Rectal Bleeding and its Management:

• Indian scenario:  The first step for a person who has rectal bleeding (no matter what the age) is to hide this symptom from all. Finally when it stops there is a sigh of relief and it is never mentioned until it recurs and then one speaks to a General Physician who will generally show a lack luster approach till the patient returns for a follow up. The number of episodes will decide how many physicians or surgeons will see this patient without doing a physical examination including a digital rectal examination.Finally with the word of mouth or some practitioner pointing towards a colonoscopy the person sees an endoscopy specialist who offers a colonoscopy. When a colonoscopy is discussed, the patient either never returns or dilly dallies for months before finally having this done.
• UK scenario: A person with rectal bleeding goes to his GP usually promptly and is assessed with blood tests as well as a digital rectal examination or even a rigid sigmoidoscopy before referring to an endoscopy clinic to be seen asap (generally within 2 weeks) for a flexible sigmoidoscopy or a colonoscopy.
  (The sensitivity of picking up pathology, endoscopically as well as microscopically varies and the standardization may be missing from place to place anywhere.)

Incidence of colon cancer

Affecting men and women almost equally, colon cancer is the third most common cancer in the world and fourth most common cause of death. Worldwide, it accounts for 9% of all cancers. High incidence areas are North America (particularly USA and Canada) and Australasia. Low incidence areas include China, India, Africa and South America. The developed world accounts for well over 60% of the cases but these rates are probably susceptible to ascertainment bias given the under reporting in developing countries.

It has been proven that the incidence of colon cancer is declining steadily at the rate of over 2% per year since 1998 (studied till 2005) and this has been attributed to the screening programmes offering colonoscopy (lower gastrointestinal endoscopy) which in turn improves the detection of precancerous polyps. Although, rates have declined, the overall burden of disease remains high and there is a change noted in demographics with Afro-Caribbean population now having a higher rate of incidence as compared to the white population. Interestingly the trend is opposite to what it was before 1980s.

Risk Factors (Nonmodifiable)

Age :

The risk increases after the age of 40 years and sharply increases after 50 years of age. Although more than 90% of colon cancer was diagnosed in individuals over 50 years of age, it seems to be increasing among younger people.

Personal history of Adenomatous polyp :

Tubular and villous adenomata are precursor lesions of colorectal cancer and 95% of sporadic cancers develop from these. It has been noted in US population that a lifetime risk of such a transition is 19%.

Personal history of Inflammatory Bowel Disease :

Patients with Ulcerative Colitis and Crohn’s Disease have upto20 fold increased risk of colorectal cancer and hence age has no relevance when dealing with these patients.

Family history of Colorectal Cancer or Adenomatous Polyps :

Two or more first degree relatives or one under the age of 60 years with history of cancer or polyps increase the risk strongly.

Inherited Genetic Risk

Familial Adenomatous Polyposis and Hereditary Non Polyposis Colorectal Cancer have been linked to the genes and mutations.

Enviromental risk factors :

These include a wide range of vague cultural, social or lifestyle factors and interestingly it has been found that a migrant from low risk area would automatically pick up the risk of local population where one resides. These environmental factors become important as they are modifiable and theoretically should help in prevention. The incidence is higher in urban population, particularly in males and for colon rather than rectal cancer.

Dietary factors :

A diet high in fats and meats/animal products  is known to increase the risk of colon cancer. Also a diet low in fruits and vegetables is also linked to it. This may signify that a high fibre diet which dilutes farcal content, increases bulk and reduces transit time is protective.

Physical activity and Obesity :

Excess body weight and physical inactivity is possibly related to higher incidence of colon cancer. This may be related to higher metabolic rate increasing oxygen uptake which in long term can reduce blood pressure and insulin resistance and increase gut motility.

Cigarette smoking :

Whereas it is bad for health generally it is known to form and increase the size of the polyps (larger polyps are found in smokers). An earlier average age of having colon cancer is noted in smokers.

Heavy alcohol consumption:

Acetaldehyde, a metabolite of alcohol, can be carcinogenic. Also such individuals may have poor diet.

What has been done :

The developed countries have been very aggressive towards catching the disease early and treating it with a definitive planned approach. With Indian population still struggling with the stigma of approaching a medical practitioner with their symptoms of bleeding from the back passage, the developed nations, have systems in place for colon cancer screening with colonoscopy as well as the ‘two week wait’ from General Practitioner to the endoscopy examinations.

In countries like UK where healthcare to the patient comes free, cost cutting measures have led to having Nurse Endoscopist, a trained Specialist Nurse who is trained to do diagnostic endoscopic procedures and this endeavour has led to reduction in waiting time as well as effective cost cutting.

The Indian scenario remains dismal with all control resting with the patient and very little being done to reach out for patient education and information. The public sector hospitals and practitioners are overwhelmed with work and although are doing a commendable job, they are struggling with waiting lists and patients are many times forced to rush to private sector where cost of interventions and diagnostics is a deterrent. The insurance schemes and government schemes are a huge relief and this has led to improved services and access to common man to the best available healthcare facilities.

There also seems to be an element of denial by the practitioners. In a local meeting, there was a proposal for developing a colon cancer awareness programme to do away with the shyness of discussing bleeding from the back passage and most GI practitioners were of the opinion that colon cancer is not a predominant issue in the region!

Hence, we wanted to highlight this with data and following are our findings:

We obtained data for Gastrointestinal cancers from a high volume privately run endoscopy unit with substantial number of referred colonoscopy patients over a 6 months period and the results are as follows :

• Oesophageal Cancers – 26,( M =13, F = 13), Average age = 58 years
• Stomach cancer – 9 (M =5, F = 4), Average age = 58.55 years
• Colon cancer – 20 (M =9  , F =11  ), Average age = 54.55 years

This clearly depicts that colon cancer is not a rare entity and it is very important to highlight this point to catch the disease early to save lives. It is our duty to highlight this with the month of March, which is earmarked as the Colon Cancer Month by WHO, approaching.

Let us all work towards awareness of this problem and the benefits of early colonoscopy (as well as endoscopy in general for patients who are recommended these tests).

(I am particularly thankful to my colleagues, various researchers and their data collected from all over the world who has given us an insight towards this deadly disease, its possible risk factors and its diagnosis as well as treatments.)

Top Endoscopy Specialist in Chandigarh

If you are looking for Endoscopy Specialist in Chandigarh, please contact us. Our consultant (Dr. Gurbilas P. Singh) is a very experienced endoscopist practising in Chandigarh and does diagnostic and therapeutic endoscopic procedures.