polyps

Knowing your limits is a very important part of doctoring. As Mark Twain said, "Good decisions come from experience. Experience comes from making bad decisions." Tackling big polyps with the scope is no exception to this rule. Although techniques for removing large polyps have evolved over the years, and maneuvers that were once deemed "high-risk" are now being taught fairly routinely to junior GI fellows, there is still an individual comfort level that practitioners should identify in themselves and respect.

I was surprised when the pathologist called me a few days later about the patient, since pathologists usually only call when a result is malignant or unusual. This "polyp" which I estimated to be about 15-mm in greatest diameter was a serrated adenoma (not a surprise) but also contained an 8-mm focus of adenocarcinoma. Luckily, the carcinoma portion of the polyp was completely resected with clear margins on all sides, however this polyp was truly an early-stage colon cancer!

This lesion exhibits the "mucus cap" sign. There is a thick layer of mucus adherent to the polyp that remains attached even after washing with the water jet on the scope. The mucus cap sign is often seen with a particular type of polyp called a serrated polyp. These are often located in the right side of the colon, and are thought to be easier to miss on colonoscopy due to the flat nature of their growth. Unfortunately, they can still transform into colon cancer.

Overtesting and over treatment are big problems in modern medicine. It sometimes goes like this: Have a minor complaint? It's probably nothing, but we should do an exhaustive workup because there is a 0.00001% chance it could be cancer, maybe. However,

Many lesions that have been deemed "not endoscopically resectable" can actually be safely removed by a gastroenterologist with training and experience in EMR.

The adenoma detection rate (ADR) is currently the best "report card" for colonoscopy performance available. All doctors that perform colonoscopy are not equally good at it. All endoscopists should be measuring their own individual ADR, and working to push that number higher and higher.

This is a flat polyp. It’s about the size of a dime or so. This was found on a routine colonoscopy in the ascending colon. The patient had an excellent bowel prep. Colonoscopy has been shown to prevent colon cancer by detecting and removing polyps which are known to be precancerous (known as adenomatous polyps).  … Read more