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Thanks again for joining us, I'm Kathrin Berg and this is the El Paso Physician And today we're going to be speaking about colon cancer: prevention, diagnosis and management.

We have a two veterans with us today and one person who is new and I promised him we can ask him questions last.

But Dr. Alejandro Robles, I would like for you to talk to the audience and tell the audience what a gastroenterologist does.

And let let me back up a little bit.

We have Alejandro Robles, who's a gastroenterologist.

We also have Dr. Mark Zuckerman, who's a gastroenterologist, and then Dr. Ammar Kalas, who is a gastroenterology fellow.

And we're going to talk about the separations and differences of that in just a moment.

But Dr. Robles, what do you do all day?

Every day?

- -All day every day.

Well, first off, thank you for having us here again today.

So as a gastroenterologist, we pretty much take care of the entire gastrointestinal system, from the esophagus to the stomach to the small bowel or the large bowel, the pancreas, the liver, anything that can go wrong.

We're here for that.

We do procedures, endoscopy, to try and correct and fix any of these possible complications that could arise.

And at the same time, we're also involved in preventive services like colon cancer screening, where we focus on preventing colon cancer, which we'll speak a little bit more later.

But it is the second most common cause of cancer related death in men and women.

So we try and decrease the risk of this.

And I don't think a lot of people know that because you hear a lot about other cancers.

But this is really one this is the preventable one, which is so great that we're here today about that.

Dr. Mark Zuckerman, again, you everybody kind of does the same thing.

I get it.

But your every day, day to day routine, what you do, etc., if you can explain to the audience what you do.

All right.

So I'm the chief of gastroenterology at Texas Tech.

So clinically, what what we do is we see patients with disorders of the gastrointestinal or gastrointestinal tract or liver disease but we see patients in the hospital, which is emergencies or inpatients, which is where I'm coming from now.

And we see outpatients and these these are your usual outpatient problems that Dr. Robles just alluded to.

In addition, at Texas Tech, we were involved in a teaching program, medical students, residence, and we have a big GI Fellowship program training future doctors, future gastroenterologists.

That's a three year program.

That's a three year program.

What a perfect transition.

Look at that.

You're already introduced.

Dr. Kalas with an accent on the end.

Yes.

Very nice to meet you in person and talk about the fellowship.

I mean, that that's a nice way of setting it up.

And what does that mean?

So I think that it's people that are not in the medical world.

When you're a fellow, what does that mean?

So my name is Ammar Kalas.

I'm a second year fellow now.

Thank you for having us today.

It's a pleasure.

So a fellowship usually comes after residency.

So we do initially medical school, depending on whether you're from the US or outside the US, it either would be pre-med or no pre-med And then after medical school you decide if you want to do internal medicine and that's where you can go to gastroenterology.

So internal medicine would be a three year residency and then in your second year you would decide what specialty you would want.

And depending on that, you do either gastroenterology, cardiology and so on.

And for me, GI was the main thing I wanted since medical school.

So tell me why.

This is always, to me the curiosity of this.

I don't get to speak to and you're not a student.

I get that.

But when we did have medical students around the programs, I always thought, well, why are you picking the specialty that you're picking?

And there's always a story attached to it.

What is your story?

Why?

Why gastroenterology?

For me, mainly, I wanted to do internal medicine because the term less and you learn about everything in the body.

It's a very broad specialty and gives you options as well.

And the other thing is I want to be involved in procedures.

So gastroenterology is a perfect blend of this stuff where you can go do procedures and at the same time it's very cerebral, very intellectual.

And if you want to grow in that side, then you can.

Perfect.

So here goes my transition.

And even though I said I'm going to ask you the questions last, you get the first question.

But it's okay.

We talked about this before we started.

So the colon and the reason I bring this up, we've got the large intestine, we've got the small intestine, we've got the colon, we've got the rectum, we've got the anus, we've got the entire thing going.

If you're describing the colon to someone who really doesn't understand, we just know it's all the digestive tract.

How would you describe what the colon is and what the role of the colon is in the digestive system?

Okay, so the colon is the last part of the digestive tract.

It's approximately six foot long and goes all the way from the end of the small intestine, which is the ilium to the anus.

The last part of the colon is called the rectum.

The colon and the large bowel is the same thing.

The main function of the colon is mainly to form stool.

So everything that's coming in from the small intestine usually is very liquid and comes in at a faster pace than when it reaches the colon.

The colon's main function is to suck all the water and absorb all the water and to a lesser extent, nutrients.

And form the stool so that we can excrete it That's really the main function of the colon, and that's where because it's a rapidly growing tissues in that lining, you can get cancers.

Dr. Kalas, with saying that, that brings m to the question of, you know, we've got days where we're constipated, we've got days we have diarrhea.

And so I feel like it's the decision of the colon whether to have those things happen.

But in general, when people are constipated, what does that mean?

Are they not drinking enough water again, once the food and liquids get to the colon?

The colon is thinking, okay, how much do I take out?

How much do I keep in?

What in general causes constipation and diarrhea?

I know there's a gamut of answers out there, but in general, so for constipation, it can be something as simple as you said, someone not drinking enough water, not having enough fiber, their diet.

It could be something like if somebody got recently hospitalized and now they're not moving as much.

They're not walking as much.

It's also the colon kind of takes a rest with the rest of the body.

So it's not uncommon for us to see in the hospital patients with constipation, Other things can be including medications.

Some medications for blood pressure can cause constipation.

So it's always difficult to pinpoint the exact reason for the constipation.

And that's why you have someone who is constipated for a few days and then he's normal again.

And you will never really know exactly why was it that he was constipated.

So as long as it's not something that's persistent, that's associated with things like requiring enemas or requiring to put many well, this impaction of themselves, then usually it's something that's transient.

Makes sense, makes perfect sense.

Dr. Zuckerman, I'm going to bring things over to you.

So we're talking about the colon.

We're talking about colon cancer and colonoscopies, etc., etc..

He's smiling when we're looking at a polyp.

How does a polyp develop in the first place?

And then after that, we're going to talk about screening guidelines and all the fun stuff with that.

But since you're talking about the role of the colon and everything that it's doing, its role basically is to extract the the you know, vitamins and water out of the the stool.

What is it that causes a polyp?

and is there an answer for that?

It just happens.

There is no answer.

So no answer.

I think you have a picture of a polyp right?

To help everyone understand what it looks like because there is - a polyp is essentially an abnormal collection of cells forming a small mass, let's say.

So it can vary in size.

Polyps can be like a pimple.

They can be a few millimeters, they can be like a mushroom.

They could be on the stork.

So they come in different sizes and shapes.

But I think abnormal collection of cells sort of rising up above the lining of the intestine would be a polyp.

Now, we're talking today about colon polyps because there are polyps, sort of a more general term.

But this is what we mean by polyps in the colon.

So the problem with polyps, polyps don't cause symptoms or at least small polyps don't.

So you won't necessarily know you have a polyp, but polyps: are the standard method leading to colon cancer is the polyp cancer progression.

So most of the time cancers start as polyps.

So you develop polyps and then a small percentage of polyps over time and we mean ten years, but a long time can get larger and develop into cancers.

That's the polyp cancer sequence.

And there are different types of polyps.

But generally speaking now we're talking about adenomas or just benign polyps.

So that's important on your screen right now.

These are benign polyps.

And to your point, some can look like a simple pimple and because these are benign, they're easily removed.

But this, I think, is a really nice transition into screenings and what screenings are actually looking for in the body.

And, Dr. Robles, you're you're on for that one.

So I want to talk quickly too I know the last time we were on together, the screenings used to start at age 50.

That's correct.

And now the screenings are starting at 45.

And I think we may have or if not, I'd like to repeat it what the process is of why screenings are now starting at 45.

I think it's great.

I think it's wonderful.

But in general, why is that happening?

Yeah, no, absolutely.

So, you know, colon cancer, like I said, it's one of the most common type of cancers there are.

And it's actually going up in incidence.

It's becoming more common.

It's becoming more common in younger individuals.

We start seeing a lot of new onset cases in individuals under the age of 50.

I mean, it's to the point it's the most common cause of cancer death in men under the age of 50.

And now when you start screening at 50, it might be too late for some of these individuals.

So by, you know, decreasing the age to 45, we're hoping to be able to capture a little bit more of these population, capture these polyps before they become cancers where we can remove it, we can prevent cancer.

And at the same time, a person that does have a cancer.

We capture it early where it can be treated can be cured.

Colon cancer is very treatable.

As long as you capture it early, you're not going to have symptoms early on.

Right.

So the only way to know is going in there looking for these type of things.

Exactly.

And is there any information or reasons that may have been given through the world of medicine of why people that are younger are developing colon cancer earlier?

Is it the type of food that we have?

I always go to, "don't eat processed foods" but is there a thought of that?

Yes, you know, a lot of theories, hypothesis of what's happening, what's causing these changes, it's becoming more common in younger individuals.

Diet, definitely, we believe is contributing to these things.

Modifiable risk factors, smoking, smoking in general is coming down- But yet again, our diet is it has changed.

It's changed, it's changed quite a bit.

The increasing rates of obesity, being overweight, all these are contributing--what we believe are contributing to the development of early onset cancers, increased prevalence of diabetes, glucose problems, the diet red meat, not enough fiber in the diet.

And like Kalas was saying, fiber its not only good to prevent constipation, but it can also prevent the formation of polyps and formation of cancer in that case.

So all these factors are coming into play and even some research saying that the changes in the microbiome, meaning the little bacteria that live inside the colon, can be contributing.

And so a lot of factors, a lot of things we need to keep an eye on.

And, you know, as medicine advances, we hope that we'll figure out what's happening for the polyp to form, and hopefully be able to stop it from that process.

And I feel like this too, and we've talked about on some other programs that we are kind of in an obesity epidemic.

And this is really the first time in history where we've had so much food so readily available and not necessarily healthy food, because we're just in that that process of society.

It's like, grab this on the go, grab that on the go.

So it makes sense to that.

We've got more issues going forward.

Dr. Zuckerman, yes?

Yeah.

Wanted to add This is not the answer to the question, but there is a genetic predisposition here, and we don't think that the sort of the increase in younger adults with colon cancer is due to genetics.

We think that's environmental dietary issues.

But I should say that there is a genetic component and it's a small percentage.

Some patients have a family history.

If someone has a first degree relative, meaning mother, father, sister, brother could be son/daughter, but first degree relative with colon cancer, that person has twice the risk of colon getting colon cancer as as the average person.

And still the same polyp cancer sequence occurs.

But it can in times again occur to younger age.

And there are genetic syndromes.

A small percentage of patients do have this genetic predisposition to developing polyps and colon cancer.

And when you're talking about family history, are there also certain parts of the population, certain areas of the population that are more prone to colon cancer than others other than just hereditary, or is that not I mean, there are some diseases that might be disposed you know if you have inflammatory bowel disease or ulcerative colitis.

The small risk is not that big, but over time that is a predisposing condition.

Okay, So yes, Dr. Kalas?

And usually that IBD, as you said, is more in Caucasians.

So but it's not very common as a cause of cancer.

Okay.

The other times where we see that there's a difference between different populations, is that really maybe it's not from genetics, but from access to health care.

So health care disparities can contribute to this.

So especially in the Hispanic community, it can be more likely for them to be-- or to be diagnosed with a more advanced cancer rather than an early cancer.

Okay.

And that makes sense, too.

And I want to go back to the screening questions.

I know that there are several different if you watch television or stream anything and there's commercials out there, you've got a good old fashioned colonoscopy, which I think is the way to go is the gold standard.

And then you've got other ways of screening as well.

And Dr. Kalas or Dr. Robles who would like to take that on, because I know that there are options out there.

I do want to continue talking about the gold standard, though, but what other options are there for people who are maybe having their first screening?

Yeah, absolutely.

So there's still test stool based tests which are readily available, noninvasive.

There's no anesthesia involved, no procedure involved, no prep involved.

And it's a very acceptable way of getting screened.

These stool based tests vary whether we're just checking for blood or whether we're checking for blood and changes in the DNA, like altered DNA from a polyp.

And you can see a lot of commercials about the Cologuard, and things like that.

You know?

Which checks for blood as well as for changes in DNA, and all these tests What people need to be aware of all these tests are all acceptable methods.

If you participate and you're involved in any sort of screening program, whether it's the stool based test or the gold standard, the colonoscopy, if you follow up appropriately, you will see a reduction in overall death from colon cancer.

However, that only includes if you have a positive stool based test.

This is followed up with a colonoscopy, right?

Just doing the test itself does not decrease the risk you need to have appropriate follow up thereafter.

And I do want to talk I'm going to be gross for a minute because I think it matters.

So you're doing Cologuard.

There's something funny.

I got to go get a colonoscopy.

You should do it anyway.

But colonoscopy, it's it's if you've never had one, I think it just scares people.

So I'd like to be very specific as to what this entails.

And if you talk to the majority of people out there, it's like, Oh, it's the prep.

The prep is so hard.

So the prep is.

Dr. Kalas, would you like to talk about the prep?

Yeah, sure.

Okay, let's talk about prep.

So you go in and like, you know what we need to show you for a colonoscopy?

These are the things you need to do.

Yes.

So the prep usually starts a few days before the procedure, usually a day before.

You should only be taking clear liquids because we want to make sure that there's no food in the whole colon.

And just because you don't eat the night before doesn't mean that there's no food from the morning before.

So the day before, it should be all clear liquids and then the prep, the one that's most commonly used in the in the US is the Golytely, which is Miralax, basically, but four liters of it.

And usually it's done in a split dose fashion where it's part of it, it's taken earlier in the day, then the other parts earlier in the morning before the procedure to help flush out the whole colon.

There are more different types of prep.

There are some that are less volume.

For example, it'll be two liters instead of four liters.

They might be easier for patients who really can't tolerate Golytely at all, which can happen.

There are other ways as well where some people take Gatorade with some medications to have them poop, or they'll take clear liquid for two days instead of one day.

So there are many options which should make the prep now easier.

Exactly.

Yeah.

Yeah.

And there's a lot of ways to make it more palatable.

Some people take it with Gatorade instead of with just water.

So there's some flavor and that should help.

Its not the best experience, it's 4 liters and it's only clear liquids the whole day, but it'll save you a potential cancer.

Absolutely.

And so the gross part I'm talking about is, again, I like being blunt.

It's a medical show.

We're educating people.

And I will say this because I had my second colonoscopy at the end of last year.

The first colonoscopy I did have Golytely second colo-- It was all over the counter, second colonoscopy.

It was to your point, Gatorade, some some medications.

And you are you are having diarrhea for about 8 to 14 hours, 15 hours.

Do it as much as you can the day before so you can get a good night's sleep.

But that's sure it's uncomfortable.

But we've all had it.

And I just I joke and I say, well, we're you know, this is a great cleanse, isn't it?

And you kind of start from scratch once you have your colonoscopy-- we joked about that last time too.

And the most important--yes-- most important thing in the colonoscopy is to be able to see.

Exactly.

You need everything out of that system.

Yeah.

So there's stool, you know, some stool we can clean out, but some stool that we can't.

Yeah.

And that would just have to be repeated again.

Exactly.

And again.

Why?

Why go through all that?

So go through it.

It's worth it.

Trust me.

It's worth it.

Dr. Zuckerman, What I'd like to do is go to another slide that we have here, and it is actually talking about the polyp removals.

And so with the procedures that you all do and thank you for talking about this before the show, the slide that we have in front of us, these are cold snare procedures, meaning that there's not a cauterization afterwards.

And I'm going to try to say it right.

This is a polypectomy.

A cold snare polypectomy, correct?

--Yeah.

He was messing with I don't see I knew it because he just said, just call it this.

And I'm like, I can't see that.

That's too hard a word.

But in general, talk about cold snare for the smaller polyps.

And then when you have to cauterize and it feel free to just kind of chime in, anyone that's that's listening.

All right.

But I wanted to agree with Dr. Robles and Dr. Kalas that, first of all, there are two step screening procedures or one step screening.

So one step screening is colonoscopy.

This is the gold standard.

Most effective two step means if you take the stool test, the fecal immunochemical test, FIT test, or the multi target DNA FIT test, which is Cologuard is the brand name.

If these are positive, these are somewhat sensitive.

If you take it as positive, the next step is you need a colonoscopy so you don't get out of the colonoscopy.

The colonoscopy is a preventive test.

Only colonoscopy can be can remove polyps.

The other one is just detecting it's really more detecting colon cancer or advanced polyps.

It's not detecting tiny polyps.

And then there are the more limited use tests like c.t.

Colonography you might have heard about or some sort of compromise flexible sigmoidoscopy.

But for the audience, really any screening test is better than nothing.

If we're doing a colonoscopy, as Dr. Kalas pointed out you need an absolutely clean colon to do a high quality job finding polyps.

Once you find polyps, how do we remove polyps?

Well, really tiny ones.

One to three millimeters.

We might use the biopsy forceps and just take a bite and remove it.

Otherwise, small polyps in the 3 to 10 millimeter range, we would put a catheter through the kaleidoscope and it looks like a snare or lasso around the polyp and just take it off.

That's called cold snare polypectomy So we're just cutting it off with the circular wire and then we suction it through this kaleidoscope, catch it in a trap, send it to pathology where it's looked at to get the exact type of polyp it is for larger polyps or polyps on the stalk.

We would do the same thing, but it's a hot snare and we say it's a hot snare.

Does it mean it then burns the tissue behind?

And so that's-- yes.

Electricity cauterization Okay.

You know, there's a small risk of bleeding every time you do a polypectomy So these are just techniques for doing a polypectomy Then there is some more advanced techniques for larger polyps.

But the.

Yeah.

Or is that exact go to one of these guys.

Let me ask one of these.

Let me ask one of these guys.

Since you are the chief here.

Since he's the chief, he's asking one of you guys.

So what is the the third removal of polyps?

This fellow takes that.

Thank you, Dr. Kalas So there's endoscopic mucosal resection where basically we would inject some liquid under the polyp.

If it's big to lift it up just so that when we're removing, we don't remove too deep where there's a higher risk of perforation, especially when we use the heat, these this heat sometimes transmits through the walls.

So we want to minimize that by lifting it up.

So that's one way.

And then there's a way now with the endoscopic sub mucosal dissection, which is basically using like a something similar to a knife and slowly cutting it around edges.

And this is more useful for very, very large polyps where you don't want to remove it in more than one piece.

Because when we remove it in more than one piece, you're more likely to miss a few tiny pieces right behind sets.

And those obviously again and the reason I ask this too is, people and I do want to talk about side effects or lack of a different word, or things that that could result in some bleeding.

And if that is the case, what is the course of action after that?

Say there some bleeding, which I think is very natural if it lasts for what, more than a day or two days.

Will a person be able to see this in their stool?

So depending on the way we remove the polyp, like we were talking about the cold in the hot, actually, that has something that comes into play in determining the bleeding with a cold snare, we're able to see if it's bleeding right there and then.

You cut.

It bleeds.

We have the chance to stop it.

Sometimes it bleeds for a while, stops bleeding, but we're able to see that it stopped bleeding.

The individual may see a little bit of blood in their stool, maybe that day, the day after.

But that should should probably be it.

And that's actually acceptable.

It's not a big concern.

It's when we start using the heat source, the hot source of the cauterization, and where it's not going to bleed because we burn through the process, through the through the --- process.

We put some clips close off the area.

But however, once this kind of starts going off, individuals can sometimes develop bleeding maybe 5 to 7 days later, and this bleeding tends to be a little bit more is larger volume than your cold snare.

And most of these individuals will come back to the hospital and that happens.

We will have to go back in and try and close that area back again.

It's rare.

It's rare.

It does happen, but it is a rare possibility.

And the nice thing's that there is a fix, there's the bottom line.

There is a fix for that.

Excellent.

The next slide, which is the fun slide.

This is where you don't want to get.

So I am just going to I'm just going to have some fun with this and say, okay, this is a 62 year old who decided that he didn't want to do his colonoscopy.

And of course, he's a "he", maybe she didn't want to do his colonoscopy or her colonoscopy.

And now we've got cancers.

When we're looking at someone who does have a colon cancer.

I've got several questions.

The biggest one, how do you treat it from there?

Do we go in and try to remove these snare off?

Do we take some of the colon out?

There's all kinds of answers here, and I'm throwing this out to whoever wants to take it first.

And since you're the chief, you get it.

Dr. Zuckerman, is that ok?

Well, yeah.

In the case that you're that you're describing, if we see something that looks like a mass in the colon, that and we biopsy it and it turns out to be colon cancer, then the primary treatment is surgical.

Now we'll do a workup.

We're going to have to get blood tests and CT scan and check to see if this is localized or spread beyond the colon.

But the basic treatment in early detection, localized cancer is surgical removal and surgical removal.

Describe what you're talking about.

Referred to surgery.

Okay.

Take, for instance, if this is in the lower part of the intestine, then the surgeon may take a piece of the sigmoid colon out, let's say, and remove that and reattach.

So it's varies depending upon location.

And the rectum is a little more difficult to deal with.

And we talk about colorectal cancer.

It's sort of the rectum.

The less part of the large intestine that 15 centimeters or so and the rest of the colon.

So that might be a slightly different approach to the two But the basic treatment would be surgical for early cancer or non--not too invasive.

Okay.

And Dr. Robles, if we can extend that a little bit too now and say we've got several areas that are cancers within the colon, If you take part of the colon in one area, can you take another part somewhere else?

Do you I guess depending on how close together they are, you would section that off in general, kind of carry that a little bit further and how do you suction the colon back together?

So so having cancer in multiple areas of the bowel- it's rare, it does happen.

It does happen it's rare and usually unfortunately a lot of these individuals tend to have a little bit a little bit more advanced disease at the time this happened.

So a lot of these individuals will probably be treated with chemotherapy first to try and decrease the size of the tumor before they do any sort of before the removal.

That's correct.

And it depends on little colon.

I mean, if you have two masses in the right side of the colon, sometimes just cutting off the right side of the colon and you kinda connect the small intestine to the remainder of the large colon, that can be a possibility.

That can be a possibility.

But we start dealing with cancers and one that's in the right side.

Once in the left side, then it starts getting a little bit more complicated.

This is we work very closely with our colorectal surgeon colleagues as well as our medical oncologist in a way to we plan what is the best course for the management of certain individuals.

But like Dr. Zuckerman, was saying early onset cancer, I mean, surgical approach.

You just literally just cut that part of the bowel.

You put that part of the bowel together, it's cured.

We capture that cancer early.

It is a cure.

Most of early cancers don't have symptoms, so that's why the colonoscopy comes into place.

And again, colon cancer, 90% survival at five years.

As long as you catch it early, it starts going down quite a bit.

And once you have a little bit more advanced type of disease.

So so now let's talk about someone who has had the cancer, has now had the surgery from their point on, because now it's self-history, not just family history, it's themselves.

How often should they go back and have a colonoscopy from then on out, is there a certain, like first couple of years and then, you know, I always think about the five year mark, like after five years, it's like, not that you're clear clear, but you're relatively clear.

Yes.

Good question.

So initially, after the initial surgery, you'll have a follow up colonoscopy.

You should have the one year timeframe at the one year time frame.

Everything goes well that time, that colonoscopy, There's no polyps, there's no cancer.

You have the next one in three years, and after that it'll be five years.

And instead of doing it every ten years, like an average individual, you'll be screening and or surveilling at a five year interval from now on, just because you develop cancer once, technically, you may have a little bit higher risk for developing it again.

So we keep a little bit closer eye on these people.

Nice.

And I was, missed it a little bit earlier, but when you have when a 45 year old goes in and his is he's good and he's doing his first check and is completely polyp free, then he doesn't have to do the test for another ten years, ten years.

So that was my first case.

My second case I did have a polyp a little itsy bitsy baby polyp.

It was benign, but now I do my checkup in five years of one polyp.

Yeah.

Oh, look at me on testing out of that.

It didn't come out right, But right now.

Now I do my second follow up in five years, even though there is nothing wrong, there was a polyp.

They did remove it.

So it's like, okay, I am a person who developed polyps.

I actually had a polyp removed from my tonsils about 15 years ago.

So there's just something in my system that I know I'm kind of I might become polyp girl, so I'm just like, I might just go in after three years.

I'd like to really check that out.

I would like to talk a little bit too about colostomy bag, because that is often talked about with the world of colonoscopy.

Not colonoscopies but with colon cancer, with surgeries.

When is the colon in a shape to where a person would need a colostomy bag and is that forever or can that be reversed?

And I'm throwing that out.

Dr. Kalas, would you like that one too?

Look at me putting him on the spot.

The colostomy bag requirement really depends on, first of all, the location of the cancer.

How much colon did they remove?

Did they remove it emergency or was it elective?

So whenever it's usually emergent, usually they'll have a colostomy, at least temporarily.

And let me back up because I didn't explain what it is first, explain what the colostomy bag is.

I should have said Colostomy bag is basically when they bring part of the colon or the small intestine, actually the ostomy for the small intestine, but they bring part of the colon to the skin and it'll be an opening on the skin where the stool comes out from.

So when it's done emergency, it's usually done for an obstruction.

In these cases, they'll put the colostomy bag so that the obstruction is relieved and then they'll plan about the surgery and what approach to take, what part to take, usually it's reversible.

But if somebody, for example, has his whole colon removed with the rectum, then they might be with the colostomy bag forever.

But in general, it's reversible.

I like hearing that.

Okay, there is.

I worked with the American Catch.

That's how this program started.

28 years ago, I was working with the American Cancer Society and one of our volunteers had a had a colonoscopy bag.

That's the first time I've ever seen or knew anything about it.

I was in my twenties, but she was great about just going around people, showing them what this is.

This might be your surgery.

I'm fine.

She was the most lively person I knew, so I just thought to myself, This is great.

I do have a quick question.

We were talking about symptoms and that often there are no symptoms I want to quickly go into because this is kind of a gastro show.

I want to go into irritable bowel syndrome for just a minute.

I know it's not about that, but I have a son in law and literally this weekend he had an emergency appendectomy.

Why am I talking about that with colons?

It's just something that-something's hurting, something's not right.

If people are at the point where they do have a colon cancer, if something doesn't feel right, go get it checked out.

Even if you are that 62 year old person that hasn't been there before.

But when colon cancer is a point where there are symptoms, what does it feel like?

What are they looking for?

Are they looking for blood in the stool when they have them look back in the toilet and see?

I'm throwing that out there again to anybody who wants it.

Dr. Zuckerman, you haven't talked in a while.

Yeah, how about that?

I wanted to make one comment about you were asking about after colon cancer.

So we call it colon cancer screening.

When we're when someone has no history of colon polyps or colon cancer, if we find a polyp or if someone should have colon cancer after that, we call the procedure surveillance.

It's no longer screening.

The patient has a polyp or cancer.

We do surveillance.

And so here we're now we're talking about sort of different surveillance intervals.

And this depends on the polyp, the size of the polyp number of the polyps.

Colon cancer is another category.

So all these you mentioned, you know, one polyp, depends on the size and the type.

And so there are all these different intervals, but the best you can do is ten years anyway.

There's an overlap of symptoms with people with bowel problems and certainly irritable bowel syndrome symptoms may overlap with colon cancer syndromes.

With colon cancer in particular, there are alarm symptoms or along there's certain things that would definitely draw your attention when we're screening, we're we're really talking about asymptomatic patients without complaints.

But symptoms could be changing in bowel habits.

You're suddenly going less frequently or change in stool caliber or consistency.

Now your stool is pencil thin, you're straining if there's blood in the stool.

GROSS blood.

This is a problem.

It may be hemorrhoids, but we can't assume it's hemorrhoids.

But I do want to talk about that because a lot of people have that issue.

So I'm glad that you brought that up Yeah, yeah.

So blood and so blood in the stool for sure.

Also on blood tests, if you're anemic, you have a certain type of anemia that suggests chronic blood loss.

That would be a big one.

So these are some of the things we could look for.

Okay.

I do want to add.

Yes, blood in the stool should never be taken as just hemorrhoids.

Never.

Never.

That's one of the causes.

We believe that, you know, younger individuals are postponing their procedures because I am too young for colon cancer.

This is just hemorrhoids.

So any time there is blood in the stool, this is an alarm symptom.

Like Dr. Zuckerman was saying, this is something that definitely requires an evaluation.

Don't ever overlook blood in the stool.

It's always something that needs to be investigated, cannot be put on hemorrhoids unless we do the colonoscopy at that time.

I like the way this is set up, and I know Dr. Kalas had something to add to that within that question.

So blood in the stool, depending on how fresh the blood is, could look differently.

So I would love to take this moment to describe what that might be.

So fresh blood, maybe hemorrhoids, because it's fresh meaning bright red blood versus blood that looks a little bit red, brown, rusty.

Let's let's go through that for a little bit and what people might be looking for, what they might recognize.

Okay.

So using the blood color alone is never accurate.

It's never accurate because because it could be that the stool, for example, or the blood stays longer in the colon, so the color will change.

So somebody who poops once a week will likely have a different color than somebody who poops every day.

So the the stool color on its own is not accurate.

It can give you an idea if it's fresh red, as you said, it could be something more on the left side or more distant like hemorrhoids, even like an inner fissure that's really badly bleeding or it could be a cancer.

Other causes could be also contributing like Diverticulosis.

Somebody who's bleeding from that an ulcer is unrelated to cancer, like people who take NSAIDs or people who are having the ischemia or something.

And then the right side tends to be a little bit darker.

The blood to be sometimes even black and to be confused as a as an upper bleeds.

But usually it'll be darker.

And is it the right side is darker?

Is it just farther away?

It's farther away.

Okay.

So the longer the blood stays in the colon or in sight, the more it's going to be metabolized and change the color.

That's why the upper, for example, usually causes black.

The lower is more reddish maroon-ish.

Okay.

Just because of the duration, everything.

And bottom line, again, I'm being blunt, we kind of all know what our stool looks like.

Get used to it.

Look at it every now and again so that when you do look at it, it looks different.

That's when it's time to to pay attention for.

The lack of anything else.

Sorry.

Yes as you said.

So IBS should never have bleeding.

If somebody has bleeding in IBS, it should always be further evaluated to make sure it's nothing else.

It could hemorrhoids, but we have to make sure that it's nothing like cancer because this is with IBS.

Usually they have more complaints.

They'll be going to the doctor with abdominal pain, which must be frustrating for the patient, but sometimes it might be taken lightly and that would cause misdiagnosis.

So weight loss, blood, severe pain out of proportion.

All of these should be investigated more.

Okay.

And IBS, if I didn't say it earlier, IBS is irritable bowel syndrome or inflammatory bowel disease is something that people talk about too.

On on that note, and I want to I want to talk a little bit about the couple of things that you mentioned, which I think is great.

We're looking at fissure, we're looking at diverticulitis and we're looking at ulcers.

So let's talk about a fissure, your whatever.

What is it?

What I know it's like a little pivot or a little, I guess.

Yeah, it's like a small cut.

Yeah.

In the perianal area, it can happen if somebody strains a lot, is very constipated, has very hard stool.

It can sometimes make a tear and this tear can make it make the patient more scared to go to the bathroom, which will worsen the constipation.

They'll hold it in longer, then they'll go bigger again.

So they have to mainly avoid constipation.

There are some medications for it, but that's the main thing for fissure And will it heal on itself or is that something that a person will always have?

No, it can heal own And if it's not healing, then there are medications to be given to relax the sphincter so that it starts healing the skin slowly.

But the most important.

No constipation?

No.

Yeah.

That's the big thing.

Ulcer.

I think we'll save that for a different show.

But diverticulitis, I think is something to describe it.

Is there a higher risk of any type of colon cancer?

You have diverticulitis.

Is it related at all?

And if not, since you're shaking your head, actually, I'll give you a break, Dr. Robles, let's talk about what diverticulitis is, just describe what it i So diverticulitis is inflammation or diverticulosis.

So it's actually underlying diverticulosis little pouches that form in the bowel can usually arise.

Maybe a life lifelong life of maybe low fiber diets.

So lack of fiber, your colon is having to squeeze more, having to work extra hard.

And this results in maybe pouches that form These pouches are benign.

They don't increase the risk for colon cancer, but they do put you at risk for diverticulitis, which is inflammation of one of these pouches.

Maybe one of these pouches gets obstructed with a piece of stool we call fecal lift If inflammation happens, they can develop an abscess and sometimes even develop a perforation.

Part of that back can open up and then becomes an emergency, and then you may end up with an ostomy bag as well during that time.

So that's what we want to prevent.

High fiber diet helps with that, stay hydrated and yet not a true association, but it's associated with low fiber.

And low fiber is also associated with colon cancer.

So fiber prevents constipation helps decrease the risk for these other causes.

So drink water and what exact even if it's Gatorade, to mask taste.

I get that.

I just want to add something to what Dr. Robles said.

So Diverticulosis doesn't have a risk for colon cancer, but sometimes patients will have diverticulitis, usually after 6 to 8 weeks of the initial episode.

We should do a colonoscopy to look for cancer, not because the diverticulosis caused the cancer, but sometimes the cancer can precipitate diverticulitis from surrounding inflammation.

So it's like not one causes the other, but opposite way around.

Yeah, it could be hidden.

Yes, it can be hidden.

That makes that makes a lot of sense.

And along the lines of the your question previously about colostomy or so colon cancer is not the only reason you might get surgery and end up with a colostomy.

It's often it's in an emergency setting.

But diverticulitis, for instance, diverticular complications might be another reason you need surgery and then temporary colostomy.

Also inflammatory bowel disease like ulcerative colitis or something like that in an emergency.

So or after surgery for inflammatory bowel disease.

So there are different reasons, not just colon cancer.

All these things overlap.

That's why medicine is difficult.

It is it is a complex thing and our bodies are complex, But I'm super happy that you're bringing this up because I do have several things that I have here too, ulcerative colitis.

I was talking about.

And again, when we talk about inflammatory bowel disease, now when you have the word disease, it's different than a condition.

So that have the disease, what are they looking out for and when do they have in the back of their heads like, okay, do I need more colonoscopy than the normal average guy?

Do they not?

Just throwing that out there again?

Dr. Roberts Yes.

So inflammatory bowel disease, which is separate from inflammatory from IBS, irritable bowel, correct?

Yeah.

Encompasses what we call Crohn's disease and also to colitis.

So entities with ulcerative colitis maybe being a little bit more common than Crohn's disease, but these are conditions that involve inflammation in the colon and in Crohn's disease can involve inflammation of the esophagus, the stomach as well.

Now inflammation is usually the precursor to cancer because you have underlying inflammation.

Risk for cancer in the colon does increase.

It's why these individuals actually undergo what we call screening more often than your average risk individuals.

We recommend screening every 1 to 2 years for people with inflammatory bowel disease.

Actually, there's a few caveats involved.

Like how much of the past being involved, things like that.

But just in general, you usually have one or two year intervals where screening these individuals just because of the higher risk, because of the inflammation.

Okay.

And I like to expand a little bit on Crohn's disease because I'm trying to think too about the audience and what I see or hear commercials about advertising is about like Crohn's disease.

If you feel like you have to go, what?

What are some of the symptoms of Crohn's disease and say somebody has symptoms but they don't know what it is that they may be experiencing?

And I know a lot of this as Dr. Zuckerman said it kind of all, you know, dances with each other.

Crohn's disease is what?

How would you define Crohn's disease?

Crohn's disease will be defined as an inflammatory condition affecting the entire gastrointestinal tract, more commonly the large bowel, but also the small intestine.

Small percentage of people can involve anywhere from the mouth to the esophagus to the stomach, But the small bowel as well as the large intestine, mean the more common symptoms can include abdominal pain, diarrhea, diarrhea.

That happens even at bedtime, at nighttime, what we call nocturnal type of symptoms.

These individuals can be losing weight, can have blood in their stool.

And these are kind of reasons why they seek care.

We do imaging studies, we do colonoscopy, we see inflammation.

We make the diagnosis at that time.

Okay.

And the nice thing, too, is that, again, the commercials I'm hearing is because there's medications out there to help out.

Absolutely.

So we live in a time where there's medications and a daily basis coming out and oh, my great medications by the way, great medications.

Not only are we decreasing the inflammation, we're giving individuals a better quality of life.

So that's the other benefit of finding it and teating it.

- Great.

Dr. Zuckerman, you mentioned earlier that a lot of times and I feel like when I first started doing the show again 28 years ago, we did often say "colorectal cancer."

And I feel like that's been separated over the years.

But you did talk about there is a difference between colon and, you know, if there is a polyp or a cancer in the rectum.

I do want to address that really quick because there are different nerve endings in the rectum and just different issues.

Can you expand a little bit more on that?

I think it's just a little difference in the anatomy of where the rectum is and the rest of the colon is.

It's still Colorectal Cancer CRC.

It's the same as saying colon cancer, but rectal cancer is managed a little differently.

There's more chemotherapy, radiation therapy, more difficult surgery than the rest of the colon in terms of finding polyps and finding polyps and removing polyps.

Then similar.

So they're not really distinct entities.

The visual how how big is an average rectum before it gets to the colon?

When we do a colonoscopy, we start with the anus, we go into the rectum between 15 and 18 centimeters, we're in the sigmoid we're out of the rectum.

So about the first 15 - Oh that's really small.

About the first 15 centimeters.

Okay, seven inches.

Okay.

And so here's another question.

I'm just thinking as an audience, too, right.

When when somebody has hemorrhoids and we have pictures here of polyps and we're like, well, I think that looks like a hemorrhoid.

Maybe my hemorrhoid and/or polyps are at the very bottom of my anus.

These are hemorrhoids.

And I'm asking all three of you because when people come to you and they're asking you questions, what are some of the questions that you often get asked about that very subject?

What is the difference with hemorrhoids and what maybe we don't?

Let's talk about the difference between a polyp That may be the very, very end of the rectum, which is why I was talking about that.

Or hemorrhoids.

How does someone who has no idea in the medical world, how do you differentiate that?

Dr. Robles, you are you're looking and smiling and nodding.

No, it's a It's a great question.

So with our cameras that we use our our colonoscopes, we have different ways to help us determine what we're looking at now.

It's rare we can tell the difference between a polyp and the hemorrhoid.

Sometimes there's a polyp on top of a hemorrhoid and then that's when it becomes an issue.

Wow.

Yeah.

You need to cut something off but it's on top of a vein.

So right.

You know, we have ways of doing things, but we also have a lot of ways to help us determine the difference.

And again, we can see the extent of the hemorrhoids.

Not only are they going outside, but how far deep inside are they going?

Because they're going to be managed differently.

I mean, general high fiber diet, not sitting in the toilet for too long or, you know, ways that we can decrease the hemorrhoid type of issues.

But again, the polyp with our cameras that we have, we're able to channel different type of light to help us see different angles, different colors, and what we'll be able to differentiate at that time.

Okay.

And maybe and you hit the nail on the head too, a definition of a hemorrhoid is a vein that is exposed and popping out for the lack of a better word is that, and Dr. Kalas you're smiling and nodding.

So how would you describe that or how how have patients described hemorrhoids to you?

And their, their worry about them.

Exactly.

As you said.

It's dilated veins sometimes depends on their external or internal.

External ones are the ones that can be felt more commonly.

So external ones are the ones that also have more pain.

So the internal ones bleed more, the external ones have more pain than bleeding So it's usually will feel like a small I describe small cherry, maybe-- grapes -- Full disclosure.

When I was pregnant, I had my first baby at 30, had no idea what a hemorrhoid was and boom, popped the baby out.

And there's all kinds of stuff going on down there.

And I thought, What in the world are these?

I remember asking the nurse that I had no idea, and she goes, Oh, they're just think of those as mini grapes.

Little by little, they'll just pop right back inside.

And again, I'm being blunt, but that is through the women that I have known who have had babies that have not ever had hemorrhoids before.

That's the way it was described to me.

I had no idea that was even a thing until then.

So that's why I wanted to bring that up.

We are at about 4 minutes before the show wraps up, so.

Dr. Zuckerman So I wanted to mention the Texas Tech program's success or Axiom so this is a colon cancer screening program run by the Department of Family Medicine.

Dr. Molokwu was in charge of this program, and it's meant for colon cancer screening, free colon cancer screening in patients who can't afford it, who are at high risk.

So this is a grant from Texas Cancer Prevention Services Foundation.

But anyway, we've been doing this for about 13 years now.

Originally it was called Accion A C C I O N against colon cancer in our neighborhood.

And it sort of morphed into this success program.

Now Southwest Coalition against - for Colon Cancer Prevention.

And we conduct this program at University Medical Center on Alameda, where patients are referred if they meet criteria, if they either if they meet certain criteria and don't have funding for free colon cancer screening, it's been tremendously helpful to the individuals and to the community.

We've done over 3000 colonoscopies and of course, we've found many polyps and several colon cancers is generally at an early stage.

So this is a great program - -and how do people find out about it or get in line?

So to speak.

You know, they go out, we can contact Department of Family Practice and we can contact the success program directly.

But it also goes out.

We have promoters as we go out into the community, and some of them is religious places, some is community fairs, and they hand out questionnaires, they hand out fecal immunochemical tests, fit tests, or ask people about family history and they have family history of colon cancer.

So those are the specific targets, people who have evidence of microscopic microscopic evidence of blood in their stool, or a family history of colon cancer without funding.

So really beneficial program to the community.

- -What a great program Yes, we won an award from the American College of Gastroenterology Called the SCOPY Award last year for this program the SCOPY Awards I kind of love the name of that.

Just saying that that's a perfect way to end the program for the team that has won the SCOPY Award, I want to say thank you very much to Dr. Zuckerman, also Dr. Robles and Dr. Kalas You guys have been an absolute joy to have on the first program that we have here at the Turner home.

Again, the El Paso County Medical Society has been here since 1946, which is fantastic.

This has been a great program on colon cancer prevention, diagnosis and management.

If you were able to catch the whole show, that's great.

But if you want to watch certain sections again or any other programs that the El Paso County Medical Society has done, you can do that at three different platforms.

One is pbselpaso.org The other one is the El Paso County Medical Society's website, and that is epcms.com and also YouTube.com.

So you can go on there, search the "El Paso Physician" and then find the topic that you want to watch.

Thank you so much for watching.

I'm Kathrin Berg, and this has been the El Paso Physician.

The El Paso County Medical Society is a nonprofit organization established in 1898 that unites physicians to elevate the health of the El Paso community.

We have been bringing the El Paso Physician Television program to your home for the last 27 years on PBS El Paso.

If you should have any medical questions relating to this program, you may email us at epmedsoc@AOL.com.

And we will try to have our experts answer your questions.