TUMORS OF THE LARGE INTESTINE

Benign

Polyp – a clinical description of any elevated tumor.

Polyps can occur:

  • Singly
  • Synchronously in small numbers or
  • As part of a polyposis syndrome

In familial adenomatous polyposis (FAP), >100 adenomas are present.

Adenomatous polyps

Classification of polyps of the large intestine

Adenomatous polyps vary from tubular adenoma rather like raspberry on a stalk, to the villous adenoma, a flat spreading lesion.

Solitary adenomas are usually found during the investigation of colonic bleeding or sometimes fortuitously.
Villous tumors more usually give symptoms of

  • Diarrhoea
  • Mucus discharge
  • Occasionally hypokalaemia

Risk of malignancy developing in an adenoma increases with increasing size of tumor.

Adenomas larger than 5mm in diameter are usually treated because of their malignant potential. Colonoscopy snare polypectomy click here or diathermy obliteration with hot biopsy forceps click here can be used.

Huge villous adenomas of the rectum can be difficult to remove even with techniques per anus, and occasionally protectomy click here is required ; the anal sphincter can be preserved.

Proctectomy is a surgery to remove all or part of the rectum.

Familial adenomatous polyposis

Clinically defined as presence of >100 colorectal adenomas.

Over 80% of cases come from patients with a positive family history.

20% arise as a result of new mutations in the adenomatous polyposis coli gene (APC).

It is less common that hereditary non-polyposis colorectal cancer (HNPCC) and accounts for <1% of colorectal cancer (CRC).

Although the large bowel is mainly affected, polyps can occur in the stomach, duodenum and small intestine.

It’s inherited and mendelian dominant conditions.

Risk of CRC is 100% in patients with FAP.

Males and females are equally affected.

It can also occur sporadically without any previous sign or history, presumably by new mutations. There’s often, in these cases, a history of large bowel cancer occurring in young adulthood or middle age, suggesting preexisting adenomatosis.

FAP can be associated with benign mesodermal tumors such as desmoid tumors and osteomas. Epidermoid cysts can also occur (Gardner’s syndrome) ; desmoid tumors in the abdomen invade locally to involved the intestinal mesentery and, although non-metastasising, they can become unresectable.

Up to 50 per cent of patients with FAP have congenital hypertrophy of the retinal pigment epithelium (CHRPE), which can be used to screen affected families if genetic testing is unavailable.

Clinical features

Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30 years.

Carcinoma of the large bowel occurs 10–20 years after the onset of the polyposis.

One or more cancers will already be present in two-thirds of those patients presenting with symptoms at the time of diagnosis

Symptomatic patients

Are either patients in whom a new mutation has occurred or those from an affected family who have not been screened.

They may have

  • Loose stools
  • Lower abdominal pain
  • Weight loss
  • Diarrhoea
  • Passage of blood and mucus

Colonoscopy is performed with biopsies to establish the number and histological type of polyps.

If over 100 adenomas are present, the diagnosis can be made confidently.

If there are no adenomas by the age of 30 years, FAP is unlikely. If the diagnosis is made during adolescence, operation is usually deferred to the age of 17 or 18 years unless symptoms develop.

Screening policy

  • At-risk family members are offered genetic testing in their early teens.
  • At-risk members of the family should be examined at the age of 10–12 years, repeated every year.
  • Most of those who are going to get polyps will have them at 20 years, and these require operation.
  • If there are no polyps at 20 years, continue with yearly examination until age 50 years; if there are still no polyps, there is probably no inherited gene.

Carcinomatous change may exceptionally occur before the age of 20 years. Examination of blood relatives, including cousins, nephews and nieces, is essential, and a family tree should be constructed and a register of affected families maintained.

Treatment

The aim of surgery is to prevent the development of colorectal cancer. The surgical options are:

  • colectomy with ileorectal anastomosis (IRA);
  • restorative proctocolectomy (RPC) with an ileal pouch-anal anastomosis, the anastomosis may be defunctioned with a loop ileostomy;
  • total proctectomy and end ileostomy (normally reserved for patients with a low rectal cancer).

The patient is almost always young and likely to prefer to avoid a permanent stoma and so the choice is normally between the rst two options.

The advantage of an IRA is that

  • it avoids the temporary stoma frequently required for an RPC
  • avoids the potential compromise to sexual function that accompanies proctectomy.
  • has a lower morbidity and mortality.

However, the rectum is left and requires regular surveillance, as there is a risk of adenomas and carcinomas in the residual large bowel. Even with optimal surveillance of the rectal remnant, up to 10 per cent will develop invasive malignancy within a 30-year follow-up period.

Restorative proctocolectomy has the advantage of removing the whole colon and rectum (although a small cuff of rectal mucosa may be left behind with a stapled anastomosis). However, there is a pouch failure rate of about 10 per cent. In addition, and particularly where a stapled anastomosis has been created, there remains a very small but denite incidence of cancer developing in the small strip of rectal mucosa between the pouch and the dentate line. This is why some colorectal surgeons advocate complete mucosectomy of the residual rectal cuff and a transanal pouch anal anastomosis, although it is acknowledged that this results in worse function.

Postoperative surveillance

  • rectal/pouch surveillance, with biopsy of the pouch-anal anastomosis.
  • Gastroscopies are also carried out to detect upper gastrointestinal tumours.

Even with prevention of colorectal cancer, FAP patients have reduced life span due to the development of duodenal and ampullary cancers and the complications of desmoid tumours.

Hereditary non-polyposis colorectal cancer (Lynch syndrome)

characterised by increased risk of colorectal cancer and also cancers of the endometrium, ovary, stomach and small intestines.

It is an autosomal dominant condition that is caused by a mutation in one of the DNA mismatch repair genes. The most commonly affected genes are MLH1 and MSH2.

The lifetime risk of developing colorectal cancer in Lynch syndrome is 80 per cent, and the mean age of diagnosis is 45 years.

Most cancers develop in the proximal colon.

Females with HNPCC have a 30–50 per cent lifetime risk of developing endometrial cancer.

Diagnosis

Tumours of the large intestine 1163 HNPCC can be diagnosed by genetic testing or the Amsterdam II criteria:

  • three or more family members with an HNPCC-related cancer (colorectal, endometrial, small bowel, ureter, renal pelvis), one of whom is a rst-degree relative of the other two;
  • two successive affected generations;
  • at least one colorectal cancer diagnosed before the age of 50 years;
  • FAP excluded;
  • tumours veried by pathological examination.

Patients with HNPCC are subjected to regular (every one to two years) colonoscopic surveillance.

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The bodaboda man

You will never know lunch time frustration, when you’re hungry, tired, worried about something, until you board a motorbike with an incessantly talking rider.

Ideally, all motorbike riders and passengers ought to wear a helmet meaning no communication can take place. Even in the absence of helmets, the wind blows against the direction of the motorbike meaning sound will be lost in between and hence discouraging talking. But no! Some people’s determination will make you marvel.

I swear this man couldn’t shut up. He went to the extent of literally turning to try and be heard. My heart rate was over the roof the whole of that ride. I almost asked him, do you have a wife? A grandmother at home? A friend to talk to back at home? No? That’s unfortunate because you can talk! I wondered so because I recall one of our lecturers mentioning that while taking a history from patients, especially the elderly, they will tend to go on and on mostly about irrelevant things. They will start telling your about their chicken back at home and you have to politely guide them back to track. They do this because they’re lonely. Yes, they’re lonely. Society has neglected the old.

About a fortnight ago, my cousin broke down while explaining to me how our step grandmother has been neglected by everyone. I mean, we visit her, she visits us but that’s about it. Very few check up calls are made to her and she has to live alone for the rest of her life. She talked about how you could feel the excitement and thrill in her voice everytime she picked the phone. As if she was eagerly waiting for the phone to buzz. It broke my heart honestly and made me start to appreciate the essence of nursing homes. Perhaps it’s about time we embrace this idea and set in motion a plan to cater for the old and to give them a reason to continue living long after their children have moved out and spouses died and no one is around for them anymore save for the occasional visits from their grandchildren.

This is why I did not get offended with the man’s chatter for they say be kind always for you never know what someone is going through.

Don’t we just love the dead?

Don’t we just love the dead? Is a question one of my lecturers posed during one of his lectures which made me pause and think. They say that people won’t worry about your existence, they won’t call you to check up on you, they might not even help you in your time of need but will book the earliest flight they can to attend your funeral. They will buy exquisite bouquets of flowers to place them on your grave and then they will gather and talk about how they wish they called you the last time they attended a conference in your area of residence or how they should’ve called you for that coffee, returned your missed call. Their faces full of regret and shame

There’s this song I used to love as a teenager called If I Die Young by The Band Perry. It’s lyrics and link

https://m.youtube.com/watch?v=7NJqUN9TClM&feature=youtu.be

[Intro]
If I die young, bury me in satin
Lay me down on a bed of roses
Sink me in the river at dawn
Send me away with the words of a love song
Oh-oh, oh-oh

[Verse 1]
Lord make me a rainbow I’ll shine down on my mother
She’ll know I’m safe with you
When she stands under my colors
Oh and life ain’t always what you think it ought to be, no
Ain’t even gray but she buries her baby
The sharp knife of a short life
Well I’ve had just enough time

[Chorus]
If I die young, bury me in satin
Lay me down on a bed of roses
Sink me in the river at dawn
Send me away with the words of a love song

[Pre-Chorus]
The sharp knife of a short life
Well, I’ve had just enough time

[Verse 2]
And I’ll be wearing white when I come into your kingdom
I’m as green as the ring on my little cold finger
I’ve never known the lovin’ of man
But it sure felt nice when he was holdin’ my hand
There’s a boy here in town, says he’ll love me forever
Who would have thought forever could be severed by

[Pre-Chorus]
The sharp knife of a short life
Well, I’ve had just enough time

[Bridge]
So put on your best boys, and I’ll wear my pearls
What I never did is done
A penny for my thoughts—oh no, I’ll sell ’em for a dollar
They’re worth so much more after I’m a goner
And maybe then you’ll hear the words I’ve been singin’
It’s funny when you’re dead how people start listenin’

[Chorus]
If I die young, bury me in satin
Lay me down on a bed of roses
Sink me in the river at dawn
Send me away with the words of a love song

[Outro]
Ooh, ooh, the ballad of a dove
Go with peace and love
Gather up your tears, keep ’em in your pocket
Save ’em for a time when you’re really gonna need ’em
Oh, the sharp knife of a short life
Well, I’ve had just enough time
So put on your best boys, and I’ll wear my pearls

When she sings about how her thoughts will cost more after she’s a goner and she talks about how people listen more when you’re dead she’s basically reiterating the concept of us loving the dead more than when they were alive. Michael Jackson made more money dead than alive. The irony.

So why do we do what we do? Why do we tend to care more about things or people after we lose them? Is it because familiarity breeds contempt? Or is it because we’d rather weep than laugh?

Make that call, help a friend and most of all be there when your loved ones need you. You only have one family.

Does the camera love you?

Some people, no, most people love taking photos of themselves. I don’t. The camera doesn’t love me but most of my friends, well, let’s just say the camera does justice to them and the captions! I swear some people were born gifted. The captions makes you hit like if it’s on Instagram and smile a tad bit if it’s in WhatsApp and text them ‘ You’re looking gorgeous’.

I bet when I die, my mom would have to go to my Google drive to find my images because well, I love deleting stuff. It’s an obsessive compulsive disorder of sorts. After a conversation, I delete it. I like my phone looking tidy. It’s not that I have something to hide, it’s just a preference. But I do back up all my photos.

Not to digress, yes the camera is picky. I feel like it hides the parts that matter. It’s a facade. Someone can look prettier, more handsome than their actual self or mostly, better than they look in person and we fall for it then get disappointed when we meet them I guess that’s why blind dates have been known to go sour.

C’est la vie.

But hey, when you’re photo phobic like me you live for other people’s photos. You compliment where it’s due and appreciate the photography. I wish I loved photos because they’re a source of immortality, apart from writing. Once you’re gone, it’s what remains. It makes you invincible because the internet never forgets so snap away that meal that looks gorgeous before you dig in. Snap away that city you’re visiting. You don’t have to post it on social media because your mind and camera will always remember. The moments will be frozen in time.

Jewels

I’m honestly not the person you want be chatting with. I’m terrible at chatting especially on WhatsApp. I either reply in seconds (okay, minutes. Let’s be honest, I don’t sit around waiting to hit reply on my notification window) or 2 days later. I know I suck but interestingly enough, some of my best friends have never given up on me. I swear my best friend from primary school still texts me. He’ll send me a meme and I’ll see his text when I manually open WhatsApp because I’ve turned off the notifications. I’ll stare at the conversation and because I love him so much, I don’t want to open it then not reply hence blue ticking him. I’m not impolite like that. I press back button and log off and then three days later when I’m looking at my phone screen, I recall that he’d texted me so I log onto WhatsApp and I find the meme hilarious so I laugh out loud and send him the ‘I’m laughing and crying simultaneously emojis’ because yes, he cracks me up and even though I take ages to respond I honestly love him and think about him. We call each other, maybe not as often as we should but he’s still my best friend. He’s so patient with me and my terrible texting habits that sometimes I just want to show up at his workplace (he works a town away) and buy him lunch and have him talk to me about life and how his girlfriend wants to meet his parents and he’s not ready but he’s serious about her and how he wants to buy a car before the end of the year and then he shows me his mpesa messages from sportpesa and for a few minutes I consider gambling too but then he tells me ladies don’t do that and I’m like yes, I’m a lady like that and drop the idea as fast as I adopted it. He honestly makes me laugh till my ribs hurt. An hour spent with him feels like a lifetime of happiness. It’s nirvana for me. Which I think is why I’m terrible at chatting with him because I feel like the words and the emojis are insufficient to show him how happy he makes me and how much he makes me laugh. It doesn’t mean I do not care for him and something tells me he has come to understand me and that’s why even after I reply his message after a week, he’ll still text me, make me laugh and we’ll catch up for a few minutes then go back to our lives.

Nevertheless, when we talk over a phone call, we catch up on everything, literally. And then my heart rests and I smile to myself and thank God for giving me the gift of such a good friend.

To have

One my worst fears is finding love then losing it. Having it in the palm of your hand and then like water it slips smoothly through your fingers as you helplessly watch.

It’s a hellish feeling. Almost as if someone punched you in the gut and reminded your lungs how much they like the taste of air. Close to that terrible feeling is saying goodbye to someone you deeply love. I read somewhere that hospitals have heard more prayers than the walls of churches and airports have heard countless painful goodbyes. Methinks what makes it unbearable is the helplessness of the situation. If you could, you’d accompany them and not leave their side but no, life has a wicked sense of humor like that. It gives you a mouthful taste of that which your heart craves for then pulls the spoon back and leaves you gaping at it like a child crying for more food after a little teasing.

What can you do when it all becomes overwhelming? I guess you have and hold onto that which you can while you still can and hope that the universe smiles upon you a little longer and let’s you waltz in your own happiness a little longer.

Ruskin Bond, in his book, A book of Simple living says that happiness is a mysterious thing, to be found somewhere between too little and too much. But it is as elusive as a butterfly, and we must never pursue it. If we stay very still, it may come and settle on our hand. But only briefly. We must savour those moments, for they will not come our way very often.

The kind boy

I stood there one hand clutching onto my backpacks strap, my phone and my navy blue sling bag and the other lifting the slightly heavy green bag with food that I’d just had warmed hoping it won’t get cold before I found my brother.

It had been a grueling journey which is why I’ve always felt that if God granted people pleasure from doing certain activities He definitely had removed traveling from the list of mine. After about 7 hours of sitting in that tiny car courtesy of the old geezer we had for a driver I arrived at Gitaru stage and headed to Kikuyu town in a rush that only God knows.

In hindsight, all this could’ve been avoided had I woken up as early as planned but apparently a girl can sleep through 3 very loud alarms!

As I stood there looking like a lost puppy, I walked up to one of the boys – he was a few inches shorter than me, in a navy blue sweater and a grey track trouser that hang loosely onto him as if borrowed or not made to his fit.

‘Excuse me, what form are you in?’

Form one.’

I’m looking for Jay, a form four. Is there any way you could help me locate him?’

Not really. It would be hard for me to find him as he’s in form four so he’s either watching football or in class.’

‘Okay. Could you please ask any form four for me?’

He responded by moseying towards the football field.

‘Sorry. I couldn’t find him.’

‘Okay. He’s in form 4D, could you direct me to the class please? He could be there.’

It’s a grand school, alliance. The boys waltzing around in their faded green shorts and jungle green sweaters others in their games attires wildly cheering at their football team. I would later learn that it was sports day as usual – every Saturday. I had a hard time catching up with the kind boy. His steps were small and quick.

Can I help you with that?

He suddenly asked pointing to the green bag that was weighing on me. Not to judge but judging from his body frame, I didn’t want to impose but he insisted so I handed it over. It was a gesture that reminds you of the goodness of people in a harsh, corrupted world.

After minutes of walking, we got to the class and Jay wasn’t there and we went out again to search for him. All this while, the kind gentleman carried my bag without the slightest hint of complaint for taking a break from his activities to help me find my brother.

‘Thank you very much. Its been kind of you to help me find him. I wish I could repay you.’

I thanked him graciously as my brother approached and he smiled, nodded and replied,

its no problem.’

I hugged my brother and we walked away and guess what, I had to force my luggage which was in other words, his, on my brother!

His first instinct wasn’t to help!

Where does this distinction arise?

And who said chivalry is dead? Unless you met my bro then yes it is lol. Just kidding.