Small & Large Intestine

What are colon polyps?

Colon polyps are tiny growths that form on the inside (mucosa) of the colon. They do not usually cause symptoms. But some polyps can contain or become cancer, therefore polyps should be removed.

Why do polyps develop?

Risk factors for colon polyp development include a family history of colon polyps or colon cancer, increasing age, a diet high in fat and red or processed meat and low in fiber, cigarette smoking, alcohol and obesity.

What types of colon polyps exist?

Colon polyps are divided into 2 main types: serrated polyps (also called hyperplastic) and adenomas (Figures 1-5). Both may advance over several years to cancer (Figure 6).

Figure 1
Figure 2
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Figure 4
Figure 5
Figure 6

How are colon polyps diagnosed?

The best test to diagnose colon polyps is colonoscopy. Moreover, colonoscopy enables polyp removal usually at the same session, thus eliminating the future risk for colon cancer development. 

What happens after I have polyps removed?

In some people polyps may come back, so you might need to have a colonoscopy every few years. The recommended interval depends on the type, size and number of removed polyps. If the polyps you had removed were of the precancerous type, people in your family might need to be checked for polyps and colon cancer, too.

At what age does screening for polyps begin?

In average risk persons CRC screening begins at age 50 years (men and women). In those at high-risk (see above) it begins earlier and is more frequent.

How common is colorectal cancer (CRC)?

CRC is the third more commonly diagnosed cancer in both sexes and the second cause of cancer death. Each individual has a 5% lifetime risk of CRC development and men have a 25% higher incidence than women.   

What are the CRC risk factors?

Positive family history or personal history for CRC or colon polyps,  increasing age, a diet high in fat and red or processed meat and low in fiber, cigarette smoking, alcohol and obesity are risk factors for CRC. Those suffering from IBD (inflammatory bowel disease) or hereditary polyp syndromes are also at increased risk.

How does CRC develop?

Most CRC develop from pre-existing precancerous polyps (Figure).  There are two types of polyps: adenomatous and serrated (also called hyperplastic). Both can become cancerous over time. However, this progression may take approximately 10 years in most cases.


How does CRC present?

CRC may remain asymptomatic in the initial stages. Alarm symptoms include the following: rectal bleeding, anemia, persisting alteration in bowel habits (diarrhea or constipation), a sense of incomplete defecation, abdominal pain and weight loss.

How can I reduce my risk of developing CRC?

In 2 ways: a) following a healthier lifestyle and b) adhering to the available CRC screening programs, including colonoscopy.

What lifestyle modifications are helpful?

Increase in physical activity, increased intake of fruits and vegetables, low-fat diet, decreased red meat intake, avoidance of tobacco and alcohol consumption, adequate blood glucose control for diabetics and management of obesity.

Are there any drugs that reduce the possibility of CRC development?

A variety of drugs is under investigation. Among them aspirin and NSAIDs seem to be effective in preventing the development of colon polyps and CRC. Other agents include statins, hormonal replacement therapy after menopause, bisphosphonates etc. Nevertheless, no recommendation for pharmaceutical CRC prevention in average-risk individuals is available.

At what age does CRC screening begin?

In average risk persons CRC screening begins at age 50 years (men and women). In those at high-risk (see above) it begins earlier and is more frequent.

What are the available CRC screening modalities?

According to international guidelines, CRC screening can be accomplished with one of the following examinations: a) colonoscopy every 10 years (if the index examination reveals no polyps), b) flexible sigmoidoscopy every 5 years, c) CT (“virtual”) colonoscopy every 5 years, d) stool tests (including gFOBT, FIT and DNA test) every 1, 1 and 1-3 years.

Why colonoscopy performs better than the other methods in CRC screening?

During colonoscopy your doctor inspects carefully the entire colon, while you remain under sedation. The most important advantage of colonoscopy is that it enables polyp removal usually at the same session, thus eliminates the future risk for CRC development.

How common is colorectal cancer (CRC)?

CRC is a frequent disease that may be potentially lethal. An average individual has a 5% chance to develop CRC. That means that about 1 person out of 20 will be diagnosed with CRC during their life. This risk is even greater for those who have a first degree relative with CRC or another malignancy, such as uterine, stomach, pancreatic or urinary tract cancer. Other risk factors for CRC include high consumption of red meat and fatty foods, smoking, alcohol and obesity.

Are there any preventive measures for CRC?

In the vast majority of cases CRC develops on preexisting polyps (Figure). These represent a growth or protrusion on the inner part of the intestine. They usually do not produce any symptoms but can be identified during colonoscopy (see «Colonoscopy»).

Numerous studies have shown that removal of these polyps with colonoscopy protects from future CRC development (see  «Endoscopic polypectomy»). On this basis, several large scientific medical associations (including the American Medical Association and the American Cancer Society) recommend screening colonoscopy as an effective tool for CRC prevention.

Preventive methods other than colonoscopy also exist (see«Colorectal cancer» in Diseases Section). However, only colonoscopy offers both diagnosis and therapy, i.e polyp removal.

Figure 4

Who should be offered a colonoscopy?

If only individuals with a family history of CRC or colon polyps underwent screening colonoscopy, 60% of CRC cases would be missed. That is the reason why everyone should be screened for CRC, even if no symptoms are present. Colonoscopy for CRC screening is performed to remove any polyps, including small and asymptomatic ones.

At what age should CRC screening be started?

Given that most cases of CRC present after the age of 55 years and the transformation of a polyp to cancer needs approximately 8-10 years, international medical societies suggest CRC screening initiation at the age of 50 years. If a person has worrisome symptoms or a positive family history for CRC or its related cancers, screening should be started at an earlier age. The exact recommendation will be provided by an expert gastroenterologist in order to avoid unnecessary endoscopies at young ages.

What is irritable bowel syndrome?

Irritable bowel syndrome, or “IBS,” is a condition that causes belly pain and problems with bowel movements (diarrhea or constipation, or alternating diarrhea and constipation).

Is IBS frequent in the general population?

IBS may affect up to 15-20% of the population. Women suffer twice as frequently as men, while IBS becomes infrequent after the age of 65 years.

What causes IBS?

A lot of causes have been proposed. These include stress and psychosomatic disorders, abnormal gut-brain interaction, alteration in gut bacteria, and dietary factors.

Is there a test for IBS?

No specific test for IBS exists. Your medical history and a careful physical examination may guide your doctor to the IBS diagnosis. Sometimes your doctor may recommend blood tests, an abdominal ultrasound or even gastroscopy or colonoscopy to check for other possibilities.

Are there any complication?

IBS causes no complications. Furthermore, there is no assocciation between IBS and cancer. However, it may affect your quality of life.

How is IBS treated?

The first step is to stop eating foods that might be making your IBS worse, including dairy products, fatty foods and possibly carbohydrates. Physical exercise also seems to improve the symptoms. For those suffering from constipation, an increase in dietary fiber intake, as well as laxatives may help. Anti-diarrhea agents may improve those with diarrhea. Moreover, some antibiotics, probiotics, antispasmodics or even antidepressants are sometimes indicated for symptomatic relief. Nevertheless, it is most important to establish good communication with your doctor so as to find the best approach that works for you. Rest assured that IBS is a benign, functional chronic condition and try to avoid unnecessary tests and treatments.

What is celiac disease (gluten sensitivity)?

Celiac disease refers to the intestinal damage caused by a protein called gluten.

What are the symptoms of celiac disease?

Many people have no symptoms. When symptoms do develop, they include diarrhea, weight loss, bloating, abdominal pain, oily stools and slow growth in children. It is also associated with iron deficiency anemia, osteopenia/osteoporosis as well as other extraintestinal manifestations such as hypothyroidism, diabetes mellitus, skin rashes, liver disorders, neurologic disorders etc. 

Is there a test for celiac disease?

Celiac disease is diagnosed with a special blood antibody test and is confirmed by upper gastrointestinal endoscopy with biopsies from the duodenum.

How is celiac disease treated?

The main treatment is to stop eating gluten completely. Common foods that contain gluten are bread, pasta, pastries, sauces and beer. Consultation with a dietician is recommended. Your doctor might also prescribe vitamins to make up for nutrients that you have not been getting from food or are in deficiency due to disease-related malabsorption.

What does the term inflammatory bowel diseases (IBD) refer to?

The term IBD encompasses two distinct diseases, namely Crohn’s disease (CD) and ulcerative colitis (UC). Both are characterized by chronic inflammation of the digestive tract. UC involves only the colon, while CD may affect any part of the digestive tract from mouth to anus.

Who may develop IBD?

IBD is more common in the developed countries and affects equally both sexes. Their etiology is unknown, although several genetic and environmental factors are considered responsible. A minority of IBD patients have positive family history of either CD or UC.

What are their symptoms?

UC is associated with rectal bleeding, while CD with abdominal pain, diarrhea and development of strictures, fistulas and abscesses. Extraintestinal manifestation including arthritis, eye lesions, skin lesions etc. may also accompany both entities.

How are they diagnosed?

IBD diagnosis involves several examinations including endoscopy with biopsies, blood and stool tests (Figure 1, 2).

Figure 1
Figure 2

How is CD and UC treated?

There are many different medicines that can help to reduce the symptoms and provide long-term relief. They include anti-inflammatory agents (i.e. mesalamine), steroids, immunosuppresants (i.e. Azathioprine) and newly-developed biologic agents (Remicade, Humira, Entyvio). Under special circumstances, surgical management is indicated. Dietary therapy alone is not effective, although dairy products and fiber should be avoided during exacerbations.

What if I have IBD and I want to get pregnant?

In most cases, these diseases do not affect a woman’s fertility. If you want to get pregnant, talk to your doctor before you start trying so you get the tests you need before and during pregnancy. Drug modification may also be necessary.

How will my life change after CD/UC is diagnosed?

Nowadays, there are a lot of effective drugs available that help in symptom control and remission maintenance. A close relationship with the gastroenterologist is of great importance and most people continue to lead normal lives. Of note, you do not need to undergo endoscopies often but only attend your regular follow-up visits.

What is microscopic colitis?

Microscopic colitis is an inflammatory condition of the colon that causes chronic watery diarrhea. There are 2 types of microscopic colitis, lymphocytic colitis and collagenous colitis. Both types cause the same symptoms and are treated the same way. The etiology of microscopic colitis is not fully understood.

Who is at risk and what are the symptoms of microscopic colitis?

Microscopic colitis affects most commonly middle-aged persons, especially women. Its characteristic symptom is chronic watery diarrhea.

How is it diagnosed?

Microscopic colitis is diagnosed with biopsies taken from several parts of the colon during colonoscopy. The appearance of the colon during colonoscopy is surprisingly normal, but biopsy examination reveals the diagnosis.

How is microscopic colitis treated?

Microscopic colitis treatment involves the following: a) discontinuation of possible offending agents (e.g. drugs), b) dietary modifications, c) anti-diarrheal medication, and d) steroid (i.e. budesonide) administration. It is noteworthy that microscopic colitis is a chronic condition that often requires long-term treatment, given that symptoms may come back after treatment is stopped.

What are diverticula of the colon?

Diverticula are sac-like protrusions of the colonic wall. Diverticulosis merely describes the presence of diverticula (Figure 1).

Figure 1

What factors cause diverticula?

Contributing factors include aging, low-fiber diet, obesity and lack of physical activity.

What are the associated symptoms?

The majority of people with colon diverticula never have symptoms – only a small minority develop a complication (i.e. diverticulitis, bleeding). Diverticulitis is characterized by lower abdominal pain and fever, while bleeding from diverticula is painless (Figure 2). 

Figure 2

How are diverticula diagnosed?

Most often diverticula are diagnosed incidentally during colonoscopy or CT of the abdomen.

Is there any risk for cancer?

Absolutely not.

How are diverticula treated?

Asymptomatic diverticula (diverticulosis) does not require treatment. However, most clinicians recommend increasing fiber in the diet, which can help to bulk the stools and may prevent the development of new diverticula, diverticulitis, or bleeding. We do not suggest that patients avoid seeds, corn, or nuts.

What is acute diverticulitis?

Acute diverticulitis is a condition that occurs due to inflammation of colonic diverticula (Figure 1). Diverticula are small pouches in the colon wall, especially in the lower left area (sigmoid).

Figure 1

What are the symptoms of acute diverticulitis?

Abdominal pain, fever, and problems with bowel movements.

What causes acute diverticulitis?

The cause of acute diverticulitis is not clear. Diet is possibly not involved. An association with non-steroidal anti-inflammatory drugs has been suggested.

Is there a test for acute diverticulitis?

Your doctor might be able to diagnose it by history and physical examination. An abdominal CT scan confirms the diagnosis (Figure 2).

Figure 2

How is acute diverticulitis treated?

If you have mild symptoms, your doctor may place you on a clear liquid diet for a short time, and may prescribe antibiotics. For more severe symptoms you might need to stay in the hospital in order to receive fluids and antibiotics intravenously. If you develop an abdominal abscess the doctor might put a tube into your belly to drain the infection. Rarely, surgical removal of the affected part of the colon may be necessary.

What comes after an episode of acute diverticulitis?

A few weeks later, your doctor may recommend that you undergo a colonoscopy. Contrary to popular belief, there is no need to strictly avoid seeds, nuts, popcorn, or other similar foods longterm, though moderating their intake may be wise.

What is constipation?

Constipation is a condition that makes it hard to have bowel movements. The patient may experience various symptoms including hard stools, difficulty passing stool, fewer than 3 movements per week, excessive straining during defecation, sense of incomplete defecation or even application of several manipulations to help stool get out.

What causes constipation?

Several factors may be responsible, including low-fiber diet, limited fluid intake, no physical activity, and several drugs (e.g. antidepressants, opioid analgesics, iron supplements, some antihypertensives etc.). Constipation is very common above a certain age, as the bowel tends to ‘gets lazy’ with decreasing activity. Other medical conditions, such as diabetes mellitus, hypothyroidism, Parkinson’s disease, irritable bowel syndrome, or colorectal cancer may also account for constipation.

How is constipation diagnosed?

A detailed personal medical history and physical examination are the cornerstone of diagnosis. In some cases your doctor may ask for further work-up including blood tests, flexible sigmoidoscopy or colonoscopy, radiologic tests and colon functional tests

Should I see a doctor?

You should see a doctor if the symptoms are new or uncommon to you, if you have not emptied your bowels for a few days, you are in pain, you have symptoms like bleeding, weakness, weight loss, fever or you have people in your family with colon cancer or polyps.

How is constipation treated?

Management of constipation includes dietary and lifestyle modifications (increased fluid and fiber intake, encouragement of physical activity), drugs (either swallowed or suppositories/enemas), biofeedback and extremely rarely surgery. Conditions that are responsible for constipation should be also treated. The gastroenterologist is able to suggest the appropriate strategy for each patient.

What are hemorrhoids?

Hemorrhoids are enlarged veins in the lower rectum. They are part of the mechanism that prevents the involuntary leakage of stool (Figure).


What does the term hemorrhoidopathy refer to?

It refers to the problems that develop when hemorrhoids are enlarged or prolapse through the anal canal, being susceptible to injury, bleeding or thrombosis.

Which factors predispose to hemorrhoidopathy?

The main predisposing factors are chronic constipation and pregnancy.

What are the clinical manifestations?

The most common is painless bleeding which is usually associated with a bowel movement, although it can also be spontaneous. The blood has bright red color and coats the stool at the end of defecation or may drip into the toilet. Other symptoms include itching of the perianal skin, mild leakage of rectal contents and a palpable lump in the area. In case of thrombosis this lump is associated with intense pain.

Are hemorrhoids dangerous?

Hemorrhoidopathy is not a dangerous condition. In very rare cases bleeding hemorrhoids may lead to iron deficiency anemia. However, exclusion of other causes of anemia should be first performed. An anoscopy or flexible sigmoidoscopy is indicated for patients over 40 years.

How can hemorrhoidopathy be treated?

Several conservative and surgical methods exist.

The most effective conservative measures are sitz baths (warm saltwater baths) and treatment of constipation. Numerous ointments are available without prescription and may provide some relief in some patients. However, long-term application of cortisone-containing ointments should be definitely discouraged.

Surgical management is only rarely indicated. One should also take into account that hemorrhoidopathy may recur after surgery and therefore carefully weigh the risk and benefits from such an intervention.

What is an anal fissure?

An anal fissure is a tear in the lining of the anus, which can cause pain and bleeding, especially during a bowel movement.

What causes anal fissures?

Most commonly, an anal fissure is caused by passage of hard, dry stool.

What are the symptoms of an anal fissure?

Most people who have an anal fissure feel a tearing or burning pain during a bowel movement. This pain can last for hours thereafter. They may also see bright red blood on the toilet paper or on the surface of the bowel movement. Itching or irritation around the anus may also occur.

How is a anal fissure diagnosed?

A gastroenterologist can check whether you have anal fissure by gently spreading your buttocks apart and examining the anal canal (Fissure). In case of bleeding he may suggest a sigmoidoscopy or colonoscopy. However, if you are in a lot of pain it is better to wait until the pain subsides in order to proceed with such examinations.


How are anal fissures treated?

You will need to increase the dietary fiber intake and possibly use a stool softener so as to treat the co-existing constipation. Sitz baths are also of great importance (1 to 2 times daily, for 15 to 20 minutes each) – these are warm baths in salty water. Sometimes the gastroenterologist may prescribe cream containing nitroglycerine, Botox injections or even surgical management.