Rectal Bleeding and Hemorrhoids

“Hello doctor, I am Maggie, Susan’s mother. I have been passing blood in my stool. Do you think it is hemorrhoids? Dave and Susan think it could be cancer.”

Maggie is sixty seven. She has been bleeding rectally for the last two years. Over-the-counter medications for local application have not helped. Has she got colon or rectal (colorectal) cancer?

Colorectal cancer affects men and women equally. It is the fourth most common cancer site. It is the second leading cause of cancer deaths in men and women combined ( A Snapshot of Cancer in Alberta-1996).

Do we know what causes colorectal cancer? No. If we did then prevention and cure would be easy. But we do know the risk factors.

Like breast cancer, age is a significant factor. Before the age of forty, the incidence is pretty low. But by the age of fifty, the risk begins to increase dramatically.

What about lifestyle and nutrition?

Studies have shown that death from colorectal cancer can decrease with increased intake of fiber, fruits, and vegetables. Decrease in fat intake also helps.

Increased physical activity, aspirin and avoiding cigarette smoking may be beneficial.

Heredity and genetics is now recognized as a risk factor for this disease. Studies have shown that if there is a family history of colorectal cancer in a parent or a sibling , then a person’s lifetime risk of colorectal cancer jumps from 1.8 fold to 8.0 fold.

Previous history of colorectal cancer or polyps, inflammatory bowel disease and exposure to radiation are other significant risk factors.

With this information in the back of my mind, I take a full history from Maggie and do a thorough physical examination.

The physical examination is normal. A digital rectal examination reveals no suspicious lumps. A proctosigmoidoscopy ( a hollow tube with a light at one end to examine the rectum) shows internal hemorrhoids but no lumps to suggest a new growth of tissue.

Although Maggie has internal hemorrhoids, there are about fifty percent chances that the blood could be coming from higher up in the colon. This may or may not be due to cancer. But she requires further investigation like colonoscopy.

Examination of the entire colon by colonoscopy (a thin, flexible tube made of fibers that transmit light) is the most important test for looking, taking biopsies and when possible, removing growths. Maggie agrees to have the test done as soon as possible.

Maggie has to take laxatives to clean the colon completely of waste products the day before the procedure. The test is done at the hospital as day surgery and under sedation.

A polyp (new growth of tissue) is discovered and removed during colonoscopy. This is sent to the lab for testing to see if it is benign or malignant. In the meantime, she makes an appointment to see me in the office for the results.

Susan accompanies Maggie to make sure her Mom understands the results and its implications. Susan also wants to know how the findings will affect her (Susan’s) health in the future.

“Maggie, I have good news for you. The polyp is benign in nature but it’s a type which can come back and turn into cancer if not picked up early and removed.”

“Dr. B, thank you for the good news. Now I have the same old question for you. How can my mom and I stay one step ahead of the game?” Susan asks with a sense of relief.

Eat less fat. Eat more fiber-containing foods. Have a digital rectal examination and annual stool test for hidden blood and colonoscopy every 3 to 5 years. Report to your doctor earlier if there is any change in bowel habit.

Maggie and Susan are happy that this is all over. As they leave the examination room, I overheard Maggie say to Susan, “I hope now you will listen to your mother and start eating bran flakes cereal in the morning!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Miscellaneous Health Topics

Some items of interest from the world of medicine:

1. Heart Disease:

Heart disease continues to be number one killer. This was recognized in the late 1940s. Since then several risk factors have been identified, including high blood pressure, high cholesterol level and cigarette smoking.

Over the past 30 years, death rate from heart disease has declined by more than 50 percent. This downward trend is continuing. Despite important advances in treatment and prevention, heart disease remains the single most common cause of death in North America.
(The New England Journal of Medicine, September 24, 1998)

2. Alcohol Problems in Canada:

In 1994, 4.1 percent of Canadians had alcohol dependence. Excessive alcohol abuse was a factor in 6701 deaths in this country in 1992. Clearly, alcohol abuse is an important public health issue that needs to be dealt with.

In a recent publication, Poulin and colleagues found that 85 percent of Canadians with alcohol dependence do not seek help, the need for screening and brief interventions is great.
(Canadian Medical Association Journal, Dec 1, 1997)

3. Teenage Girls and Smoking:

Weight control is a major reason that teenage girls take up smoking, according to a study of nearly 3000 British and Canadian school girls.

Girls who smoked were 30 percent more likely to be overweight, were prone to overeat, and were twice as likely to be worried about their body image than non-smokers.

Most smokers also wanted to be considerably thinner than they were and were twice as likely as others to induce vomiting after overeating.
(British Medical Journal, August 8, 1998)

4. Doctors and Religion:

The Medical Post 1997 National Survey of Doctors reveals that 52 percent of physicians consider religion an important part of their life. 26 percent pray outside formal religious services at least once a day. For 13 percent, religious beliefs influence birth control consultations.
(National Survey: the Medical Post 1997 National Survey of Doctors, Fall 1997)

5. Good Health and Multivitamins:

Since the mid-1970s, twenty five percent of American adults have regularly consumed a multivitamin containing 400 micrograms of folic acid. The current evidence suggests that people who take such supplements and their children are healthier.

Consuming a standard multivitamin or a serving of fully fortified breakfast cereal is a convenient, effective, safe, and inexpensive way to increase consumption of folic acid by 400 micrograms of folic acid rapidly.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Prostate Cancer

“Is it my prostate, doc?” Dave asks me at the golf course as he rushes to the washroom for the fifth time.

As a travelling salesman, Dave finds it difficult to make many washrooms stops. He makes an appointment to see me.

Dave is 40. His father has had prostate cancer. Dave wants to know what are his risks and what can he do for prevention and early detection.

The prostate is a small gland, usually weighing about 20 grams. It surrounds the urethra where it joins the bladder. Enlargement of the gland causes voiding problems and may cause bleeding in the urine which may or may not be visible.

Prostate cancer is, after lung cancer, the most common cause of cancer-related death in men. The risk of developing prostate cancer increases with age. At 40, the probability of prostate cancer occurring within five years is 0.01 per cent. At 80, it is eight per cent.

Although the risk is only eight percent, it is important to note that 80 per cent of men at 80 will have prostate cancer. But this will not affect life or life expectancy.

“What’s up doc?” Dave greets me as I enter the examination room.

We discuss symptoms. In a physical examination we find his prostate is slightly enlarged, smooth but quite firm.

There are no hard lumps to cause alarm at this stage.

Although most prostate cancers are diagnosed at 70, they can occur at a younger age. Since Dave has a family history and his prostate is enlarged and firm, he is referred to Urologist for further investigation.

Dave has a blood test – prostate-specific antigen (PSA). This is slightly abnormal. Therefore he has rectal ultrasound and a needle biopsy. This is reported as normal.

“Doc, how often should I have checkups for my prostate?” Dave asks.

His Urologist indicates Dave should have a repeat antigen test in three to six months.

If this is abnormal then he may need a repeat prostate biopsy.

Screening is recommended for men 50 and over. Half the men in this age group develop prostate problems. This may or may not be due to cancer.

Digital rectal examination and antigen tests are recommended for screening high risk patients like Dave. Although neither tests are hundred percent accurate for early diagnoses, they are accepted as part of routine medical checkups.

Dave is happy there is no cancer and his anxiety level improves. He feels reassured about his health.

He is ready to hit the road for another few days of good salesmanship.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Breast Lump

Dave and Susan were anxiously waiting for me.

Since her last visit, Susan has practiced breast self examination. She found a breast lump.

Susan is aware that breast cancer is the most common cancer diagnosed in Alberta women. It also accounts for about 21% of all cancer deaths in women (Breast Cancer – The Picture in Alberta: 1998).

Susan came straight to the point. She told me about her breast lump.

“Dr B, do you think it is cancer?”

“Susan, I will have to do some investigations before I can answer your question.”

I started with clinical history. How long the lump has been present? Has any change been noted? Is there a previous history of breast biopsy or breast cancer?

Age is the most significant risk factor for breast cancer in women. At age thirty, the probability of developing breast cancer in the next five years is 1 in 667. At seventy, it is 1 in 65.

Susan is thirty eight. Her risk is 1 in 208.

Any other risk factors? Susan’s sister had breast cancer. It is estimated that less than 10 percent of all breast cancers have genetic predisposition.

Breast cancer may or may not be painless.

A fine needle aspiration biopsy of the lump was required to establish whether the lump is solid or cystic. A cystic lump has a very low probability of cancer. I also arranged a mammogram. This would provide further information on the nature of the lump. It would also pick up smaller lumps which were not felt during the physical examination.

Susan and Dave were made aware that eighty percent of breast lumps are benign in nature but a breast lump is suspected to be malignant unless proved otherwise.

Within a week I had good news for Susan. The needle biopsy and mammogram did not reveal cancer. She was advised to see me seven to ten days after she starts her next menstrual cycle.

Susan arrived as planned.

I gave her another physical examination to see if the lump had changed or even disappeared. The lump was still there.

Unfortunately, none of the tests we do are hundred percent accurate to rule out cancer.

“Doctor, I know this. I have been talking to my sister. What’s next for me? A surgical biopsy?”

Yes. This would entail a surgical procedure under local or general anesthetic.

Susan underwent day surgery as planned. There was no cancer.

I saw Susan again a few weeks later. She was happy and relieved.

“Doctor, what should I do to stay one step ahead of the game?”

Mammography and physical examination are the mainstay of screening in breast cancer (Cancer Screening in 1995; Current Oncology; March 1995).

Susan got ready to leave. I gave her some pamphlets to read.

“Call me if you have any questions,” I said as Susan stepped out of the door.

She smiled and said, “Thank you, doctor!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!