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!