or polyps.  Only 2 % of cancers occur in patients under the age of 40, while 90 % of patients with colon cancer are over the age of 50.  Patients with inflammatory bowel disease affecting the colon are also at increased risk. Crohn’s disease and ulcerative colitis are examples of two types of inflammatory bowel disease.

There are some genetic syndromes which greatly increase the risk of developing cancer.  Familial polyposis is one such genetic syndrome which predisposes patients to developing large numbers of polyps at an unusually early age; therefore, predisposing these patients to development of cancer much sooner.

WHAT ARE THE EVALUATIONS LIKE? 

There are a number of examinations which can be done to evaluate for the presence of polyps or cancer.  The type of exam recommended by a physician depends upon the patient’s age, risk factors, and the presence or absence of symptoms.

The most common screening methods include the following:

1)  Digital rectal exam – this allows examination of the anal canal and lower rectum.  The prostate glad is also evaluated during this exam.

2)  Hemoccult testing – this test checks for trace amounts of blood in the stool that is not visible to the naked eye.  There is a high false negative as well as a high false positive rate with this test.  What this means is, that a cancer can be present even if the test is negative, while the opposite is also true – that a positive test does not always indicate the presence of a cancer.  In fact, cancer is not present in the majority of cases where the test is positive.

3)  Rigid proctosigmoidoscopy – this is an exam done with a short rigid scope.  This is a limited exam which allows evaluation of the rectum.

4) Flexible sigmoidoscopy – this involves the use of a flexible lighted instrument which allows direct examination of the rectum and sigmoid colon.  Approximately one-fourth to one-third of the colon can be examined by this method.  The portion of the colon examined by this method, is the part of the colon where approximately 60 – 65 % of polyps and cancers occur.

5)  Colonoscopy – this procedure also uses a lighted flexible instrument which is long enough to examine the entire colon.  This examination is done under sedation and allows for removal of polyps or biopsies of cancers and other suspicious areas.  Contrary to popular belief, this exam can be done very comfortably in about 30 minutes.  The use of sedation makes this a very easy examination in most patients.

6)  Barium enema – this exam involves the use of a solution to fill the colon.  X-rays are then taken which show the outline of the colon.  This exam is limited because it only shows the outline of the colon and any abnormality must usually be evaluated by follow up endoscopic examination.

WHAT ARE THE SIGNS AND SYMPTOMS FOR COLON AND RECTAL CANCER?  Rectal bleeding, blood in the stool, and changes in bowel pattern are the most common symptoms seen with this cancer.  Other symptoms include abdominal pain, weight loss, urgency, or excessive mucus in the stool. It is very important to emphasize that polyps and early cancers very seldom cause symptoms.  It is for this reason that routine exams are recommended for all people, especially those with risk factors.  A common misconception is that a person needs an exam only when symptoms are present.  Unfortunately, by the time symptoms have developed, a patient may have advanced disease.  The best approach is to do regular exam so that polyps can be detected and removed before they become cancerous.

WHEN SHOULD REGULAR EXAM BE STARTED?  Patients without symptoms are viewed as being at average or increased risk, depending upon their history.  Those patients with no family history of cancer or polyps are considered at average risk.  People with a family history of cancer or polyps are at increased risk to develop colorectal cancer.  The American Cancer Society’s current guidelines call for regular screening to begin at age 50 in those of average risk.

For patients at increased risk, total colonoscopy is recommended beginning at age 40 with repeat examinations every three to five years.  Exams should be performed at an earlier age if there is a history of family members with cancer at an unusually early age.

Any patient over the age of 40 with bleeding or other symptoms should also have an examination.  The type of exam is determined by the patient’s physician, depending upon the exact symptoms and finding on preliminary physical examination.

Total colonoscopy is an examination that is usually done by a specialist.  Most colonoscopies are done by either a colon and rectal surgeon or a gastroenterologist.  These exams can also be done by general surgeons, internists, and family practitioners who have had appropriate training.

Although most of us are embarrassed by these examinations, and afraid that they are associated with a great deal of pain, these exams can usually be done without significant discomfort in your doctor’s office.  Total colonoscopy is generally done with sedation which makes the examination very comfortable.  Removal of a polyp or a biopsy is also painless due to the fact that the inside lining of the colon does not contain pain fibers.  After a colonoscopy a patient can resume a normal diet immediately and there are usually no restrictions in activity once the sedation has had time to wear off.

The bottom line (no pun intended) is this; colon and rectal cancer is a common cancer and we are all at risk.  This risk can be significantly reduced by undergoing regular examinations once we have reached the age of fifty, with earlier exams being done if we have a family history of cancer or have developed symptoms.  The examinations can be done comfortably by well trained physicians with minimal discomfort or embarrassment to the patient.

Colorectal cancer is a preventable and curable disease especially when detected early.  If you are over age 50 and have not had an exam, contact your physician soon about beginning regular screening. 

Products containing probiotics have flooded the market in recent years. As more people seek natural or non-drug ways to maintain their health, manufacturers have responded by offering probiotics in everything from yogurt to chocolate and granola bars to powders and capsules.

Although probiotics have been around for generations – think of the “live active cultures” in several brands of yogurt – the sheer number of products with probiotics now available may overwhelm even the most conscientious of shoppers. In some respects, the industry has grown faster than the research and scientists and doctors are calling for more studies to help determine which probiotics are beneficial and which might be a waste of money.

Probiotics are living microscopic organisms, or microorganisms, that scientific research has shown to benefit your health. Most often they are bacteria, but they may also be other organisms such as yeasts. In some cases they are similar, or the same, as the “good” bacteria already in your body, particularly those in your gut. These good bacteria are part of the trillions of microorganisms that inhabit our bodies. This community of microorganisms is called the microbiota. Some microbiota organisms can cause disease. However, others are necessary for good health and digestion. This is where probiotics come in.

The most common probiotic bacteria come from two groups, Lactobacillus or Bifidobacterium, although it is important to remember that many other types of bacteria are also classified as probiotics. Each group of bacteria has different species and each species has different strains. This is important to remember because different strains have different benefits for different parts of your body. For example, Lactobacillus casei Shirota has been shown to support the immune system and to help food move through the gut, but Lactobacillus bulgaricus may help relieve symptoms of lactose intolerance, a condition in which people cannot digest the lactose found in most milk and dairy products. In general, not all probiotics are the same, and they don’t all work the same way.

Scientists are still sorting out exactly how probiotics work. They may:

• Boost your immune system by enhancing the production of antibodies to certain vaccines.
• Produce substances that prevent infection.
• Prevent harmful bacteria from attaching to the gut lining and growing there.
• Send signals to your cells to strengthen the mucus in your intestine and help it act as a barrier against infection.
• Inhibit or destroy toxins released by certain “bad” bacteria that can make you sick.
• Produce B vitamins necessary for metabolizing the food you eat, warding off anemia caused by deficiencies in B6 and B12, and maintaining healthy skin and a healthy nervous system.

Probiotics are most often used to promote digestive health. Because there are different kinds of probiotics, it is important to find the right one for the specific health benefit you seek. Researchers are still studying which probiotic should be used for which health or disease state. Nevertheless, probiotics have been shown to help regulate the movement of food through the intestine. They also may help treat digestive disease, something of much interest to gastroenterologists. Note that probiotics mostly supplement rather than replace digestive disease treatments.  Some of the most common uses for probiotics include the treatment of the following:

 Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a disorder of movement in the gut. People who have IBS may have diarrhea, constipation or alternating bouts of both. IBS is not caused by injury or illness. Often the only way doctors can diagnose it is to rule out other conditions through testing.

Probiotics, particularly Bifidobacterium infantis, Sacchromyces boulardii, Lactobacillus plantarum and combination probiotics may help regulate how often people with IBS have bowel movements. Probiotics may also help relieve bloating from gas. Research is continuing to determine which probiotics are best to help treat IBS.

 Inflammatory Bowel Disease

Though some of the symptoms are the same, inflammatory bowel disease (IBD) is different from IBS because in IBD, the intestines become inflamed. Unlike IBS, IBD is a disorder of the immune system. Symptoms include abdominal cramps, pain, diarrhea, weight loss and blood in your stools. There are two main types of IBD: Crohn’s disease and ulcerative colitis.  In Crohn’s disease, ulcers may develop anywhere in your intestine including both the large and small bowels. In ulcerative colitis, inflammation only involves the large intestine. Bouts of inflammation may come and go, but mostly, prescription medication is usually needed to keep inflammation in check.

Recent research indicates that your gut microbiota plays a role in developing IBD, especially ulcerative colitis. Some studies suggest that probiotics may help reduce inflammation and delay the next bout of disease. Ulcerative colitis seems to respond better to probiotics than Crohn’s disease. It appears thatE. coli Nissle, and a mixture of several strains of Lactobacillus, Bifidobacterium and Streptococcus may be most beneficial. Research is continuing to determine which probiotics are best to treat IBD.

Please make an appointment with your gastroenterologist to learn more about Probiotics.

* adapted from AGA website

Acid reflux is a very common digestive illness. Many patients have questions about symptoms, causes and treatment. I read a very nicely written article on acid reflux from the American College of Gastroenterology and here is an edited version of that for your information.

Overview

More than 60 million Americans experience heartburn at least once a month and some studies have suggested that more than 15 million Americans experience heartburn symptoms each day.

Gastroesophageal reflux (or GERD) is a physical condition in which acid from the stomach flows backward up into the esophagus. People will experience heartburn symptoms when excessive amounts of acid reflux into the esophagus. Many describe heartburn as a feeling of burning discomfort, localized behind the breastbone, that moves up toward the neck and throat. Some even experience the bitter or sour taste of the acid in the back of the throat. The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food.

Causes

Normally, a muscular valve at the lower end of the esophagus called the lower esophageal sphincter or “LES” — keeps the acid in the stomach and out of the esophagus. In gastroesophageal reflux disease or GERD, the LES relaxes too frequently, which allows stomach acid to reflux, or flow backward into the esophagus.

Treatment of Occasional Heartburn

In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.

 Lifestyle Modification

1.  Avoid foods and beverages that contribute to heartburn: chocolate, coffee, peppermint, greasy or spicy foods, tomato products and alcoholic beverages.
2. Stop smoking. Tobacco inhibits saliva, which is the body’s major buffer. Tobacco may also stimulate stomach acid production and relax the muscle between the esophagus and the stomach, permitting acid reflux to occur.
3. Reduce weight if too heavy.
4. Do not eat 2-3 hours before sleep.
5. For infrequent episodes of heartburn, take an over-the-counter antacid or an H2 blocker, some of which are now available without a prescription.

Over the counter Medications

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional GI discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition that could worsen if not treated. If you are using an over-the-counter product more than twice a week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you, including the use of stronger medicines that are only available with a prescription.

Treatment of GERD

When symptoms of heartburn are not controlled with modifications in lifestyle, and over-the-counter medicines are needed two or more times a week, or symptoms remain unresolved on the medication you are taking, you should see your doctor. You may have GERD.

When GERD is not treated, serious complications can occur, such as severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), bleeding, or a pre-malignant change in the lining of the esophagus called Barrett’s esophagus.  A 1999 study reported in the New England Journal of Medicine showed that patients with chronic, untreated heartburn of many years duration were at substantially greater risk of developing esophageal cancer, which is one of the fastest growing, and among the more lethal forms of cancer in this country.

Symptoms suggesting that serious damage may have already occurred include:

1. Dysphagia: difficulty swallowing or a feeling that food is trapped behind the breast bone.
2. Bleeding: vomiting blood, or having tarry, black bowel movements.
3. Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
4. Weight Loss

GERD is a problem that is symptomatic by day but in which much damage is done by night. Treatment should be designed to: 1) eliminate symptoms; 2) heal esophagitis; and 3) prevent the relapse of esophagitis or development of complications in patients with esophagitis.

In many patients, GERD is a chronic, relapsing disease. Long-term maintenance is the key to therapy; therefore, continuous long-term therapy, possibly life-long therapy, to control symptoms and prevent complications is appropriate. Maintenance therapy will vary in individuals ranging from mere lifestyle modifications to prescription medication as treatment.

Lifestyle modifications

In order to decrease the amount of gastric contents that reach the lower esophagus, certain simple guidelines should be followed:

1. Raise the Head of the Bed. The simplest method is to use a 4″ x 4″ piece of wood to which two jar caps have been nailed an appropriate distance apart to receive the legs or casters at the upper end of the bed. Failure to use the jar caps inevitably results in the patient being jolted from sleep as the upper end of the bed rolls off the 4″ x 4″. Alternatively, one may use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
2. Change Eating and Sleeping Habits. Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.
3. Avoid Tight Clothing. Reduce your weight if obesity contributes to the problem.
4. Change Your Diet. Avoid foods and medications that lower LES tone (fats and chocolate) and foods that may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).
5. Curtail Habits That Contribute to GERD. Both smoking and the use of alcoholic beverages lower LES pressure, which contributes to acid reflux.

Medical treatment of GERD

GERD has a physical cause, and frequently is not curtailed by these lifestyle factors alone. If you are using over-the-counter medications two or more times a week, or are still having symptoms on the prescription or other medicines you are taking, you need to see your doctor. If results are not forthcoming, medications may be used to neutralize acid, increase LES tone, or improve gastric emptying.

Surgical treatment of GERD

Surgical measures to prevent reflux can be considered if other measures fail or complications occur such as bleeding, recurrent stricture, or metaplasia (abnormal transformation of cells lining the esophagus), which is progressive. The surgical technique improves the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring. Consultation with both a gastroenterologist and a surgeon is recommended prior to such a decision.

Diagnosis

Your doctor or gastroenterologist may wish to evaluate your symptoms with additional tests when it is unclear whether your symptoms are caused by acid reflux, or if you suffer from complications of GERD such as dysphagia (difficulty in swallowing), bleeding, choking, or if your symptoms fail to improve with prescription medications. Your doctor may decide to conduct one or more of the following tests.

UGI Series

For the upper GI series, you will be asked to swallow a liquid barium mixture (sometimes called a “barium meal”). The radiologist uses a fluoroscope to watch the barium as it travels down your esophagus and into the stomach.

Endoscopy

This test involves passing a small lighted flexible tube through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives. It is the best test to identify esophagitis and Barrett’s esophagus.

Esophageal Manometry or 24 hour pH testing

This test involves passing a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus. Also, the degree of acid refluxed into the esophagus can be measured over 24 hours.

Measure Yourself on the Richter Scale/Acid Test

How significant is your heartburn? What are the chances that it is something more serious? Here is a simple self-test developed by a panel of experts from the American College of Gastroenterology.

Take this “Richter Scale/Acid Test” to see if you’re a GERD sufferer and are taking the right steps to treat it.

• Do you frequently have one or more of the following:
  • an uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
  • a burning sensation in the back of your throat?
  • a bitter acid taste in your mouth?
• Do you often experience these problems after meals?
• Do you experience heartburn or acid indigestion two or more times per week?
• Do you find that antacids only provide temporary relief from your symptoms?
• Are you taking prescription medication to treat heartburn, but still having symptoms?

If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you live pain free.

The above information was accessed and edited from the article on “Acid Reflux” in the Patient Education & Resource Center at the American College of Gastroenterology.