Polyps are fleshy outgrowths on the internal lining of organs. For example, polyps can be found in the nose, stomach, colon, and gallbladder, among others. Polyps in the internal lining of organs is akin to pimples or lumps on the surface of the skin.
There are many different types of polyps, some of which are benign and will never turn cancerous while others are benign but harbour the potential to develop into cancerous growths.
Colonic and rectal polyps are essentially polyps growing in the internal lining (mucosa) of the colon and rectum. These two parts of the gastrointestinal tract are grouped together as they have essentially the same characteristics.
The term colonic/rectal polyps encompasses the entire gamut of polyps, ranging from Hyperplastic Polyps that are completely benign, Peutz-Jeghers Polyps that are a result of a congenital condition, to Adenomatous Polyps that have the potential to turn cancerous in the future. It is important to differentiate between these polyps as it influences the decision to remove the polyp, the frequency of colonoscopic surveillance and the risk stratification of future cancer development.
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Colonic/Rectal polyps are outgrowths from the internal lining of the colon and rectum. In a normal colon/rectal lining, there should not be any development of polyps. Most polyps develop in later life as a result of damage to the lining. This damage can be due to the food we eat or due to the effects of ageing. As a result of the damage, changes occur in the genes of the cells forming the lining, and it is these changes that drive the development of polyps.
In a minority of individuals, polyps develop at a very early age from their late teens to early twenties. In such individuals, they usually have underlying inherited genetic diseases such as Familial Adenomatous Polyposis (FAP) or Peutz-Jeghers Syndrome. In the case of FAP, over a hundred polyps can be found in the colon and the individual is at a much higher risk of developing colorectal cancer. Thankfully, such genetic diseases are very uncommon in our local context and account for less than 1% of our patients who have diagnosed polyps.
It is important not to be overly worried about colonic polyps. Most polyps can be easily discovered and cleanly removed during a colonoscopy and are often still in a benign stage. This is the reason why a colonoscopy is being advocated by the Ministry of Health Singapore as one of the screening tests for the colon in individuals nearing the age of 50.
An individual can go for a colonoscopy either as a screening procedure or if there are worrying symptoms.
The symptoms that warrant a colonoscopic assessment include:
1. Bleeding on passing motion
2. Abnormal and sustained changes in bowel habits – usually manifesting as diarrhoea or watery stools
3. Unexplained and sustained abdominal pain
4. Unexplained weight loss
5. The sensation of incomplete passing of motion – feels as if there are more stools to be passed out
It is important to note that the above symptoms can occur singularly or as a combination.
For individuals with no symptoms but are in their mid-40s and above, there is a role for doing a colonoscopy as a screening test. The screening colonoscopy aims to allow early pick up of polyps or any cancerous tumours that may already be present. An early pick up of a cancerous condition may mean that the tumour is diagnosed at an earlier stage whereby it is potentially more curable. It is important to note that a screening colonoscopy is carried out the same way as a colonoscopy for a symptomatic patient.
A variety of methods can be employed to remove polyps. Small and flat polyps (sessile polyps) are best removed with a biopsy forceps or snaring. Polyps with a stalk (pedunculated polyps) are best removed by snaring, akin to lassoing a bull. Both the biopsy forceps and snare can be either employed as a cold cut technique or be used in combination with diathermy for lower bleeding risk.
Large but flat polyps will require a specialised technique called EMR (Endoscopic Mucosal Resection) while large pedunculated polyps may need a clip to be placed across the stalk to prevent bleeding after snaring.
Colonoscopy allows polyps that are up to 2-3cm in size to be removed without needing to resort to major surgery.
At least 50% of the polyps in the colon and rectum are Adenomatous polyps. These polyps have the potential to develop into cancerous tumours if left to grow unchecked. By removing the polyps during colonoscopy, the risk of cancer change is effectively near to zero.
A colonoscopy is a safe procedure that is carried out as a day procedure.
A day prior to the scheduled colonoscopy date, bowel cleansing is needed. Bowel cleansing involves ingestion of bowel laxatives with subsequent passage of multiple episodes of stools. Drinking adequate fluids is essential to ensure adequate hydration.
On the day of the scope, sedation will be administered in the endoscopy room prior to starting the colonoscopy. After the patient is adequately sedated and in a semi-unconscious state, the scope is then introduced through the anus. The endoscopist will then manoeuver the scope, through a combination of angulating the flexible tip and gentle pushing pressure, to reach the caecum. The caecum is the first portion of the large intestine and the scope is then slowly withdrawn to allow careful inspection of the lining of the colon. Contrary to common belief, the inspection is done during withdrawal and not during insertion. Any polyps noted with be removed and any suspicious lesions will be biopsied. The colonoscopy procedure can be combined with ligation (tying up) of piles which is carried out at the end of the colonoscopy procedure.
A Colonoscopy is a very safe procedure. The overall serious complication risk is around 0.28%. The most serious complications of perforation and bleeding occur at a rate of 0.1% each. Other than being a safe procedure, the colonoscopy is also the most sensitive and accurate method of examining the colon, with a miss rate for significant lesions of less than 5%.