From the Guidelines
I strongly recommend proceeding with the GI consult for colonoscopy for this 50-year-old male patient, as this is clearly indicated based on his risk factors. The patient has multiple high-risk features that warrant immediate evaluation: a significant family history with two brothers who died from colon cancer, and a 10-year history of intermittent hematochezia (blood in stool) that presents as both bright red and dark blood. While waiting for the colonoscopy, the patient should be monitored for worsening symptoms such as increased bleeding, abdominal pain, weight loss, or changes in bowel habits. The patient should be instructed to maintain adequate hydration and report any new symptoms immediately. The presence of both bright red blood (suggesting a distal source like hemorrhoids or rectal lesions) and dark blood (suggesting a more proximal source in the colon) is particularly concerning when combined with the strong family history.
Key Considerations
- The patient's family history of colon cancer in two first-degree relatives (brothers) increases his risk of developing colorectal cancer, as noted in the guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer 1.
- The patient's symptoms of intermittent hematochezia for 10 years also warrant further investigation, as they may indicate the presence of a colorectal lesion or other gastrointestinal pathology.
- Colorectal cancer screening would normally begin at age 45 for average-risk individuals, but this patient's symptoms and family history make him high-risk and require prompt evaluation regardless of screening guidelines.
- The colonoscopy will allow for direct visualization of the colon, identification of any lesions, and biopsy of suspicious areas if needed.
Recommendations
- Proceed with the GI consult for colonoscopy as soon as possible.
- Monitor the patient for worsening symptoms while waiting for the colonoscopy.
- Instruct the patient to maintain adequate hydration and report any new symptoms immediately.
- Consider the patient's family history and symptoms when interpreting the results of the colonoscopy and developing a plan for future surveillance or treatment.
From the Research
Patient Presentation
- The patient is a 50-year-old male with a family history of colon cancer, reporting that both of his brothers died from the disease.
- The patient presents with a 10-year history of blood in the stools, sometimes bright red and sometimes dark.
- A GI consult for a colonoscopy has been requested for this patient.
Indications for Colonoscopy
- Colonoscopy is an invasive, endoscopic procedure used for various diagnostic purposes, including the detection of colon cancer 2.
- The patient's family history of colon cancer and symptoms of blood in the stools are indications for a colonoscopy.
- Elevated carcinoembryonic antigen (CEA) levels can also be an indication for colonoscopy, especially in patients with a family history of colon cancer 3, 4.
Role of Carcinoembryonic Antigen (CEA)
- CEA is a tumor marker that can be elevated in patients with colorectal cancer 3.
- Elevated CEA levels can indicate advanced or metastatic disease, and failure of CEA to return to normal after surgery can indicate residual or recurrent disease 3.
- However, measurement of CEA levels alone is not sufficient to improve survival rates, and its use as a screening tool for colon cancer is limited 5.
Colonoscopy in Patients with Elevated CEA Levels
- Colonoscopy should be recommended for healthy subjects with an elevated level of CEA accompanied by anemia, as anemia is an independent predictive factor of CRC in this group 4.
- The incidence of CRC is higher in patients with elevated CEA levels than in those with normal CEA levels, and patients with elevated CEA levels are more likely to be diagnosed at advanced stages 4.