It is terribly important to follow the instructions for the bowel preparation.  If not properly followed, there may still be faeculent fluid or worse still, thick faeces covering some of the lining of the large intestine. This could hide a small polyp. Also the procedure becomes longer as the endoscopist has to spend time trying to wash and suck out the faeculent fluid as much as possible. (This wouldalso mean the anaesthetist giving the patient more sedation)

Also it is important to avoid food with seeds in the few days preceeding the colonoscopy. Small seeds are a nightmare to the endoscopist as they become stuck in the suction channel of the scope when the faeculent fluid is sucked out!

Other things that have been seen during a colonoscopy include: pill granules,  vegetable material …and even a fruit sticker  stuck on the wall of the bowel!

Also the bowel preparation work best when one drinks plenty of fluids in order to “wash” out all the faeces in the colon. So remember to take lots of drinks when taking the bowel prep! (But avoid alcohol or coffee !)

Recently another patient in his early 40s went to see his GP for a skin lesion.  The GP suggested he has a FOBT too during the consultation. The FOBT turned out to be positive.  He subsequently had  a colonoscopy which showed a small caecal cancer. He went on to have a right hemicolectomy. Further scans have not shown any evidence of spread.

Were it not for his GP ordering the FOBT, this patient’s cancer would probably not have been detected until a few years later(usually the patient would either present with anaemia; occasionally one can get a right sided abdominal pain  from this that could be the same as an appendicitis type pain). This raises the dilemma for the all doctors  – how aggressively does one screen the patient and from what age? Also is there enough resources to do this especially in the public system?

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

A most interesting case out of the textbook.

Patient in the 20s walked into the clinic. Has been referred to me for a colonoscopy.

First thing I noticed was the reddish nodules on the shins of both the legs. The patient says that these has been quite painful. The pain had thougth this was due to mosquito bites or some sort of reaction to insect bites. (Clinically on examination, this was consistent with erythema nodosum)

Further history taking reveals the patient has been having diarrhoea. The patient had also been feeling tired.

Colonoscopy was performed and it showed proctitis as well as distal colitis. Biospsies were taken – histology was initially reported as normal but when I queired it with the pathologist, a second opinion was sought and the consensus opinion was that is was consistent with ulcerative colitis.

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.

This is a difficult question to answer for the individual.

Just last month a man in his 40s was seeing his GP for a skin problem when the GP suggested that he take the test. The faecal occult blood test came back positive – in fact, positive on all specimen. He was then referred for a colonoscopy.

On colonoscopy, a bowel cancer in the caecum was found.

He subsequently underwent a bowel resection.  The pathology showed that is was a fairly advanced cancer – with lymph glands involved. Further scans suggest the possibility of spread to the liver already..

The main difference is actually the Medicare fees – say you are referred to a specialist because you have been screened for faecal occult blood and the test has been positive. For the initial consult, the Medicare benefits(100%) for the gastroenterologist is $139.45 while for surgeons it is $79.05.  This difference is because different specialities are allowed to claim different rates for the consults and in the past, not many physicians do procedures such as endoscopy.

Also in general, surgeons tend to treat the haemorrhoids at the same time while most gastroenterologist would refer the haemorrhoids to a surgeon for treatment(eg banding of haemorrhoids)

Not all general surgeons do colonoscopies as they concentrate on their specialized fields.  But there are general surgeons too who specializes in colonoscopy.

The most important thing is to check if the endoscopist is allocating enough time to do the scope in order to have a good thorough gentle look for polyps. One can easily miss a polyp in a mucosal fold or under a pool of faeculent fluid if one does a colonoscope too quickly(eg if there are time or economic pressures)

You should always speak to the endoscopist about this. It is best for the endoscopist to allocate on average about 30minutes to do a colonoscopy.

Bowel cancer is so common (About 1 in 20 Australians will develop bowel cancer in their lifetime) and so are haemorrhoids. It is not safe to assume once symptoms is due to haemorrhoids alone. It is best that this is discussed with your general practitioner. And if there are any concerns, you should be referred to a surgeon or endoscopist.

There has certainly the cases where patients present with clear symptoms of bleeding from haemorrhoids but on colonoscopy, a bowel polyp or even bowel cancer has been found!

Haemorrhoids can present in a variety of ways.

Presentations:

1. Bleeding – either blood on the toilet paper or blood dripping on the toilet bowl. The latter can be quite alarming for the patients

2. Palpable lump – usually comes out after one opens the bowels and can either go back in spontaneously or needs to be pushed back in

3. Pain – uncommon. This is caused by a thrombosed haemorrhoid (the blood in the dilated blood vessel within the haemorrhoid becomes clotted)  The pain can be severe especially in the first 3 days.  After that, as the swelling subsides, the pain reduces.  On examination, one can find a large swollen tender lump in the perianal area

Faecal Occult Blood Test (FOBT)

What types of FOBT are there?

There are two main types of FOBT – namely the guaiac and immunochemical tests.

The National Bowel Cancer Screening Program uses an immunochemical FOBT called ‘Detect™’.

An immunochemical FOBT is better than a Guaiac FOBTs because they have no potential for interference by diet or medication, and are considered to be less intrusive, more reliable, more acceptable and more likely to achieve higher participation rates.

What does the test involve?

The FOBT is a simple test that can be done at home before sending it to a pathology laboratory for analysis. The test is quick, easy and painless. To increase the chances of detecting tiny amounts of blood in the bowel motion, samples are taken from two separate bowel motions. Because the test involves taking separate samples, it is not practical to do the test at a doctor’s surgery. Once both samples are collected they are returned by post to a pathology laboratory for analysis.

How accurate/effective is the test?

Like any screening test, a FOBT is not 100% accurate. However, it is currently the most well researched screening test for bowel cancer.

Because cancers and precancerous growths only bleed intermittently it is possible that the FOBT will miss one. This is why it is important to screen regularly and see a doctor if symptoms develop, regardless of the FOBT result.

Why do more than one samples need to be provided?

As cancers and precancerous growths only bleed intermittently, providing more than one samples helps to ensure a more accurate FOBT result.

Is a special diet required before collecting the samples?

No. It is not necessary to change your diet in any way.

Are there any restrictions for medication?

No. It is not necessary to avoid taking any medicines before the sample collection. The test is specific for human blood, so the test is not affected by medicines.

Are there any restrictions on when samples cannot be collected?

Yes. Samples cannot be collected if:

• it is during or within 3 days either side of a menstrual period;
• haemorrhoids (piles) are bleeding; or
• blood is present in the urine or visible in the toilet bowl – in this case contact your doctor.

What does the FOBT show?

If no significant blood is found in the samples the FOBT result is negative. People who receive a negative result should repeat a FOBT in two years. If they have or develop symptoms (or become aware of a significant family history of bowel cancer) they should see their doctor as soon as possible.

If significant levels of blood are present in the samples the FOBT result is considered positive. About one in 10 people will have a positive result. The presence of blood may be due to conditions other than cancer, such as polyps, haemorrhoids, or inflammation of the bowel, but the cause of the bleeding needs to be investigated. People with a positive FOBT result will be advised to contact their doctor to discuss the result and should then be referred for a colonoscopy.

An inconclusive or incomplete FOBT result may occur for a number of reasons, including incorrect use of the test, too much faeces in the samples, a significant delay between taking the two samples or a delay in sending the test to the pathology laboratory. The test should be repeated if so.

Reference:

National Bowel Cancer Screening Program

Note:

The second phase of the National Bowel Cancer Screening Program commenced on 1 July 2008 and will only offer testing to people turning 50, 55 or 65 years of age between January 2008 and December 2010. (the reason for this is to ensure waiting times for colonoscopy do not increase dramatically – about 10% of the FOBT are positive requring referral for colonoscopy)

If you are between those ages, please speak to your doctor about getting the screening tests done.