1. James Roat, MD University of Cincinnati Division of Digestive Diseases
Colon
James Roat, MD
University of Cincinnati
Division of Digestive Diseases

2. Case 1
A 52 yo male presents after screening colonoscopy. He has no family history of colon cancer and his exam shows 2 polyps. A 7 mm ascending polyp and a 5 mm transverse polyp. Histology reveals a tubulovillous adenoma and tubular adenoma respectively.

3. When would you recommend next screening colonoscopy?
1 year
3 years
5 years
10 years

4. When would you recommend next screening colonoscopy?
1 year
3 years
5 years
10 years

5. Colon Polyps Majority of colon cancers arise from adenomas
Risk of cancer increases size >2 cm, sessile, multiple polyps, and villous
25% of Americans >50
Hyperplastic polyps: no malignant potential
Remove at colonoscopy and follow closely

6. Colonic Polyps Recommended Surveillance
Finding
Surveillance Interval (years)
No polyps 10
Small (<10 mm) hyperplastic polyps in rectum or sigmoid
1-2 small (<10 mm) tubular adenoma
5-10
3-10 tubular adenomas 3
>10 adenomas
<3 years
One or more tubular adenoma ≥10 mm
One or more villous adenomas
Adenoma with HGD
Sessile adenomatous polyp >1.5 cm
<1

7. Serrated Adenomas Recommended Surveillance
Finding
Surveillance Interval (years)
Sessile Serrated polyps <10 mm no dysplasia 5
Sessile Serrated Polyp ≥10 mm OR
Sessile Serrated Polyp with dysplasia
Traditional Serrated Adenoma 3
Serrated Polyposis Syndrome 1

8. 1 year 5-10 years 10 years No follow up needed
Case 2 55 yo male with no past medical history presents for a well check. Denies any medications, family history of colon cancer. You recommend screening colonoscopy; this was performed and shows a 5 mm pedunculated polyp in the ascending colon removed by hot snare. Pathology shows tubular adenoma. When is the follow up?
1 year
5-10 years
10 years
No follow up needed

9. Case 2
55 yo male with no past medical history presents for a well check. Denies any medications, family history of colon cancer. You recommend screening colonoscopy; this was performed and shows a 5 mm pedunculated polyp in the ascending colon removed by hot snare. Pathology shows tubular adenoma. When is the follow up?
1 year
5-10 years
10 years
No follow up needed

10. Colonic Polyps Recommended Surveillance
Previous Non advanced adenoma then negative exam (adv adenoma=Villous, HGD, >1 cm)10 years
Previous advanced adenoma then negative exam5 years

11. Colon Cancer
Most Colorectal cancers (CRCs) develop in a sequence: normal mucosamucosa at riskadenomaadenocarcinoma
APC tumor suppressor gene is mutated in 85% of CRCs

12. Colon Cancer Screening
Average Risk
General start Age 50, end Age 75
Colonoscopy q 10 years if normal
Age 45 African Americans
High Risk=family history of colon cancer <60, colon polyps)
start screening at age 40 or 10 years prior to youngest relative age of diagnosis

13. Absolute Risk of CRC
FDR first degree relative

14. Colon Cancer
RECHECK THIS SLIDE

15. Hereditary Colon Cancer Syndromes
FAP-Familial Adenomatous Polyposis, caused by mutation in APC gene
Annual flex sig beginning at age 10-12, colectomy when polyposis detected
HNPCC( hereditary, non polyposis colorectal cancer) aka Lynch Syndrome
Mutations in MLH1 and MSH 2 mismatch repair genes
Colonoscopy every 1-2 years starting at age or 10 years before youngest family member diagnosed with colon cancer
Peutz Jehger Syndrome
Germ line mutation in STK11
Juvenile polyposis
Mutation in SMAD4

16. FAP
Risk of extracolonic tumors: upper GI, desmoid, osteoma, thyroid, brain, other
Majority due to APC mutations
Colectomy usually in late teens, early 20s
Annual surveillance of rectal segment post colectomy
EGD 1-3 years along with duodenoscope
Annual Thyroid ultrasound
Desmoid are fibroblast tumors

17. Lynch Syndrome (HNPCC)
Early but variable age at CRC diagnosis (~45 yrs)
Multiple (synchronous or metachronous)primary cancers
Accelerated carcinogenesis
Tumor site in proximal colon dominates
Extracolonic cancers: endometrium, ovary, stomach, urinary tract, small bowel, bile ducts, sebaceous skin tumors

18. Irritable Bowel Syndrome Rome III Criteria
Recurrent pain or discomfort at least 3 days per month in the last 3 months (with symptoms onset at least 6 months prior to diagnosis) and 2 or more of the following:
Improved with Defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool

19. Irritable Bowel Syndrome
If classic symptoms
Tissue transglutaminase, IgA
? hydrogen breath testing
No routine blood testing, structural or imaging studies

20. Irritable Bowel Syndrome When to investigate
Alarm symptoms
Change in symptoms
Remember colonic screening!

21. Diverticular Disease
Colonic diverticulosis affects 5-10% population older than 45 years and 80% older than 85 years
20% of patients with diverticulosis have an episode of diverticulitis
Sigmoid colon predominantly
Lower abdominal pain, fever, altered bowel habits (typically diarrhea)

22. Diverticular Disease
Imaging not always necessary, if uncertain can perform CT abd/pelvisfalse negative 20%
Mild attack and tolerate pooutpatient therapy and po abx (cipro/flagyl)colonoscopy in 6-8 weeks
Severe attack unable to tolerate po, persistent symptoms despite adequate outpatient therapyhospitalize, IV abx, CT
Peritonitis, perforation, uncontrolled sepsis surgery

23. Diverticulitis

24. No further testing/intervention indicated
Case 3 A 56 yo female presents with acute uncomplicated diverticulitis. She is discharged home on antibiotics. What is the next best step?
CT abd/pelvis in 6 weeks
Stool c & s
Colonoscopy in 1 week
Colonoscopy in 8 weeks
No further testing/intervention indicated

25. Case 3
A 56 yo female presents with acute uncomplicated diverticulitis. She is discharged home on antibiotics. What is the next best step?
CT abd/pelvis in 6 weeks
Stool c & s
Colonoscopy in 1 week
Colonoscopy in 8 weeks
No further testing/intervention indicated

26. Lower Gastrointestinal Tract Bleeding
Rectal bleeding
DRE exam
Colonoscopy to evaluate

27. Location Dx for Severe Hematochezia
CURE 2004

28. Colonic Source of Acute Hematochezia
Most Common: diverticulosis
Common: neoplasia, ischemia, anorectal disorders, postpolypectomy
Infrequent: radiation colitis, IBD, angiodysplasia, other colitis

29. Ischemic Colitis Painful Often watershed area
Seen post aortoiliac surgery
Complications infrequent

30. Diverticular bleed Acute Painless Usually major
Rebleeding risk 15% after first bleed and 25-50% after 2nd bleed

31. Diverticular bleed Treatment Endoscopic: clipping/cautery
Radiologic: angiography
Surgical: total or subtotal colectomy

32. Vascular Ectasia Sm bowel or colon Melena, hematochezia or occult
Acute or Chronic
Treatment: Correct coagulopathy, stop AC/NSAID, iron replacement
Specific:Endoscopic, angiographic, medical tx, surgical tx
**high risk of recurrence with all treatments
Sanson CGH14, Jackon AJG 14, Octreotide, thalidomide, endoscopic tx, heart valve surgery are all of benefit

33. Benign Anal-Rectal Disorders
Hemorrhoids
Fissures
Stercoral ulcers

34. Thank You!