Not uncommonly, an abdominal CT scan report may say there is thickening of the bowel wall in particular the rectum. The differentials here include:
1. normal bowel wall – perhaps the muscles the wall were contracted at the time of the scan
2. Rectal cancer in particular a circumferential tumour – therefore the next investigation from this is usually a colonoscopy
3. Inflammatory bowel disease, diverticular disease – but one would also see the diverticula etc
An elderly patient was referred with rectal bleeding thought to be from haemorrhoids(The patient has just had colonoscopy <2 years ago by a gastroenterologist which showed only haemorrhoids and was otherwise reported as normal) The patient’s bleeding had not really settled at all since the previous colonoscopy and the patient’s bleeding was attributed to the haemorrhoids reported in the colonoscopy. The patient was referred recently for the haemorrhoidal bleeding and a colonoscopy was performed. A low rectal cancer measuring about 5cm was found(the cancer was arising from a tubulovillous adenoma, located just above the anal canal, the tumour can be felt on rectal examination – mobile, T2 on MRI). Fortunately, this could be treated with a transanal excision of the rectal cancer and the patient recovered quickly from the surgery.
The points to learn from here is that :
1. One should not always assume any rectal bleeding is due to haemorrhoids- especially if this persist despite treatment of the haemorrhoids. (If haemorrhoids have been bleeding up to the colonoscopy, it would be a good idea to band them at the end of the colonoscopy) If symptoms persist, reinvestigate or refer on.
2. A rectal examination is still useful even in the 21st century- As Norman Browse’s book on Symptoms and Signs of Surgical Diseases says “”Every patient with a rectal complaint should have a rectal examination”". This still holds true today. Be thankful that there are gloves these days – I have heard in the past in places where gloves were not easily available, doctors used to put soap into their fingernails before doing the rectal examination. ( A good tip is to double glove the hand doing the rectal examination – that way you can throw away the top glove after the rectal exam before doing anything else)
3. On colonoscopy, care must be taken to look carefully at the anal canal and what is just above. Sometimes faeculent fluid can obscure the view – this should be sucked out. A J manouvre at the end in the rectum is also useful. In fact during my training, I remembered one of my mentors telling me how he heard about a case of a low rectal cancer being missed during a colonoscopydue to too rapid an insertion.
By right, being an investigation, there really should not be such a long wait for a colonoscopy. After all, one of the main reason the test is being done is to exclude a bowel cancer.
Why should a public patient wait for such a long time for an investigation? Does anyone have to wait more than 4 weeks for a blood test or any Xray?
Currently there are so many patients on public waiting lists all over Australia. Mathematically, I cannot see how this would get any shorter if the current situation persist. In fact, it will only get longer as the population ages, more and more people leave private insurance and hospital budgets become tighter. Also in public hospitals, the throughtput is much less than in a private endoscopy centre for a number of reasons including:
1. Hospital bureaucracy slowing turnover of patients
2. Working culture
3. Need for trainee anaesthetists and surgeons/gastroenterlogists to learn hands on
4. Financial model in public hospitals do not given any incentives for the hospital to do more scopes(they would go over budget, they can only have a certain percentage of patients are day cases, and only do a certain number of scopes a year) nor do they give incentives for specialists(paid by the hour on a rate far less than what one gets privately, often moral is low due to hospital bureaucracy, most are staying on only out of a duty to care for their patients and to teach the trainees) to increase throughput
Hence in the public hospitals, the average colonoscopes booked to a half day list(with registrars) may be about 6-7 while privately one can have 8-10 cases on a half day list.(Some private centres do even more than that – but doing a colonoscopy too quickly is also not good as polyps may be missed. Ideally, 30min should be allocated for each colonoscopy procedure to allow time to have a careful look on withdrawing the colonoscopy)
Frail lady in her eighties presented to her GP with change of bowel action.
Colonoscopy shows 5cm low rectal tumour.
Transanal excision performed – ie surgery via anal canal to resect the tumour alone, not needing a laparotomy.
Histology: Rectal adenoma
How long is it before someone would present with bowel cancer?
This varies from person to person – these days, the sooner one brings this to the doctors attention, the sooner this can be looked at.
Recently a patient in the 70s who has been on holidays travelling around Australia presented to his local GP complaining of a change of bowel action. He was investigated and found to be severely anaemic. He was sent to the Emergency department as he has had increasing difficulty opening his bowels.
On examination, he was found to have a low rectal cancer on rectal examination. Further investigations showed that he has lung metastates.
He went on to have a resection and permanent stoma.
In the last month, I have found two low rectal cancers on colonoscopy – both were palpable on rectal digital examination and had symptoms that the patients have brushed off as being nothing too serious for months.
Lesson from this to all my readers:
If you have any rectal bleeding, passage of mucus, change in your bowel action, feeling of not being able to completely empty your bowels – please see your general practitioner as soon as possible!