Hemorrhoids It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions. One of the most common findings at the time of colonoscopy is that of hemorrhoids. While it may seem like a simple topic, I believe that hemorrhoids are highly misunderstood! Let’s start by discussing what hemorrhoids are. They are simply engorged veins near the anal opening. Misunderstanding number one is that many patients are under the impression that it is mandatory to treat and/or remove all hemorrhoids. That is not true. Since hemorrhoids are really not linked to an increased risk of colorectal cancer, and do not necessarily lead to anything more sinister, there is no reason that hemorrhoids automatically need to be treated or removed. I tell patients that the main reason to be aggressive with hemorrhoids is if they are causing significant symptoms. Most people with hemorrhoids do not have symptoms. Those who do have symptoms must decide if the symptoms are bothersome enough to warrant doing something about them. That is really “in the eye of the beholder”. How much a patient is willing to put up with varies from person to person. The second major misunderstanding regarding hemorrhoids is “If it hurts down there, it must be hemorrhoids”. The fact is, that hemorrhoids can certainly cause discomfort. However what patients perceive as pain from hemorrhoids is often from other causes. For example, an anal fissure-which is a small cut in the skin at the anal opening-can cause severe anal discomfort. Likewise, irritation of the skin right around the anus, from eczema, dermatitis, or yeast infections can cause discomfort . Taking a good history of the patients symptoms and doing a good physical examination are critical to diagnosing the source of a patient’s symptoms. While it seems self evident, an accurate diagnosis is critical in providing the proper care for a patient with pain in the anal/rectal area. I have seen all too many patients who were treated for hemorrhoids-sometimes even surgically, when the underlying source of their symptoms was not actually their hemorrhoids. In addition to discomfort, hemorrhoids can also bleed. This bleeding is often minor, and does not necessarily mandate aggressive treatment. On the other hands sometimes the bleeding is persistent and severe enough to warrant intervention. Examples of this are when the bleeding leads to frequent soiling of clothing, or is extensive enough to cause the patient to become anemic. It is important that what is perceived as hemorrhoidal bleeding is not from something more sinister such as a malignant tumor of the colon or rectum. Evaluation with colonoscopy may be necessary in order to rule out tumors or other lesions as a source of the bleeding. Once it has been determined that hemorrhoids are the source of a patient’s problems, then next issue is how to treat them. Bleeding, in my opinion, is best treated with either band ligation or surgical hemorrhoidectomy. I favor trying band ligation first, since it is less invasive, and generally well tolerated and effective. The technique I use employs the O’Regan hemorrhoid banding equipment made by CRH. (www.crhsystem.com)

Diverticulosis

While the information contained in The Colonoscopy Chronicles will be as accurate as possible, it is not intended as medical advice. You should consult your personal physician regarding your own medical issues. So, you've had your colonoscopy, and now your doctor tells you that you have diverticulosis. You nod your head knowingly, since your doctor acts as if you should know exactly what that means, as she speeds on to her discussion about your hemorrhoids. But in reality, you really don't know what that means, and by now, it's too late to ask her. The recovery room nurse hands you a slick brochure telling you all about diverticulosis. You tell your friends at the health club the next day that they found diverticulosis, and suddenly your hearing stories about nuts, seeds, popcorn, Aunt Sally's ruptured colon, antibiotics, and now your head is swimming. After all, you just came her for a good workout and now your ready to check into the Mayo Clinic. Help!! Well-Doctor Mike is here to give you the Baby Boomer's Underground Guide to Diverticulosis. Stick with me, kid, you'll be fine! I am going to try and distill twenty three years of experience as a Gastroenterologist into a few paragraphs about diverticulosis-so please realize that this is not a comprehensive review of the topic. Rather, I am going to tell you the exact same thing that I tell my patients, what I consider the basics about diverticulosis.So here goes............ First of all,when the colonoscopy is over and we are reviewing the results, if diverticulosis is present, I let the patient know. I explain that it is a common finding-that probably at least 60-70% of people get diverticulosis. However, the good news is that the vast majority-perhaps 95% or so-will never experience any problems related to their diverticulosis. I go on to explain that diverticulae are little pouches in the colon,and while they are extremely common, we don't exactly know what causes them. There are many theories, most relating to the amount of dietary fiber we eat,but they are probably genetic to some extent, since they tend to run in families. I also explain that while the vast majority of people do not develop problems from the diverticulosis, the two major complications are diverticulitis, and bleeding. I explain that diverticulitis occurs when the pouches become infected. This leads to abdominal pain that is usually in the left lower part of the abdomen, and sometimes in the middle af the abdomen, below the navel. Other associated symptoms can include fever, or constipation. I advise patients to be aware of those type of symptoms and to seek medical attention right away if they occur, since they might need antibiotics to combat the diverticulitis. I explain that the bleeding associated with diverticulosis is usually painless, and sudden in onset. The bleeding is usually fairly severe when it occurs. Again, I advise patients to seek medical attention immediately if they have suspected diverticular bleeding. Finally, I explain to them that for years we advised patients to avoid nuts, seeds, and popcorn, on the theory that those particles are undigestible, and can get lodged in the diverticular pockets and cause diverticulitis. It seemed like a logical instruction-but the problem is, that it turned out that there was really no good evidence that ingesting nuts, seeds, and popcorn had anything to do with diverticulitis. Therefore, I currently do not restrict those items in my patients with diverticulosis, but rather just suggest a general high fiber diet. And that, my friends, is my "Readers Digest" version of diverticulosis. Naturally, this is a very simplified version of a very complicated topic. I did not touch on some of the less common, but very serious complications of diverticulitis, such as perforations, abscesses, or obstructions which may require surgical intervention. I also did not touch on those who have frequent, recurrent episodes of diverticulitis that may require elective surgery. But remember, these serious complications are not common. But because they may be fairly dramatic,even though they are not common, they get a lot of notoriety.

Removing Polyps With Snare

Snare Polypectomy We have discussed the use of the biopsy forceps to remove polyps. That technique is generally limited to the removal of smaller polyps-usually less than 5 millimeters. Larger polyps are generally removed using the snare technique. Just like the use of biopsy forceps, snares can be "hot" or "cold"-meaning that electrocautery is used or not used. A snare is basically a wire lasso that is placed around a polyp, then tightened around the polyp tissue to cut off the polyp.

Generally, the cold snare technique is limited to smaller polyps. The hot snare technique-ie the use of electrocautery-is employed in the removal of larger polyps since the cautery provides hemostasis(bleeding control) by essentially sealing off small blood vessels the may be severed during the removal of the polyp. Because polyps come in various shapes and sizes, the snare technique is adjusted based on the polyp. Let me give you an example. Some polyps are "pedunculated", meaning they grow on a stalk-almost like a cherry on a stem.

To remove such a polyp, the snare is placed around the polyp, and the stalk is severed by tightening the snare and at the same time using electrocautery current through the wire. The diagram below shows a good representation of a snare polypectomy of a pedunculated polyp.

Once the polyp has been removed with this technique, there is usually a small burn mark on the wall of the colon, as seen below(the small whitish area).

Polyp Removal Techniques The last post on this blog discussed some of the commonly encountered types of polyps. One of the goals of colonoscopy is to detect potentially pre-cancerous polyp-the distinct advantage of colonoscopy(versus imaging studies such as lower gi x-rays, or so called "virtual" colonoscopy is the ability to not only detect polyps, but to remove them at the same time. There are several techniques that are used by gastroenterologists. The choice of technique may depend on the size and shape of the polyp, as well as the experience, training, and comfort-level of the physician performing the procedure with the various techniques. I will try not to bore you technical details of each approach, but rather, I hope to give you a general idea of each so that if you or a loved one has a polyp removed you can have an idea of what exactly that meant. FORCEPS POLYPECTOMY Forceps are basically like a tiny set of tweezers. They are on the tip of a long wire-type device that we slide down the biopsy channel of the scope, and they emerge from an opening in the tip of the scope while it is in the colon. The assistant can open the forceps, then the physician positions the forceps over the polyp, then the assistanrt closes the forceps, thus grasping the polyp. The physician then basically just pluckes the polyp off the wall of the colon. Forceps can be "cold" or "hot". In the case of a cold forceps, there is no electric cautery involved, whereas in a hot forceps polypectomy, monopolar cautery is used. The advantage of cautery is that it can prevent bleeding, and can help destroy any redsidual polyp tissue on the colon wall that was not grasped with the forceps. The disadvantage is that sometimes the polyp tissue is destroyed by the cautery and difficult for the pathologist

The Underground Guide to Polyp Removal!

How Are Polyps Removed?


We talked a little bit about colon polyps in our last post. Many patients are curious as to exactly how polyps are removed during colonoscopy. Today we will discuss that very topic. To be honest with you, the techniques we have for removing polyps during a colonoscopy are pretty amazing!

The vast majority of polyps are removed using:
1) Biopsy forceps- “cold” versus “hot”
2) Snare-“cold” versus “hot”

Biopsy forceps can be “cold” meaning that there is no electric current passing through the forceps, or they may be “hot” in which case monopolar electric current is transmitted to the tissue through the forceps. Polyps appropriate for removal with a biopsy forceps are usually quite small-up to 3 millimeters for a cold forceps and up to 4 mm for a hot forceps.

The forceps is really a tiny set of “tweezers” on a long wire that can be passed down a long hollow channel in the colonoscopy. The tweezers can be opened and closed by the technician assisting the colonoscopist. When a tiny polyp is identified, the forceps is slid down the scope, and the polyp is grasped with the open jaws of the tweezers which are then closed. If “hot” forceps are used, an electric current is passed through the forceps to obliterate the tissue, then the polyp is “plucked” off the wall of the colon with the forceps. The polyp tissue is then retrieved and sent to the pathology laboratory. If “cold” forceps are used, the polyp is grasped and plucked off the wall of the colon without any electric current.

Here is what a biopsy forceps looks like:

Here is the "business end" of a biopsy forceps:

Here is a polyp being removed with a "hot" biopsy forceps. Note the the polyp tissue is whitish color-the result of "blanching" of the tissue from the electric current:

Next time we will discuss the snare technique for polyp removal-so stay tuned!!

Colon Polyps- A Primer

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.





Colon Polyps Part I

As a practicing Gastroenterologist, one of the most common situations that arises relates to the question of colon polyps. Polyps of the colon are extremely important! Therefore my mission today is to try to debunk some of the misconceptions regarding colon polyps, and give a clear understanding of this common condition.

First off, what exactly is a polyp? A colorectal polyp is a fleshy growth lining the wall of the colon or rectum. There are a variety of types of polyps, but I will confine my discussion to the two major types. Adenomatous polyps are the most important type, because they are the principal precursor of colorectal cancer. The other type of polyps are hyperplastic polyps. The vast majority of those are small and insignificant, although as I will discuss later there is a small subset of hyperplastic polyps that do have the potential to become cancerous.
Since adenomatous polyps are the main precursor of colorectal cancer, I will focus most of our attention on them. Just to give you an idea about the magnitude of this problem, consider the fact that in the United States alone in 2010, there were 142,570 cases of colorectal cancer diagnosed(4th leading cause of cancer in the US) and 51,370 deaths from colorectal cancer(2nd leading cause of cancer death). There is a 6% lifetime chance of the average American developing colorectal cancer.The appalling part of these statistics in my opinion is that I believe those numbers are far higher than they need to be. Why? Because if precancerous polyps can be identified and removed, we can effectively reduce the risk of colorectal cancer, and in turn the risk of dying of the disease. We, as a society, are doing a much better job of getting this message out. Since colonoscopy was recognized as an effective screening method, and routine screening colonoscopy began to be covered by Medicare, the death rate from colon colorectal cancer has gradually edged down. However, sadly, only about 50% of Americans of the proper age(50 years and up) is getting routine colorectal cancer screening.
So why aren’t we shouting this from a mountaintop and having everyone checked for polyps? Good question. It is a huge public health problem, and like many things, there are a variety of opinions on how to best screen people for colorectal cancer and colorectal polyps. I could spend hours reviewing the different strategies that have been proposed. Let me just summarize by saying that in my opinion, there is no doubt that colonoscopy is the best screening test to look for colon polyps and cancer. But if you have the time and interest, feel free to look at the conclusions of the U.S. Preventative Services Task Force-which goes into great detail about the various options. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
So what are the odds that your routine screening colonoscopy will show adenomatous polyps? It is estimated that approximately 25% of Americans at the age of 50 will have polyps on a routine screening exam. The chances of having polyps increases with age. These polyps come in a variety of shapes and sizes. When it comes to polyps, size does matter. In generally, larger polyps are more likely to harbor cancer cells than smaller polyps. As far as shape goes, they may grow on a stem, almost like a cherry(pedunculated polyps) or they may grow fairly flat, more like moss on a tree(sessile polyps). These differences in polyp shape can have important implications as far as the techniques used to remove them.

Pedunculated Polyp

Sessile Polyp



Not only do adenomatous polyps vary in the their size and shape, they also vary in the way they look when examined under a microscope. By that, I mean that the polyps can be categorized as tubular adenomas, tubulovillous adenomas, and villous adenomas. Of these, the more villous component, the higher the risk of cancer transformation. Fortunately, about 80% of polyps are tubular adenomas.
Next time we will discuss the management of polyps including methods for removal, safety of removal, and subsequent followup.