Bowel Cancer

There is a lot of worry about Bowel Cancer in UK. Some of this is justified and I find there is a lot of good information at this site https://www.bowelcanceruk.org.uk/

What I present below are my musings about different symptoms that may or may not lead to a diagnosis of bowel cancer. Many of these symptoms are general and the underlying diagnosis is often benign problems. The difficulty for patients and their doctors is that in a small number of patients the same symptoms can signify bowel cancer. Hence my attempt at putting this in context. Please read them. I hope it helps in your choices and awareness of symptoms.

I have described them in some detail here in these headings….

1. Understanding Symptoms

2. Understanding Bowel Polyps and Bowel Cancer

3. Glossary of Medical terminology

The NHS has a great site about understanding bowel cancer and I would recommend it. It collects information carefully and it is reliable and up to date. https://www.nhs.uk/conditions/bowel-cancer/

About ten years ago I had made a patient information DVD on bowel cancer. You may find that useful http://www.ennovations.co.uk/p/48/bowel-cancer-colon-cancer-rectum-cancer-dvd-and-booklet. When I made that I had also created a glossary of terms.

Understanding Symptoms

Rectal Bleeding

Bleeding from your rectum is alarming in the first instance. But within that statement is a whole range of bleeding patterns. It can vary from occasional minimal blood in the toilet paper to a splatter of bright red blood in the toilet or an insidious blood mixed in with your stools. Those are broadly speaking the three different but common scenarios that present in my clinic. There are many more variations but as these are the most frequent I will cover them here.

Bright red blood seen on wiping yourself! This usually suggests the bleeding is form the anal canal. See the drawing for an outline of what part of the anatomy is called the anal canal. Bleeding can come form the colon (i.e. higher up in the bowel) or from the rectum, or the anal canal. It helps to form an opinion as to where the bleeding is coming from. If it is bright red and only on wiping yourself, not mixed with stools this suggests the bleeding is coming from the anal canal. However it may also come from the rectum which is just higher up. After all the anal canal is only 3 – 5 cms in length. There are a whole gamut of reasons as to why one may bleed from the anal canal. Common in these are haemorrhoids which are dilated or distended venous channels which may get traumatised and so bleed. Other reasons for bleeding are fissures which is a split in the very edge of the back passage. This can be awfully painful – sometimes agonisingly so. There are of course many other causes to consider like fistula in anal canal and also the very rare but important cause of anal cancer. Because there are so many causes of bleeding it is worth having a discussion with your doctor.

Rectal bleeding splattering the toilet – this is more dramatic and hence most patients get alarmed and seek help soon when they are in this situation. Though I make a distinction of the kind of bleeding from the previous scenario in reality it may be a combination of the two kinds of bleeding both occurring at varying times in the same person. And the two scenarios may occur form similar pathologies – e.g. haemorrhoids can cause both kinds of bleeding. As can inflammation of the rectum (what doctors call proctitis) which can be due to a variety of causes like ulcerative colitis or radiation induced proctitis (e.g. some people have had radiotherapy for prostate cancer and because the prostate lies just in front of the rectum some years later a small percentage of these persons may develop proctitis of the rectum). Other causes may be rectal polyp or indeed rectal cancer. The way to diagnose which one of these is the underlying cause is by putting in a scope (a thin black flexible tube no thicker than your pointing finger and certainly thinner than most sausages I know. That way one knows what the underlying cause is and then plan further management And then finally comes bleeding that is insidious. The sort where a person notices occasional dark or bright red blood mixed with stools, not a lot initially

but getting increasingly frequent. This may be associated with other symptoms like a change in bowel habit such as an insidious change towards either constipation or more frequent passage of stools This sort of constellation of symptoms are thought of as ‘alarm’ symptoms but essentially signal that it is worth investigating the bowel – however it may not be the case in everyone. However a number of patients with this sort of symptoms will have benign causes. However it is worth being investigated and knowing that there are no worrying causes like tumours or caners. Both my parents have had these symptoms and have been investigated and fortunately in both the investigations were reassuring in that there was no cancer. Most of persons who come with these sort of symptoms particularly when associated with a change in bowel habit go on to have an endoscopy of the bowel which could take the form of a limited examination like flexible sigmoidoscopy or a more complete examination like a colonoscopy. There is more about these tests elsewhere. And of course one has to consider if you are fit for these tests and also alternatives like CT colonography or Barium enema. We will discuss this in another section

And finally there is the bleeding that one does not see at all!!! That seems paradoxical. Here I am talking about blood that is only picked up when stool So would one do this? This testing stool for hidden or “Occult” blood is used as a screening tool. You will hear the term FOB i.e. Faecal Occult Blood. People from the age of 60 onwards are screened in the UK. I have covered the issues of screening in (put link here).

Change in Bowel Habit

This is a difficult one ! Because no one really remembers what their bowel habit is really like. If right now I ask you to recollect when you last opened your bowels you will have to stop reading this article and think. And if I asked you what happened the day before yesterday that will throw you ! And so it is that this question often briefly confounds my patients. I remember one lady who I saw recently in m private rooms who said a “most definite yes” and that in itself was a very noticeable fact for me. Most people. Most people are taken aback by this question.

I think it would help you to think a little about this issue before your consultation. Also spend some time thinking whether this is a change towards less frequency or a change towards greater frequency of stools. Occasionally some have a varying frequency – becoming sometimes constipated and sometimes getting diarrhoea. Now people with Irritable Bowel Syndrome may have this sort of irregular bowels – but the important fact is that this is their “normality”. What matters really is if there has been a recent and a persistent (lasting for about 6 weeks) change.

What the doctor is looking for is the trend, they want to know if there is a change in the general trend of your bowel habit – in form of frequency or consistency or both. And whether this is associated with other symptoms like rectal bleeding. If you are a person who opens your bowels once in two days has this changed and of course is this change a persistent one. It is not an important issue if for one day or so you become loose or constipated. But what is important is a persistent change over a period of time, say about 6 weeks. The Association of Coloproctology of Great Britain (ACPGBI) which is an national association of colorectal surgeon of UK has picked 6 weeks as a period of time after which one should consult with a doctor and that doctors should consider whether what you are describing are ‘alarm’ symptoms. But on practical terms what I find is that people either do not notice their bowel habit change or if they notice it they do not report to their doctor. Occasionally the change in your bowels cues a subtle difference in either frequency or consistency or other characteristics.

It may worth reflecting whether this change was associated with some event in life. For example I have seen a person starting a statin and a few weeks later developing a change in bowel habit towards looser stools. I have seen the same happen with Metformin, a tablet that is used to treat diabetes,. I have also seen this side effect of Omeprazole which is a tablet that reduces stomach acid. So it is worth knowing what medications you are taking and remember to bring the list with the doses along with you. Think back about whether you have changed the brand; e.g. you bought the same medicine but by a different manufacturer and that change ay well be an important clue.

There are a few other things to think of. One is travel history. A person may pick up a bug and get “traveller’s diarrhoea”. Or it may well be that they get constipated. By going to new places, with the added stress or organising accommodation and the many little logistics that go with it. Then there is the stress of unfamiliar surroundings and the change of diet to new and different kinds of food or even the issue of new and unfamiliar toilets all conspiring to alter your bowels.

It is also worth finding out about your family history as your doctor may ask you about it. Find out if anyone in your family developed bowel cancer. If so find out what their age was, how they were related to you, what age they were when they developed it, what treatment they had, were they operated, did they have a colostomy (colloquially called a bag) how long did they have the cancer for and what was the outcome of their treatment. Also find out if thre was anyone else in the family with bowel cancer. Occasionally the family history may not be of bowel cancer but that of breast, kidney, uterus, stomach bile ducts etc. These later cancers are of some significance in a syndrome called HNPCC (Hereditary Non Polyposis Colorectal Cancer) – a syndrome where in certain types of cancers occur in families.

Other questions you will be asked is the list of operations you have had, what they were for, which year they done in, any complications from the surgery or anaesthesia etc. Also useful to tabulate is the list of medications you are on and what dose you take them. For example you will be asked if you have diabetes, asthma or high blood pressure and what medications you use to control them. Such questions may not seem relevant to your presenting health complaints but may well provide clues to your doctor who is thinking about your overall situation. Similarly make a note to remember to tell about your allergies. For example if you are allergic to shell fish some people have a cross reaction to iodine which is a component of skin antiseptic preparation called Betadine which the surgeon uses to paint the abdomen prior to your surgery. Telling the surgeon this means they would be cautious and use an alternative fluid for the skin preparation e.g. chlorhexidine.

Finally it may be important to think about what is important to you form the consultation. Are you looking for reassurance that you do not have cancer or are you looking for complete resolution of symptoms. Some patients tell me the change in bowel habit does not bother them but all they want is to know that they are not wrongly ignoring it. With media messages in abundance there may be a gnawing worry within them. Or may be not. Your symptoms may be hindering you significantly and what you want is a complete resolution of your symptoms. Whatever your perspective on your illness is, this is an important issue. Similarly you being clear in your mind as to what you see as your priority will help the doctor have clarity in planning your management so there can be a successful resolution.

Constipation

This is a difficult subject to talk about. Most patients of mine when faced with questions find it distasteful and then find they have really not observed their bowel habit. I find it takes them awhile to answer these questions. When you go to your doctor there is a series of questions that are generally asked - predominantly the doctor is working towards making a decision whether the symptoms are something that can be managed with simple dietary modifications or whether there is a need for further investigations. Careful consideration is to be made particularly as some of these investigations are quite invasive to the body and the dignity of the person.

Short Term Constipation

This is a rather short term event of a few days usually ones I see relate to a holiday which generally involves a change in diet. You might over indulge as one does on a holiday. I am about to go on a holiday and I know I will eat more - in fact I am looking forward to the time spent walking around, having leisurely lunch, an evening out with the family, good food and merry times. But of course all this ends ordering an extra stake or an additional course and so on and so forth. Or it may just be unfamiliar bathrooms, unfamiliar hotels in foreign countries. Our body is a creature of habit and certainly bowel movements are regulated by a complex mechanism of neurological inputs and other features. I find even a change in venue seems to set off alteration in bowel habit amongst other factors overlaying this change of venue. So the doctor will quiz you about duration of your symptoms. One of the queries is whether this is a recent change or a persistent change. In order to know if it is a change at all you will have to know what your normal bowel habit is. Often patients say to me "But I do not know what is normal" or words to that effect. The point here is that you need to know what is normal for you - is it once a day or three times a day as an example. or it could be once in two - three days. the point I am making is that there will be something that is normal for you. Spend some time reflecting and you will know what is normal for you.

Then you will know how long there has been a change and what that change is. This helps the doctor assess if this is a short term change. Often short term changes can be managed by increasing the amount of fibre and fluids in your diet. I will talk about the subject of dietary modification elsewhere.

When on a high fibre diet it really is about increasing the fibre content but also increasing fluids. The fibre is really got to be natural fibres such as greens like beans, broccoli, salads, bran etc. What this does is that the fibre in diet is not broken down into absorbable constituents and so remains to add bulk to stool. But in itself it can make stool hard. Adding lots of fluid like water means this bulky stool becomes soft and so passes easily and you do not have to strain.

What fluids - my patients often ask. Well - our bodies are made to use water. And a lot of it. We are made of water predominantly. Almost 60% of us is water in adults while newborns can have up to 75%. The water is within the cells in our body and we are made of trillions of cells. Just hold that thought - "trillions of cells". A trillion is such a huge number we cannot visualise it. So water is a vital constituent. Physiologists i.e. those who study our body's physiology (inner workings) have worked out that we need to drink about 2.5 to 3.5 litres of water a day. A lot of patients exclaim "that is a lot of water"! But if you breakdown this volume into smaller chunks it seems eminently feasible. One trick is to have a 1 litre jug at home and fill it with water. Every time you have a drink you fill your glass from this jug. You will find that you will finish that litre and before long you will have emptied two times without particular effort. Of course water in juices, tea and coffee also count. People have asked me if water in beer counts. Well I guess it would except that beer and spirits are diuretics too and so you end up weeing a lot and over all you are in net dehydration. So I think that argument does not quite work. Back to the issue of plenty of fluids needed with plenty of fibre. Consider this - you will have seen parched earth. Sometimes in dry weather the earth gets parched and after a while all you see if clumps of dry cracked earth. And yet as soon as you pour water on it - or rather if nature does that for you in the form of rain you see the mud turn into slush. And so it is with your bowels! The more you drink the more stools get soft and so they find it easier to exit without you having to strain. "High Fibre" increases bulk of stools and "High Fluids" make it soft

Significant Constipation (needing investigation)

Diarrhoea

Abdominal pain

Pain is subjective. Only the person who feels it knows its true character, shades and nuances. When you meet your doctor it may be difficult at that moment to remember all the details and so what I am writing about is to help you through that process. Doctors ask lots of questions and when faced with them you may feel some of them are pointless and how can one possibly remember details when you are in agony. It is difficult and what with the issue that pain is such a non specific symptom with grades of variation that makes the clues gathering exercise difficult. Taking a careful story gives a clue as to what may be the underlying issue and then one can tailor the investigations appropriately.

Things to think about with respect to pain are about it character and pattern. Hence make a note of when the pain started, what you were doing at the time when the pain began, did it come out of the blue (like a colic) or did it build up gradually. How long did the pain last – doctors think of this as Onset, Duration and Progression! Other things to think about are if some bodily functions aggravated the pain or in fact resolved it. For example you may find pain in the upper abdomen that kicks off on eating fatty or greasy food – this sort of story may suggest pain due to gall stones. It is not te only thing and usually gall stone pin is on the right side of the upper abdomen just below the rib cage and radiates through to the back, can come in waves or be a strong pain that is present for hours. It may radiate to the lower tip of the scapula (the winged bone on the high back) and may radiate to the tip of the right shoulder. And so on and so forth. But by noticing where the pain was (below the rib cage), how it began (gradually or as a colic), what started it off (fatty foods), how long it lasted ( a few moments or an hour), how long it took to wear off, did it come back again and at what frequency (the pain may occur in waves), was it associated with vomiting (biliary colic may make you throw up due to the intensity of the pain) or a change in bowel habit. Anything else you noticed – for example in some patients who have gallstones they get jaundice (yellowness of the eyes and skin) or may notice absolutely dark coloured stool or pale coloured stools or even a generalised itching. These last three symptoms may suggest bile is not draining properly from the liver into the gut and tell you one may need check that apart from stones in your gall bladder there are stones in the main channel that carries bile from the liver to the gut – shown here as the CBD (common bile duct).

The point of writing all this is to help you think of tings to make a note of prior to your consultation so you can get the maximum out of the meeting. The more clues you can provide the greater the “accuracy” of the clinical impression formed on the basis of which investigations will be suggested. The more targeted the investigations the higher is the pick up rate for correct diagnosis

So think a bit about this. Abdominal pain is indeed a very complex and most of the time we ignore things and the symptoms pass. As you can see from this drawing the abdomen has a lot of organs and each organ has many different pathologies. If you have come to a point in your life that you are troubled by symptoms and decided to see a doctor then you may find it helpful to make a note of your symptoms and remember Onset, Duration, Progression (ODP)! And of course relieving and aggravating factors and associated symptoms!!

P.S. I would like feedback. If this article has helped you or not or indeed if there are additional topics you would like to see covered please email me on enquiries@mygut.co.uk.