Oncology (General Cancer)/Recurrent symptoms
I'm a 32-year-old male, 6'2", 162 lbs, with the following medical history.
10+ years of stools coated and slightly mixed with dark red bloody mucus. Severity increased gradually. No pain, diarrhea, etc.
My GP thought the chance of a serious condition to be negligible and attributed my symptoms to an anal fissure which is occasionally active. Internal hemorrhoids were not found on several digital rectal exams.
December 2011, I passed a lump of tissue, about 6mm in size. I was very wary of this, saved it in the fridge and showed it to my GP. The tissue was found to be adenomatous and showed high grade dysplasia.
Colonoscopy revealed a pedunculated adenoma, about 30mm in size, at 35cm from the anus. The adenoma was resected piecemeal by snaring (two parts).
I was later told that they were unable to retrieve the first part--it was lost in the colon.
The second part, which was attached to the stalk, was analyzed and showed a substantial area of high grade dysplasia. Resection surface at the stalk was found to be clean.
Two small sessile polyps were also removed but were not sent in for analysis.
Follow-up colonoscopy was to take place after 3 years.
Following the procedure I was symptom-free for about 8 months.
In September 2012, I started noticing symptoms similar to before: dark red/brown mucus covering the stool and also in between parts of the stool. The amounts are smaller than before. I've been experiencing these symptoms the past 2 months.
A colonoscopy was performed but no abnormalities were seen. The anal fissure was noted to be inactive.
No stalk remnant was seen at the approximate site of polypectomy. My doctor said that it had probably retracted.
He believes the anal fissure to be the likely cause of my symptoms and referred me back to my GP for treatment of the fissure.
I have some trouble understanding how an inactive fissure can be responsible for my current symptoms, particularly how the mucus would end up between parts of the stool.
My main concern is the possibility that a recurrent lesion could instead be responsible, which may have been missed during the recent exam.
A number of “unknowns” contribute to this concern (as you can probably tell I've done a little reading about my condition):
* The origin of the adenomatous tissue passed in the stool is not certain, although it is likely the subsequently removed adenoma.
* With part of the adenoma passed in the stool and another part being lost, the histological image was incomplete. One article suggests a substantially lower accuracy for grading large and/or incomplete polyps and, as such, areas of HGD and invasive carcinoma can be missed. ( http://ajcp.ascpjournals.org/content/116/3/336.full.pdf
* The site of polypectomy was not “tattooed” for later inspection.
* The two small sessile polyps were not analyzed.
I would really appreciate your opinion on my case.
I realize I may be too vigilant, but on the matter of (potential) malignancy I'd rather be safe than sorry.
Finally I would like to thank you for the time and effort you spend answering these questions. You are doing people a great service.
The passage of blood tinged mucus for ten years or more suggests to me that you might have low grade ileitis or colitis, and your doctors have been diverted by the presence of the fissure. Fissures can be associated with blood, but usually large amounts of mucus point elsewhere. And your story suggests that the fissure was inactive the last time anyone looked. As for the polyps, if you were rendered free of polyps and cancer was not detected, your doctors are right in recommending another exam in three years. This is because it takes at minimum about five years for a polyp to transform into a cancer, and with a negative colonoscopy and no history of polyps, the recommendation is changing to every ten years. The last colonoscopy being clean really is a dead end; if there are no abnormalities that can be seen, further analysis of the situation can't really be done. The fact that a piece of the polyp was lost is unfortunate, but again, nothing can be done about it at this point. And finally, it isn't common to tatoo the base of a polyp if it was easily snared and removed. Knowing how far past the rectum it was seems sufficient for careful inspection. Sessile polyps are generally not analyzed, as they are not malignant, and if completely removed, shouldn't be a problem.
In summary, at this point you don't have cancer of the colon; and the blood/mucus stuff you are passing may be due to some other condition. I would recommend that you add a dose of citrucel or metamucil or something like that to your regimen, to keep the stool very soft. Over time, the fissure should heal, and if it does, you've eliminated that.
Hope this helps.