1000-2000 5 ьшò

ICD10

C18.9 Malignant neoplasm of colon, unspecified

C18.2 Malignant neoplasm of ascending colon

C18.8 Malignant neoplasm of overlapping sites of colon

CLINICALPEARLS

Microcytic anemia in men of all ages and postmenopausal women is CRC until proven otherwise.

Colon cancer screening decreases mortality from colon cancer, but optimal screening method is unclear.

Colonoscopy offers ability for diagnosis of colon cancer and intervention if polyp is discovered.

Multidisciplinary communication in the treatment of colorectal cancer patients improves outcomes.

Minimally invasive surgery leads to less pain and faster recovery for patients with equivalent oncologic outcomes.

mebooksfree.com

COLONIC POLYPS

Marcelle Meseeha, MD Maximos Attia, MD, FAAFP

BASICS

DESCRIPTION

Intraluminal colonic tissue growth; most commonly sporadic or part of polyposis syndromes

Size classification:

– Diminutive ≤5 mm, small 6 to 9 mm, large ≥10 mm Morphologic classification:

– Depressed, flat, sessile, or pedunculated Clinical significance:

– >95% of colon adenocarcinoma arise from polyps.

EPIDEMIOLOGY

Colorectal polyps are more common in non-Caucasian men in Western countries.

Incidence

Incidence increases with age.

Prevalence

15–20% of all adults

30% of U.S. population >50 years

6% of children

12% of children with lower GI bleed

ETIOLOGYAND PATHOPHYSIOLOGY

Mucosal

–Neoplastic

Adenomatous polyps (tubular >80%, villous 5–15%, tubulovillous 5– 15%)

Serrated polyps

Sessile serrated polyps are common, more in proximal colon, with low malignant potential if no dysplasia and significant malignant potential if dysplastic.

mebooksfree.com

Traditional serrated adenoma is uncommon, more often noted in distal colon, with significant malignant potential.

–Nonneoplastic polyps (hyperplastic, juvenile polyps, hamartomas, inflammatory pseudopolyps)

Hyperplastic polyps are very common, more in distal colon, with very low malignant potential.

Juvenile polyps are common in childhood, benign hamartomas, more in rectosigmoid, and not premalignant.

Submucosal (lipomas, lymphoid aggregates, carcinoids)

Genetics

Inactivation of tumor suppressor genes as adenomatous polyposis coli (APC) or mismatch repair genes (MLH1) causes polyps to grow into cancer.

Familial adenomatous polyposis (FAP) is autosomal dominant. By age 40 years, almost all patients develop colorectal cancer (CRC).

MUTYH-associated polyposis (MAP) is autosomal recessive caused by biallelic mutations in MUTYH gene.

Juvenile polyposis syndrome (JPS) is autosomal dominant. 50–60% of patients have a mutation in the SMAD4 or BMPR1A gene. By age 35 years, 20% of patients develop CRC.

RISK FACTORS

Family history of intestinal polyposis, polyps, or CRC

Advancing age; male

High-fat, low-fiber diet; tobacco use

Excessive alcohol intake: >8 drinks a week

Inflammatory bowel disease is associated with a decreased prevalence of colon polyps (but with higher risk of colon cancer).

GENERALPREVENTION

Low-fat, high-fiber diet

Avoid smoking.

Decrease alcohol intake.

Use of NSAIDs and calcium is associated with decreased incidence and recurrence of polyps.

No lower rates of CRC with azathioprine, 6-mercaptopurine, folate, calcium, multivitamins, or statins

mebooksfree.com

COMMONLYASSOCIATED CONDITIONS

Hereditary polyposis syndromes: Adenomatous

–FAP

Classic (CFAP)

Attenuated (AFAP)

–MAP

–FAPvariants:

Gardner syndrome

Turcot syndrome

Hamartomatous

–Peutz-Jeghers syndrome (PJS)

–JPS

–Familial juvenile polyposis

–Cowden syndrome

ALERT

JPS imposes a higher risk of CRC, although juvenile polyps are not premalignant.

DIAGNOSIS

HISTORY

Generally asymptomatic

Painless rectal bleeding, bright or dark red, mixed with stools, dripping, or on wiping

Diarrhea or mucous stool

Abdominal pain

Constipation

Chronic bleeding resulting in iron deficiency anemia

McKittrick-Wheelock syndrome; large hypersecretory rectosigmoid villous adenoma, resulting in persistent severe diarrhea, electrolyte disorder, dehydration, and prerenal acute renal failure

Social and family history

PHYSICALEXAM

Usually normal

mebooksfree.com

Rectal polyps noted as prolapsed or palpated on digital rectal examination

(DRE)

Fecal occult blood test (FOBT) by DRE is less effective than FOBT by stool passed spontaneously.

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC; anemia with chronic bleeding

Basic metabolic panel; electrolyte disorder with hypersecretory adenomas FOBT, insensitive screening test, as small polyps don’t usually bleed:

–Guaiac (gFOBT)—uses a chemical indicator with color change in presence of blood

–Immunochemical (iFOBT or fecal immunochemical test [FIT])—uses antibodies against human hemoglobin

Stool DNAtest is more sensitive and less specific than FIT.

Diagnostic Procedures/Other

Colonoscopy is the gold standard test for detection of polyps and polypectomy. Not a perfect screening test, with increased miss rate with rightsided colon polyps, smaller polyp size, low quality of colon prep, less endoscopist experience

Computed tomographic colonography (CTC) is less sensitive with flat polyps and requires excellent bowel preparation.

Double-contrast barium enema

Colon capsule endoscopy

Enhanced optical technologies can potentially differentiate between neoplastic and nonneoplastic colonic lesions (1)[A].

Enhanced optical technologies include:

–Narrowed spectrum endoscopy (narrow-band imaging [NBI])

–Image-enhanced endoscopy (i-scan)

–Fujinon intelligent chromoendoscopy (FICE)

–Confocal laser endomicroscopy (CLE)

Patients with >10 colorectal adenomas should undergo genetic testing for APC and MUTYH (2)[C].

Test Interpretation

Tubular adenoma

– Gross: tend to be polypoid

mebooksfree.com

– Micro: dysplastic epithelium with a tubular architecture

Villous adenoma:

–Gross: tends to be sessile

–Micro: dysplastic epithelium with fine fingerlike projections

Tubulovillous adenomas have a combination of tubular and villous architecture.

Hyperplastic polyps are composed of hyperplastic colonic mucosa.

Hamartomatous polyps include muscularis mucosa.

Juvenile polyp

– Gross: pedunculated, smooth, red mass, 1 to 3 cm (3)

TREATMENT

SURGERY/OTHER PROCEDURES

Colonic polypectomy; diagnostic, therapeutic:

–Snare polypectomy with electrocautery for pedunculated polyps

–Endoscopic mucosal resection for sessile polyps

–Endoscopic submucosal dissection

Colorectal surgery; prophylactic in FAPand MAPand when there are numerous polyps or persistent bleeding (2,3)[C]:

–Total colectomy ileorectal anastomosis

–Proctocolectomy ileal pouch anal anastomosis

Chemoprevention: NSAIDs and calcium may reduce incidence and recurrence of polyps in patients with FAPand MAP(4)[A].

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Follow-up colonoscopy in:

10 years if no polyps or distal small hyperplastic polyps (<10 mm) (5)[B]

5 to 10 years if 1 to 2 small tubular adenomas (<10 mm) (5)[B]

3 years if 3 to 10 adenomas if any polyp ≥6 mm (5)[B] or if all polyps <6 mm (5)[C]

<3 years if >10 adenomas (5)[B]

3 years if one or more adenomas ≥10 mm (5)[A]

mebooksfree.com

3 years if one or more adenomas with villous features of any size or with

HGD (5)[B]

5 years if sessile serrated polyp(s) <10 mm with no dysplasia (5)[C]

3 years if sessile serrated polyp(s) ≥10 mm or with dysplasia or traditional serrated adenoma (5)[C]

1 year if serrated polyposis syndrome (5)[B]

Patient Monitoring

Colonoscopy for CRC screening starts at age 50 years and earlier for at-risk patients.

Stop screening if life expectancy is <10 years.

In CFAPand AFAP, screen for extracolonic manifestations: thyroid cancer, desmoid tumors, and gastroduodenal polyposis (every 6 months to 5 years) (2) [C].

In families, lifetime screening is indicated in mutation carriers (2)[C]:

–In CFAP: with sigmoidoscopy or colonoscopy every 1 to 2 years starting at age of 10 to 11 years

–In AFAPand MAP: with colonoscopy every 1 to 2 years starting at age of 18 to 20 years

After colorectal surgery, surveillance of the rectum (every 6 to 12 months) or pouch (every 6 months to 5 years) is indicated (2)[C].

First-degree relatives of patients with JPS require screening by colonoscopy and upper endoscopy after age 12 years (3)[C].

DIET

Low-fat, high-fiber diet (insufficient evidence)

PATIENT EDUCATION

Importance of colonoscopy as a screening tool

PROGNOSIS

Regression or no change in size, more with small hyperplastic polyps and with patients on NSAIDs

Recurrence: Juvenile polyps recur in 45% of children with multiple polyps and 17% of children with solitary polyps (3).

Risk factors for colon cancer (6)[A]:

–Polyp pathology Adenomatous

mebooksfree.com

Serrated

With high-grade dysplasia

With >25% villous histology

Polyp size >1 cm in diameter

Polyps located in proximal colon

More than three polyps

Recurrence rates <10% postpolypectomy

COMPLICATIONS

Polyps: progression to cancer

Polypectomy: bleeding 2–11%, perforation 0–1%, higher with endoscopic submucosal dissection

Colonoscopy: complications related to anesthesia and procedure itself

REFERENCES

1.Wanders LK, East JE, Uitentuis SE, et al. Diagnostic performance of narrowed spectrum endoscopy, autofluorescence imaging, and confocal laser endomicroscopy for optical diagnosis of colonic polyps: a meta-analysis. Lancet Oncol. 2013;14(13):1337–1347.

2.Stoffel EM, Mangu PB, Limburg PJ; for American Society of Clinical Oncology. Hereditary colorectal cancer syndromes: American Society of Clinical Oncology clinical practice guideline endorsement of the familial risk-colorectal cancer: European Society for Medical Oncology clinical practice guidelines. J Oncol Pract. 2015;11(3):e437–e441.

3.Thakkar K, Fishman DS, Gilger MA. Colorectal polyps in childhood. Curr Opin Pediatr. 2012;24(5):632–637.

4.Johnson CC, Hayes RB, Schoen RE, et al. Non-steroidal anti-inflammatory drug use and colorectal polyps in the prostate, lung, colorectal, and ovarian cancer screening trial. Am J Gastroenterol. 2010;105(12):2646–2655.

5.Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844–857.

6.Gao Q, Tsoi KK, Hirai HW, et al. Serrated polyps and the risk of synchronous colorectal advanced neoplasia: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110(4):501–509.

mebooksfree.com

ADDITIONALREADING

Ashraf I, Paracha SR, Arif M, et al. Digital rectal examination versus spontaneous passage of stool for fecal occult blood testing. South Med J. 2012;105(7):357–361.

Cooper K, Squires H, Carroll C, et al. Chemoprevention of colorectal cancer: systematic review and economic evaluation. Health Technol Assess. 2010;14(32):1–206.

SEE ALSO

Colon Cancer; Rectal Cancer

CODES

ICD10

K63.5 Polyp of colon

D12.6 Benign neoplasm of colon, unspecified

K51.40 Inflammatory polyps of colon without complications

CLINICALPEARLS

Colonoscopy is the gold standard tool for diagnosis of polyps.

Small hyperplastic polyps should be biopsied to differentiate adenomatous and serrated polyps.

Use of NSAIDs and calcium is associated with decreased incidence and recurrence of polyps.

The progression from normal mucosa to polyp to carcinoma takes years to develop.

mebooksfree.com

COMPLEMENTARYAND ALTERNATIVE MEDICINE

Paul Crawford, MD

BASICS

Complementary and alternative medicine (CAM) are medical and health care systems, practices, and products not presently considered part of conventional medicine.

The National Center for Health Statistics (NCHS) reports nonvitamin, nonmineral dietary supplements, chiropractic or osteopathic manipulation, yoga, and massage therapy are the most common complementary health approaches.

Medical professionals who incorporate CAM into their medical practice often refer to this model as “integrative medicine.”

DESCRIPTION

Definitions and additional terms

–Complementary medicine is used in conjunction with conventional medicine to address a health concern. For example, massage plus physical therapy for low back pain or medication plus osteopathic manipulation for recurrent headaches.

–Alternative medicine is used in place of conventional medicine to promote healing of conditions not fully explained by the conventional biomedical model or for which the effectiveness of therapy is not yet established by clinical research.

–Integrative medicine is the combination of allopathic medicine with CAM and may be provided to the patient by a single licensed medical professional trained in CAM or by a group of diverse health care providers.

–Holistic is a descriptive term for a practitioner’s approach to patient care. Holistic care assesses the emotional, spiritual, mental, and physical state of wellness of the patient and works to provide comprehensive care. Aholistic practice may include practitioners of different disciplines to address

multiple aspects of wellness or illness.

Biologically based therapies: diets, herbals, vitamins, supplements, flower essences

mebooksfree.com