Observing World Piles Day Colorectal Cancer
- Why we should not ignore blood in stool? -

Dr (Major) Anil Ayekpam *

Colorectal Cancer is a collective term for cancer arising in the Large Intestine (the colon) and the lowermost part of the large intestine (the rectum). Colorectal Cancer is the 3rd most common cancer and constitutes about 10% of all the cancer diagnosed, and accounts for 9.4% of all cancer deaths (next only to Lung Cancer).

Worldwide about 19 lakhs new Colorectal Cancer were diagnosed and 9 lakhs succumb to the disease in the year 2020.

Colorectal Cancer incidence is rising even in developing countries likely due to changes in lifestyle factors and diets such as increased intake of animal source foods, sedentary lifestyle and increasing epidemic of obesity.

Other risk factors include heavy alcohol consumption, cigarette smoking, consumption of red or processed meats, environmental pollution and genetic predisposition. Primary prevention remains the key strategy to reduce the increasing global burden of Colorectal Cancer.

Screening which means performing a test or examination in an asymptomatic individual is recommended after the age of 45 years to reduce Colorectal Cancer deaths. Options for Colorectal Cancer screening include:

o Annual FOBT – test for presence of blood in stool.
o Flexible Sigmoidoscopy every 5 years
o Colonoscopy every 10 years
o CT Colonography every 5 years

However mass screening effort in a country like India is not currently justified given the significant cost of colonoscopy and inadequate implementation of diagnostic and treatment services.

Most Colorectal Cancer in our practice are diagnosed on investigations for patient symptoms like visible blood in stool and mucus & blood mixed in stool. Blood in stool is usually identified by an individual while defecating or blood stains in his or her undergarments.

The most common cause of blood in stool is however piles or hemorrhoids. Often pile bleeding is bright red, spurting or in drops, occurs often before or after defecation and usually does not mix with stool or mucus.

A cancer in the rectum may block the venous drainage and presents itself as a haemorrhoid or an aggravation of an existing haemorrhoid. It is this presentation where the individual or even the unsuspecting physician may miss the more sinister diagnosis.

Other common presenting symptoms include a change in bowel habits, particularly alternating constipation and diarrhoea, persistent discomfort, such as cramps, gas or pain, a feeling that the bowel does not empty completely, pencil shaped stool, generalized weakness, weight loss and loss of appetite.

An interesting presenting symptom is spurious or overflow diarrhoea, where the bowel is blocked by hard, impacted stool or the cancer itself, releasing intermittently large amounts of liquid stool relieving, abdominal discomfort and pain.

Colon and Rectum, though in continuity, are two different organs due to its distinctive anatomy, function, disease presentation and treatment strategies. Colon cancer is usually treated by surgery followed by chemotherapy. Surgery for colon cancer is usually straightforward and often requires only a single procedure and most patients will have a normal pre-disease function.

However, Rectal Cancer due to its location, function and nature, treatment is more complex and may be a staged procedure. A Rectal Cancer treatment may need a month-long radiation therapy before a surgery followed by chemotherapy extending months. Patients may need a Colostomy when presented with obstruction.

During the definitive surgery, often a surgeon may leave a Colostomy/Ileostomy which is an intestinal opening made in the abdomen to excrete body waste, either temporarily or may be permanently. A Rectal Cancer treatment may permanently change a patient’s social function, bowel habits, sexual or urinary function.

With advances in Oncology and better treatment sequencing and better surgical technique, morbidity has been greatly reduced. The use of surgical staplers in Rectum Cancer surgeries may avoid a colostomy permanently thereby giving a much better functional, social and individual patient image. Stapler though costly are also much more cost effective than maintaining a colostomy for lifelong.

Like most cancers, treatment is much more effective when the disease is diagnosed early. So, an early diagnosis of Colorectal Cancer can save lives and reduce morbidity. Treatment for cancers are often lengthy, costly and increasingly effective. It is the joy of seeing our patients getting a better life after cancer that makes surgeons keep pushing our limits.