What is the likelihood of colorectal cancer in a 50-year-old male with a significant family history and a 10-year history of intermittent hematochezia?

From the Guidelines

I strongly recommend an urgent GI consultation for colonoscopy for this 50-year-old male patient due to his significant risk factors for colorectal cancer. The patient presents with two critical warning signs: a strong family history (two brothers who died from colon cancer) and a 10-year history of hematochezia (blood in stool) that varies between bright red and dark blood. These symptoms require immediate evaluation as they strongly suggest possible colorectal pathology. The bright red blood may indicate distal bleeding from hemorrhoids or anal fissures, while the dark blood suggests more proximal bleeding that could be associated with colorectal neoplasms. Given his age, family history, and prolonged bleeding symptoms, this patient should be categorized as high-risk and prioritized for colonoscopy, as suggested by the U.S. Multi-Society Task Force on Colorectal Cancer 1.

While awaiting the procedure, the patient should be advised to maintain a record of bleeding episodes, note any associated symptoms like abdominal pain or changes in bowel habits, and report any worsening symptoms immediately. A complete blood count should also be ordered to assess for anemia from chronic blood loss. Early detection through colonoscopy is crucial as it allows for both diagnosis and potential therapeutic intervention, including removal of precancerous polyps, which can significantly improve outcomes in high-risk individuals like this patient. The American College of Physicians also supports the importance of screening for colorectal cancer in individuals with risk factors, although their guidance is more focused on average-risk adults 1.

Key points to consider in the management of this patient include:

• The patient's family history of colon cancer in two first-degree relatives (brothers) who died from the disease
• The patient's 10-year history of intermittent hematochezia
• The importance of colonoscopy in the early detection and prevention of colorectal cancer in high-risk individuals
• The need for prompt evaluation and management to improve outcomes in patients with significant risk factors for colorectal cancer.

From the Research

Patient Presentation and History

• The patient is a 50-year-old male with a family history of colon cancer, having two brothers who died of the disease.
• He reports experiencing blood in his stools, sometimes bright red and sometimes dark, for the last 10 years.
• A GI consult for a colonoscopy has been requested for this patient.

Colonoscopy and Bowel Preparation

• Colonoscopy is the gold standard for visualization and diagnosis of conditions involving the colon and terminal ileum, and facilitates screening and prevention of colorectal cancer 2.
• Adequate bowel cleansing is essential for thorough visualization of the colon and successful detection of colon polyps 2, 3.
• Split-dose preparation is strongly recommended, and same-day preparation regimens are also supported by additional data 2, 3.
• The Boston Bowel Preparation Scale (BBPS) is a validated and reliable scale for evaluating cleansing quality, and documentation of preparation quality is essential to guide follow-up examination timing 2.

Bowel Preparation Regimens

• Polyethylene glycol (PEG) solution is commonly used for bowel preparation, and the use of PEG plus contrast medium has been shown to improve the quality of bowel preparation for CT colonography and conventional colonoscopy 4.
• A 2 L regimen may be sufficient for bowel preparation, and limiting dietary restrictions to the day before colonoscopy is recommended 3.
• The adjunctive use of oral simethicone for bowel preparation before colonoscopy is suggested, and routine tracking of adequate bowel preparation rates is recommended 3.

Patient Care and Procedure

• Colonoscopy is an invasive, endoscopic procedure used for diagnostic purposes, and patient care before, during, and after the procedure is crucial 5.
• Bowel preparation for colonoscopy and surgery can be achieved through mechanical and oral antibiotic preparation, although the current methods of bowel cleansing include sodium phosphate and polyethylene glycol 6.