So, we're going to be talking about lower GI bleeding and some of its causes, and kind of just talk a little bit about colon cancer. So, cancer of the rectum or any part of the colon is a part of the colorectal cancer. And the management of this is multidisciplinary, so we are often the people who diagnose, but after that, the management kind of is transferred over to the oncology folks, which is the cancer doctors, and then the surgeons and the oncologists sort of manage that while we, you know, just give the emotional support to the patient. It is one of the most common cancers in the United States, and the risk is pretty high, 5%. That's why we have a whole screening protocol to screen for the cancer. So, natural history is that there's a polyp that can have certain changes over time, and this polyp can then eventually develop cancer. This cancer has a potential to be invasive and can become malignant. So, our goal is to find the polyps, which is still in the, hopefully, in the hyperpolyphysian state, but maybe in the adenomatous polyp state, so where they could be small or large, and then we talked about various ways of how we do the polypectomy. So, that's what a gastroenterologist is truly looking for when they do their first colonoscopy, and that's kind of what we explain to the patient, that we're going to be looking for anything that's percuting out that looks abnormal, and we use different sort of lights and ways to find out whether this is an adenomatous polyp, because polyps could be non-adenomatous, and not every polyp will turn into cancer, but adenomatous will sure turn into cancer, that those need to be removed. How do we find patients with colon cancer? Well, ideally, if we screen for polyps, you know, then we kind of determine what risk that polyp holds, and if this patient has a family history, then we kind of combine that piece of information, and then determine how we will be monitoring them, but once they develop the cancer, then they could still remain asymptomatic for a very long time, unless the cancer, you know, depending on how big the cancer is, once it becomes invasive, then it could have symptoms, because if it's invasive nature, it has gone to different organs, or it's kind of obstructing the lumen, and patient starts complaining of obstructive symptoms where the lumen is not patent, or they start bleeding, and that's kind of how we find out, so if you have suspicious signs and symptoms, that's one we are presenting, and then again, some of these symptoms could become more emergent, requiring emergent surgeries. For screening, the cutoff has changed to 45, a few years now, so starting at age 45, everyone deserves to get screened for colorectal cancer, if they have a family history, we tend to screen them earlier, if they have any syndromes that increase the inherited risk of cancer, then they get screened earlier, and then IBD is a standalone risk for cancer, so those patients, after a certain period of their diagnosis, we know that we need to be more vigilant, because they tend to develop more invasive and aggressive type of cancer. How would, will be the methods that will be offered by a primary care doctor, because that's kind of where the care really, truly begins, so family doctor, PCP, can discuss a lot of things, the most common way of screening in United States still remains colonoscopy, and most definitive way of screening still remains colonoscopy, but it's patient, and you have to provide them with choices, which is what we try to do in every visit, so we do tell them that there are alternative ways of screening them for cancer, and those include mostly stool tests, which are the non-invasive forms, colonoscopy or a mini-colonoscopy, which is just kind of going to a certain part of the colon, they don't have to do the whole prep, which is drinking a very nasty liquid, so which not a lot of patients are interested in doing, so we could offer, you know, one of those, or a CAT scan, which is a CT scan, they still have to drink that liquid to clean out their colon, to get a better view. There are different tests listed here for stool, you know, you must have heard the word, the term cologuard, which is kind of the, it's a combination of the FIT and the stool DNA test, the goal is to find anything, so the first test is testing for blood in the stool, and then the second one is trying to be more specific to blood products in the stool, the DNA test is trying to target or test for DNA that are detected in abnormal polyps, so in whatever way we are able to capture that from the stool, we try to do that in form of screening, and once they test positive for screening, every patient has to undergo colonoscopy, so it's, you know, the definitive way of diagnosing a screening would be colonoscopy. If you see masses, which is unfortunate, but oftentimes we do now more than ever with younger patients being diagnosed early, depending on where the mass is, so the colon kind of goes from all the way right, which is your small intestine, where it connects into your, to your right colon, so it could be anywhere, so depending on where it is, we could potentially offer to remove that portion, and then just do an anastomosis, this would be a surgical way, but if the tumor has already invaded outside of the lumen, then we have to look at our cancer doctors to kind of guide the patient with chemotherapy. Sometimes it's in a too bad state, and mostly it's palliative care that we're able to provide where we would never be able to get rid of the cancer, but we could improve the quality of life. Okay, after that grim part, we go to the GI bleeding, which is an exciting aspect of GI, not so exciting for the patients. Most of the bleeding, you know, is in the, from the colon, that's the lower GI bleed, so anything that happens beyond the ligamentate, which is kind of where we divide our foregut from our hindgut, you know, midgut, hindgut area, so anything above is, you know, upper GI tract, and then from below that, it's in between your small intestines, so anything below that, we say it's lower GI, but anatomically, if someone comes in with bleeding, I'm trying to just say upper or lower, you know, based on their symptoms, and that is, you know, the symptoms and the blood work, but it's never definite, but given the odds of having a higher, you know, higher chance of a lower GI bleed, 80%, you know, the 85% of the bleeds are coming from the colon, that we try to manage with a colonoscopy or various other modalities. The obscure bleeding, the bleeding that patients don't usually see, as Dr. Matthew was talking about, usually comes from the small intestine. Bleeding could be seen by the patient, so they may see bright red blood or just sticky stool, and, or it could be felt by the patient with the blood loss, so they may start having symptoms of chest pain or shortness of breath or lightheadedness. Now, the causes of bleeding are what may cause blood to appear in the stool, so it could be diverticulosis, so these are just outpouching. They tend to have very small, you know, the blood vessels are very, very close to the lumen, so the diverticulite could bleed, and these angio-dysplasias, which are just very superficial vessels that you see, those could bleed. Ischemic colitis is when the blood is not, the colon is not getting enough blood supply, it could start oozing and become friable. The hemorrhoids, we all know, could bleed. Cancer bleeds, inflammatory bowel disease bleeds, infections of the colon, you know, infectious diarrhea or dysentery, so that's bleeding. And then sometimes it's caused by us too, when we remove a polyp, some of the complications do include oozing and bleeding. So there are a lot of things that can happen, that's why 85% of the bleeding is happening in the colon. First thing, once our patient comes in, is to make sure they have enough blood in the system before we take them to a procedure, so that's step number one. Step number two is, if it's an upper GI bleed, we try to, you know, clean out the stomach as much as we can with various ways, but eventually we have to do an upper endoscopy to see what's bleeding and try to get hold of the bleeding. When we do the colonoscopy, usually or hopefully it's done after a prep, sometimes we don't get a chance to prep the patients because it's rapid and they're bleeding too rapidly. Most times we're able to get them to at least drink some of the prep. If it's a, so here you're seeing clipping, which is if you saw an area that was potentially where a polyp was removed, now it's kind of oozing, so you could go and put in a clip and stop the bleeding. This one's more for a diverticular bleed, which is rather rare to see endoscopically. Most times the bleeding has stopped or it doesn't spurt in front of us, but if it does, then we could potentially put a clip and stop the bleeding. Other ways, and then the clip could be possibly putting an injection in there and, you know, injecting some of the basic constricting agents to stop the bleeding or clear the field for us. And following that, we could, you know, put a clip on or use cautery to kind of cauterize that area. One of the ways that bleeding can be stopped if it's happening at a very superficial level is argon plasma coagulation, or we call it APC. So argon being an inert substance, we just, it still conducts, so then that argon is used to kind of burn off the area. So we're still cauterizing, if you will, but we're doing it at a very superficial level. Banding is another way. So if there's a hemorrhoidal bleed or a superficial vessel, you know, blood vessel sitting, we could put a small band or a hair tie kind of to stop it from bleeding. So diverticulosis, it's very common. You know, 8 out of 10 people walking down the street may have diverticulosis, but how clinically significant that is, that's, you know, it usually remains asymptomatic, so it's not very clinically significant. You could have outpouching right, left, usually left more than right. What we need to know is that, you know, how, do we have to find a patient with diverticulosis every time? Probably not, but if you do a colonoscopy, we often see that and we note that in a report. It's nothing to become alarmed or, you know, be concerned about. You could also see those outpouching if a study like a barium enema, where barium is injected from the bottom is done, and you could see these outpouching on the imaging. You know, not very often, but possible complications of diverticulitis. Some patients tend to be more predisposed to developing diverticulitis, which is basically like an appendicitis. So you have an outpouching, and then that outpouching could get inflamed, you know, can get blocked, and that's diverticulitis. And then we'll talk a little bit about diverticulobleeding as well. So like here you can see this outpouching is now infected. It's blocked, and it's kind of developing some, you know, maybe abscess or some sort of infection in there. Often patients will present with fever, pain, and the blood work will show that there's some infection. It happens in about 4 to 15 percent of patients with diverticulosis. Not everyone will have it, but they could develop diverticulitis. On a scan, you could see all this gray kind of mucky area is just inflammation around an outpouching of the colon, so that's your diverticulitis. If the patient is doing otherwise fine, most recent guidelines tell you you don't really have to even do antibiotics. But if they are having fever, most people will end up giving them antibiotics, and then complicated is when it has perforated or the patient's really developed a fistula, which is a connection or an abscess. Then we call our surgical colleagues to help us out, sometimes to drain it, sometimes to take them to surgery or put like a drain in there to like give it some relief. So that's a little bit more complicated. But again, it's more rare to have complicated diverticulitis. It's common to have uncomplicated diverticulitis. From bleeding standpoint, as I said, the diverticulum is an outpouching. You can see the proximity of the blood vessel to the wall becomes more, it's more close to the lumen when the blood vessel is kind of along the wall of the diverticulum. So you tend to see more bleeding should this mucosa get eroded. So basically, if a patient has a lot of diverticuli, they could erode that mucosa and the underlying vessel could start oozing. It doesn't cause any pain. It's not an infection. Patients often present with just kind of bleeding in the form of stool, sometimes without stool. Usually patients, by the time they present, the bleeding has rapidly stopped itself, and we don't really have to do anything. But if they continue to bleed, we end up doing a colonoscopy. As I said, even on colonoscopy, it's not often that we find a diverticulum actively bleeding, but if we do find it, then we tend to clip it. We have to ask sometimes our radiology to help out because they can use more dedicated technology where they inject the dye into the blood vessel that tracks into what area of the colon it is, and then if it's actively extruvasating, then they could potentially embolize a directed, they could do embolization of that particular blood vessel to stop it from bleeding. Surgeries often, you know, also we have to ask them sometimes when the bleeding is such that it's not stopping or the patient's having, you know, just have a lot of diverticuli, multiple admissions because of the bleeding, then we ask our surgical colleagues to go in and help with the diverticula. Last part is your hemorrhoids. Everybody has hemorrhoids. It's normal to have hemorrhoids. It's how big they are that matters. So you could have external hemorrhoids, which often project out, and then you could have internal hemorrhoids that project in. The hemorrhoids, they are just basically blood vessels, so they are just swollen at times that they're irritated, so if the patients are more constipated, for some reason there's some sort of pressure on them, then they'll tend to become bigger, sort of backlog with the blood sitting over there, and then they tend to bleed or could, you know, could thrombose, and then the external ones could become very painful. The causes are of having problems with hemorrhoids, you could have advanced age, pregnancy puts pressure in the bottom, pelvic tumors, prolonged sitting, especially at work, straining because of chronic constipation or because of any other problems with evacuation that can all lead to more prominent hemorrhoids and then complication for the hemorrhoids. If it's bleeding, and we think, you know, often patients tell us one of the risk factors and then we kind of are suspicious based on how they tell that the bleeding is happening. We take a quick rectal exam, sometimes a finger examination just tells us there are hemorrhoids in there. Anoscopy is, you know, in the clinic setting actually we could do that. It doesn't require any form of sedation. We insert this and then we could get a good idea of where these hemorrhoids are, how big they are. If they are big, even banding could be pursued in an outpatient setting, but if it's too big or it's thrombosed and it's painful, we have to tell our surgeons to ask our surgeons to help out. Colonoscopy can also diagnose hemorrhoids, but it's not certainly done to diagnose hemorrhoids, but if you're doing a colonoscopy, we do take a look at the hemorrhoid area where the hemorrhoids are and we can comment and grade them for the surgeons. What do we do to treat the hemorrhoids? So obviously avoiding the risk factor is number one, but certain things you can't avoid because once you're pregnant, you can develop hemorrhoids, so that's not something that could be changed. So in those situations, we tell our patients to do certain conservative things. So there are a lot of topical steroids and suppositories available over-the-counter that could be utilized. Sitz bath is what we tell them to kind of sit in a warm bath with certain salts and that helps kind of calm down the hemorrhoids a little bit. From the procedure standpoint, banding, we discussed this before. Sclerotherapy is kind of injecting a fibro, like an agent that could cause fibrosis and then the blood supply to the hemorrhoids is blocked and then they disappear. Surgery is often needed if the hemorrhoids are too big and the above two procedures may not be helpful or have failed, so then they do a hemorrhoidectomy. That's pretty much it. Time for food.

colorectal cancer

lower GI bleeding

colonoscopy

polyps

treatment