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Questions to Ask if You Are Healthy
You don't think you have a problem now, but you want to make informed
decisions about your health care.
Colon Examinations
"Should I be doing self-testing at home?"
Self-testing is not desirable. There are commercially available
kits that can be purchased at pharmacies. These tests are similar
to the ones that are used in the doctor's office. If, however, you
are doing this test to look for small amounts of blood in the stool
because you have symptoms, then the sensitivity of these tests is
not good enough for them to be reliable. If you have symptoms, you
need to have the entire colon inspected. The cost of the physician
to do the occult blood testing in the office is minimal. For all
of these reasons, there is very little role for you to be self-testing
at home.
"What is screening, and when should I have a screening
examination?"
Screening is the process we use to look for early and unsuspected
disease. Looking for problems when they are early and small makes
sense. This applies to many types of cancer as well as heart disease
and other common problems. Colon and rectal cancer screening looks
for colon or rectal growths (cancerous and precancerous) in patients
who are at normal risk for cancer, and have no symptoms to suggest
that there is an abnormality in the colon. Screening should not
be used for patients who have a family history of colon cancer,
who have a family history of polyps of the colon, or who have a
history themselves of polyps or previous cancers, or any symptoms
to suggest colon growths such as rectal bleeding, change in bowel
habits, abdominal pain, or weight loss. Patients in one of these
categories need a barium enema or colonoscopy. In general, screening
consists of looking for small amounts of blood in the stool that
are not visible to the naked eye. This test is called "occult
blood screening" and can be carried out in the physician's
office. Another alternative is for the physician to send the patient
a kit and the patient can smear a small amount of stool onto the
card in the kit, and mail it back to the physician for processing.
Another alternative is to examine the lower part of the colon, called
the rectum with a rigid proctoscope or a flexible sigmoidoscope.
A rigid proctoscope looks at a distance of 25 centimeters, where
the flexible sigmoidoscopy looks at 60 centimeters. Either of these
is acceptable, but increasingly the medical community is using the
flexible instruments that look at more of the colon. Screening generally
begins at age 40. It typically should be done once in the 40's,
and twice in the 50's and annually over age 60. As we mentioned
earlier, this is for patients who are at normal risk.
"Who is qualified to do a barium enema or a colonoscopy?"
Barium studies are routinely done in radiology departments. Physicians
who specialize in the x-ray diagnosis of diseases are termed 'radiologists'
and they are the only persons who routinely do barium enemas.
Colonoscopy, on the other hand, is done by physicians of various
specialty training. In some cases, it is done by family practitioners,
gastroenterologists, general surgeons, and colon and rectal surgeons.
All receive specialty training in this technique. You should question
your physicians about their experience and the frequency with which
they do this examination. Most physicians who are experts in this
area will do more than 100 examinations per year.
"Have I had an appropriate examination of my colon?"
The most important question in your mind should be whether you
have had a high quality examination of your colon. This examination
does not necessarily need to be carried out by a physician, but
may also be carried out by other trained healthcare practitioners
or personnel. In general, the examination of the colon with an instrument
will require cleansing of the lower part of the colon usually with
one or two small enemas given within an your prior to the examination.
Several types of instruments may be used. A proctoscope is a rigid
tube about 2 cm. in diameter and 25 cm. in length. An anoscope is
a similar rigid tube but only about 5 cm. in length. It is usually
used with flexible instruments that do not see the anus very well.
Flexible instruments also vary in length. The flexible sigmoidoscope
is 60cm. in length and the colonoscopy is 160 cm. in length. The
colonoscope is the only instrument that looks at the entire colon.
It requires more extensive bowel preparation to cleanse the entire
colon and sedation during the examination. Over the age of 60, most
physicians are now recommending a total colon examination at least
once every 10 years.
The specifics of the examination vary from doctor to doctor. Some
patients are examined when positioned on their knees, while others
are lying on their side. In either case, the examination begins
with carefully looking at the anus. This is followed by an examination
of the anal and lower rectum with the finger. After this is completed,
the instrumented is inserted and, under direct visualization, advanced
to its full length. The lining of the bowel can carefully be examined.
If each of these points is carried out, then you can be reassured
that you have had a good examination.
"Did you find anything on my examination?"
After you have had a good examination, the only other question
is whether the examiner found anything that was not normal.
The type of abnormalities that are found may not be cancerous or
even precancerous. For instance, there can be polyps. Some polyps
can lead to cancer, but most do not. There can be hemorrhoids; there
could be other types of growths that are not precancerous, particularly
in the area of the anus. Typically, these are called hypertrophied
anal papillae. There may also be cracks or ulcers in the anal canal,
which can cause bleeding, and pain, but which are not cancerous
or precancerous.
If something that is not normal was found during the examination,
the next steps should be decided through a cooperative process between
you and your physician. Although persons other than physicians can
perform the screening examination, if there is an abnormality, it
should be visualized by a physician.
"If you find anything, how can we be certain that
it is not cancer?"
The only acceptable answer to this is to go through the steps in
Part Two of this book. There is no substitute for a biopsy. This
is painless and can be done through the examining instrument.
"Is a benign biopsy a guarantee that the abnormality
is not cancerous?"
No. The biopsy may not be representative of what the physician
sees. The physician may be convinced that there are cancer cells
present, but they may not be present on the biopsy. Sometimes, however,
if biopsy results are uncertain or if the physician feels that a
biopsy is not necessary, a repeat examination within four to twelve
weeks may be appropriate. At the end of that time, if the abnormality
is resolved, then nothing more needs to be done. If the abnormality
persists, then a biopsy would be indicated.
"What do I need to know about growths in the colon?"
All growths in the colon begin in the lining of the bowel. These
growths initially grow into the colon. Some of these growths have
the potential to become cancerous, where others do not. If they
do have this potential, at some time the cells become cancerous
and now the growths start to grow in the other direction. As the
cancer cells grow through the bowel wall, they encounter lymph vessels
and blood vessels, and have the potential to spread outside the
lining of the bowel. It is this capacity of cancer, to spread outside
of the local growing area, that can cause spread and concern.
"Do I need a colon examination?"
In-patients who are asymptomatic and not at increased risk, it
has been traditional teaching that colon examinations are not cost
effective. However, increasing information is becoming available
to suggest that individuals over the age of 60 should have a colon
examination at least once every ten years. This can be done with
either a colonoscopy or barium enema. The colonoscopy is attractive
because, if successfully completed, it can visualize most of the
colon; and, if a small abnormality is found, a biopsy can be taken,
and the abnormality might even be removed. It is unattractive because
it requires sedation and cannot be completed in about 5% of patients.
Barium is less expensive and perhaps not quite as sensitive at picking
up small abnormalities. Also, if an abnormality is found, a subsequent
colonoscopy may be necessary to biopsy or remove it. Either of these
are acceptable tests, and you should ask for the test that your
physician feels is most likely to be successful and accurate in
his practice.
When the whole colon is looked at, the goal is to identify any
new growths or abnormalities. If this is done on a preventative
basis once every ten years after the age of 60, there are statistics,
which suggest that cancer deaths will be substantially decreased.
In individuals who have symptoms or signs or signs of cancers as
were mentioned earlier, then a colonoscopy or barium enema should
be performed routinely based on those symptoms. You should never
be content to have just the lower part of the colon examined if
it is normal. If it is abnormal, an examination of the rest of the
colon is necessary to make sure that there is not a second abnormality
higher in the colon. In patients who only have a family history
of colon cancer, the evaluation of the colon should be performed
every five years beginning ten years before the age when the cancer
developed in the family member. Therefore, if you had a parent who
had a colon cancer at age 55, then a colonoscopy or barium enema
would be recommended every five years beginning at age 45.
It is important to recognize that the colon is unique in that it
is one of the few organs where the entire organ can be well visualized,
biopsies can be taken, and, most importantly, cancers are usually
preceded by non-cancerous polyps. If these polyps are removed, the
risk of cancer is all but eliminated from developing in the colon.
There is a strong incentive for patients to have their colon checked,
and thereby minimizing the risk of cancer.
"Is radiation of a barium enema dangerous?"
There is no such thing as a totally safe dose of radiation, although
recent work suggests that very small doses spread out over time
are less risky than the same doses if a short time. We all know
some studies of patients exposed to radiation in Hiroshima and Nagasaki
(large doses of radiation), as well as other intentional uses of
medical x-rays in the 1950's can cause some types of cancer. However,
there is no evidence that radiation will cause colon cancer. Therefore,
the answer is not whether the barium enema is safe, but rather what
is the risk to you, and you can feel that it is very safe.
"Is my colon examination being done correctly?"
The colon examination is more complex than it might seem at first
glance. A good colon examination requires a careful examination
with an individual in the room who is experienced and knows how
to negotiate the colon to get good visualization.
With the colonoscope, you should be adequately sedated so that
the pain is minimal, and the colonoscope must be advanced throughout
the entire colon. The colon has many folds and creases, and it is
important to make an effort to look behind each fold and crease
in an effort to visualize the colon adequately.
For barium enemas, the barium can obscure polyps that are along
the side of the colon. It would be much like dropping a marble in
a bottle of milk. It may be difficult to see the marble unless it
is sitting just right. For this reason, it is important for the
physician to have a hand on the abdomen and to thin out the column
of barium as it is being inserted through the rectum. This will
allow the "marble" to be seen and to be positioned against
the wall of the bowel in a way that will make it more visible.
If you are going to be sedated for either a colonoscopy or a barium
enema, then you will need to have someone who will take you home
following the examination.
"Why is colon cleansing necessary prior to examination?"
Cleansing of the colon prior to the examination is most important
to obtain an adequate examination. Inadequate cleansing can result
in either inadequate visualization of the colon by the colonoscope,
or a piece of stool can masquerade as a polyp and confuse the radiologist.
There are multiple different types of regimens. They generally include
oral intake of agents that will mechanically clean out the colon,
and restricting the diet to liquids for at least 24 hours prior
to the examination. The most common methods are either using a large
volume of fluid to wash out the colon or a small volume of irritant
which cause the bowel to increase its motility and thereby evacuating
the colon. Different physicians have had experience and success
with one type of cleansing or another. None is proven to be superior
to another. It is your obligation to clean the colon and if you
have had experience with a particular type of cleansing regimen
that you find distasteful or unacceptable, then you should ask your
physician for a different type of regimen. Individuals tolerate
different oral cleansing agents differently, and you should not
be embarrassed to address this issue with your physician or the
healthcare associates in the physician's office.
"Are there other alternatives to colonoscopy or barium
enema?"
Because these tests are often considered somewhat unpleasant, other
alternatives have been sought. Ultrasound is being pursued but its
sensitivity is very low and this point and should not be considered
as an acceptable alternative. Similarly, CAT scans have been used
as a "virtual colonoscopy." These CAT scans are able to
see polyps that are larger than one centimeter in size, but cannot
distinguish a piece of stool from a polyp. In addition, it does
not see the smaller polyps which can be equally meaningful to identify.
It is safe to assume that as technology improves, virtual colonoscopy
may become an alternative, but it probably will not be a satisfactory
alternative in the near future.
"What precautions are necessary after the colonoscopy?"
Generally there are few if any restrictions following the colonoscopy.
If sedations were given, someone will need to drive you home. Some
physicians request patients to limit their activities and stay on
a liquid diet for a few hours. Complications from colonoscopy are
rare. If they occur they can happen even several weeks after the
procedure and are not subtle. Usually severe pain or bleeding is
the first sign of a complication after colonoscopy.
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