By Tedler D. Depaynos, MD
malignancy. “
The patient celebrated his half a century birthday in his new beach resort and to introduce it to his friends and relatives, he maximized his invitation. Many of his guests enjoyed swimming so that some stayed for a few days. Celebration was then continuous. The patient enjoyed his spicy food which he admixed with pepper or the native “sili”. This he blamed again for his difficulty of moving due to enlargement of his “hemorrhoids”. Actually he experiences this whenever he excessively takes in his favorite “sili”, but because of the joyous happening he ignored his precautions. His problem however seems to be worse because whenever he forces himself to move his bowels, blood drips into the toilet bowl. And it was already more than two weeks and his “hemorrhoids” seem not to be subsiding. He usually does his usual hot sitz bath with “guava leaves” and recovery is usually uneventful. This time, however, there seems to be no recovery. It is unfortunate that the Covid problem suddenly occurred so that strict quarantine was implemented in his province. He was then forced to call his friend MD who referred him to a young colleague in the adjacent town connected to a provincial hospital.
The patient was diagnosed to have a 4th degree mixed internal and external hemorrhoids. When the hemorrhoids cannot be reduced inside the rectum it is 4th degree. When it could manually be reduced, it is 3rd degree. When it automatically is reduced after defecating it is 2nd degree. When it is still inside, it is 1st degree. 3rd and 4th degrees are the ones recommended for surgery. When this was advised to the patient, he immediately consented.
As a rule, however, most surgeons recommend visualization of the colorectal area to eliminate any tumor that may have caused the hemorrhoids prior to the surgery. For elderly surgeons, their visualization was limited by the rigid sigmoidoscope. At present the colonoscope which is made up of a flexible scope with a camera is being used. It has a suction that could clear the colorectal contents and could pump air inside to expand the colon for clear visualization. A biopsy could then be done to any mass that would be seen. The patient had no second thoughts in giving consent mainly because he trusted the young surgeon recommended by his friend. A colonoscopic examination was then done just before the surgical procedure.
There were no masses seen that could have caused the hemorrhoidal enlargement. A polyp at the descending colon was just identified and was excised for histopath examination. The hemorrhoidectomy which was done after was uneventful.
It was a week after when the patient returned for follow-up when the histopath result came out. The excised polyp contained a “malignant focus” and it seems that it did not penetrate the intestinal wall. It is not “poorly differentiated” and has no “vascular penetration”. In short, the identified malignant cells appear to be still confined in the polyp so that colonic surgery may not be needed yet. The young surgeon advised him, however, to undergo extensive medical work-up.
For malignant lesions in the abdominal cavity, metastasis is usually thru the intestinal draining veins or portal venous system which ends into the liver. Hence enlargement of the intestinal nodules and liver nodules when seen could be interpreted as metastasis. They usually are seen first before any other metastatic sites like in the lungs. He underwent ultrasound, CT Scan and even MRI because he cannot imagine himself taking care of a malignant lesion. Even though they were all negative, he wants to have them repeated in another medical center and to seek another opinion for his peace of mind as advised by his surgeon friend. He even borrowed the histopath slides for rereading.
As he prepared for his trip during this quarantine period, he keeps on remembering the advice of his friend surgeon that a routine esophago-gastro-doudenoscopy and colonoscopy should be done before your 50th birthday or better 5 years earlier especially if you have a relative that had a history of malignancy. Most intestinal malignancies have no signs and symptoms during their early stages when they are still curable. Although he suffered pain from his hemorrhoidal problem, he was also thankful that it was a blessing in disguise because it led him to the early diagnosis of his impending colonic malignancy.**
