S02_E05 - Yep, We’re Talking About Your Colon...

Speaker 1: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:20

Hey everybody, it's Dr. David Hilden. Welcome to episode five. And as you know, if you've been listening to this podcast on this show, we talk about everything today, we're gonna prove it as we talk about your colon, otherwise known as your large intestine. To help me out, I have Dr. Jake Matlock on the show today. He is the director of the Division of Gastroenterology at Hennepin Healthcare and a colleague of mine for over 20 years. Jake, welcome to the show. Yeah, it's a

Speaker 3: 0:47

Pleasure. Thanks for having

Speaker 2: 0:47

Me. So you're a gastroenterologist. Why should people care about their intestines? What can go wrong?

Speaker 3: 0:51

So, you know, your intestines are actually the one of the most amazing organs in your body, in my opinion. Uh, and I like to tell my patients that the colon is the organ that's responsible for modern human society

Speaker 2: 1:03

<laugh>. Okay, you're gonna have to expand on that.

Speaker 3: 1:07

So your, your intestinal tract provides about three liters of liquid waste to your colon every day. And your colon is responsible for taking that three liters of liquid waste and converting it to a small volume of solid stool and providing you the opportunity to eliminate that stool on a voluntary basis without your colon. We'd be like birds, we'd be just constantly leaking stool whenever we were walking around in the day, and we wouldn't be able to get anything else done. So without your colon, modern society wouldn't exist.

Speaker 2: 1:37

And I absolutely love that we're gonna geek out about your colon and stool today. You know, I never really thought of it that way, but you know, it actually does make life a little bit more manageable since it, uh, your whole digestive system is something sort of under your control.

Speaker 3: 1:49

Yeah, yeah. Without, without your colon, you'd be walking around, uh, constantly looking for water cuz you'd be dehydrated all the time from losing all that fluid and, uh, constantly pooping. Okay.

Speaker 2: 1:58

So most of us haven't thought about our intestines in that way. Let's talk about what could go wrong.

Speaker 3: 2:04

So the thing that people, I think hear about the most with your colon is, is colon cancer. And colon cancer is obviously a, a very important topic. Uh, it's the third leading cause of cancer in both men and women in this country. Uh, and does get a lot of attention in the media for folks who are younger. Uh, we often, uh, have difficulty with, uh, inflammation in the colon. There are a variety of different inflammatory disorders that can, uh, impact the colon. And then there's a whole class of problems that the colon can, can suffer from that don't really shorten your life or end your life, but can make things kind of miserable along the way. And here I'm thinking about, uh, issues like chronic constipation or chronic diarrhea of a non-inflammatory state that, you know, again, don't kill you, but can make you pretty miserable. And, and, and which we can help people

Speaker 2: 2:52

With. I would say those are issues that make people extremely miserable. I hear, I hear it about it all the time, both in the hospital and in the clinic. If people's bowels aren't working, it's a daily fact of life that is more than bothersome.

Speaker 3: 3:05

Absolutely. Yeah. I mean, it's a, it's a huge quality of life impact if a person's bowels are not working in a way that, uh, that kind of meets their expectations.

Speaker 2: 3:13

So you mentioned colon cancer, and I think we will focus on a little bit, uh, of that today because, you know, you're the guy that people go to see to get the colonoscopy. Ta talk a little bit, if you could, about colon cancer. How common is it and, uh, what people should know about screening?

Speaker 3: 3:28

So it is, it is a very common form of cancer. Uh, you know, as I mentioned, it's the third leading cause of cancer in this country among both men and women. It's a common misconception that it, that there is a, a significant gender predominance, uh, and that it's more of a male problem than a female problem. That's absolutely not true. So I hope that, that, uh, if there's any myth that we can dispel today, uh, it's an equal opportunity. Uh, uh, cancer, the estimates are that if you don't do anything to protect yourself from it, if you don't do any screening, that roughly 8% of people will get cancer. So about one in 12, uh, will get colon cancer in their lifetime with effective screening that's less than 2% and less than 1% will die from it with effective screening. And so, uh, I think the message there is that screening, although imperfect works, it's effective at reducing your risk. I would encourage everybody to engage with their doctor on

Speaker 2: 4:25

It. That's a dramatic drop actually, from doing nothing to doing some screening. You can. So it's sort of a good news story in that there is something you can do to, uh, reduce your risk.

Speaker 3: 4:36

Yeah, I mean, and we, we continue to refine the recommendations about who and when and how screening should be done. But I think the take home message is that the important thing is to do it, uh, regardless of how you do it, get it done. Uh, and, and, and that's the most effective way to protect

Speaker 2: 4:53

Yourself. When you say screening, what do you mean? So the

Speaker 3: 4:55

Variety of different screening modalities that are used for colon cancer, I think the one that, that everybody thinks about and everybody's heard of is colonoscopy. And that that still remains the gold standard screening method. However, there are other methods that are available, uh, and, uh, that some people might consider depending on their risk factors and discussion with their own, uh, healthcare provider. The least invasive, uh, testing methods are, are stool-based tests. Uh, so we can take a sample of someone's stool to look for markers in their stool that might indicate that they have either a pre-cancerous condition or a, an actual cancer. The advantage of these stool-based tests is that they're non-invasive. They're fairly easy to do. Uh, they're very effective if done correctly, and at their appropriate frequency. The disadvantage of them is, number one, you do have to do them more often anywhere from every one year to every three years. And if they come back positive, well then you have to follow it up with a colonoscopy to, to figure out what the issue is, what's tripped to the positive test and what you're gonna do about

Speaker 2: 5:58

It. And these tests, I i order these all the time for patients who have elected to go that route. And there's a misconception, this isn't like bringing a large sample<laugh>. I know, I know this is a lovely conversation, but you know, it's, we gotta talk about it. It isn't, you, you put a little teeny bit and you put it on a card and mail it, don't

Speaker 3: 6:16

You? Yeah, I mean, that, that's true for, uh, for several of the tests, uh, the, the I fob and the FIT test mm-hmm.<affirmative>, uh, there is a slightly more involved one called the Cologuard, which, uh, does involve producing a larger sample for, uh, analysis. But again, all of them are non-invasive tests. Uh, they don't involve any, uh, additional visits to a healthcare facility. They don't involve anything going into you or, or touching you if that is a, an, an issue for you. Uh, again, the, the major limitation that we see of these tests is that people don't perform them at the appropriate frequency. People are people, they let it slide, and if you don't do them at the right, uh, frequency than they really aren't very effective.

Speaker 2: 6:59

So that's one option. What are the other options?

Speaker 3: 7:02

So, uh, again, the other major option is, uh, colonoscopy, which, uh, we perform all day every day here at Hennepin and, and at, at other healthcare facilities around the, the cities and the country. Uh, colonoscopy offers the advantage of offering a longer horizon of benefit, I guess I would say. So you, you don't have to do colonoscopy nearly as often as these other tests for people at average risk, the recommended interval is every 10 years. So it it, if you have a normal colonoscopy, you can, you can take that off your plate and not think about it for a decade. Obviously, if you have findings that are of concern, your doctor might recommend a more frequent, uh, evaluation. But, uh, it, it, it is a, a little bit easier in terms of keeping track of the logistics. The thing that is of concern to people for colonoscopy is, is more invasive. It is more involved, uh, than a stool test. Uh, it does involve doing a preparation to clean out your colon. It involves a scope going in through your rectum and, and, and all the way to the top of the colon, uh, involves an extra visit to the, um, uh, a healthcare provider. It involves, uh, sedation usually for most people and, and a driver to get you home. So it's, it's a little bit more complicated on the front end, but does provide a longer benefit.

Speaker 2: 8:19

When should people start doing these tests?

Speaker 3: 8:21

So the guidelines have recently changed on that. Uh, historically we've recommended starting at the age of 50 for people who are at average risk,

Speaker 2: 8:30

Which is most people, right?

Speaker 3: 8:31

Right. Average risk just means don't have a close family member who has colon cancer or has colon polyps. However, guidelines have recently shifted, and we've started to recommend starting at age 45. And that's because of a recognition that the demographics of colon cancer do seem to be shifting to involve a younger population of people.

Speaker 2: 8:49

Why might that be? Do we know, uh, if,

Speaker 3: 8:52

If, if somebody knows they haven't told me<laugh><laugh>, I, uh, you know, you, you could point to to diet, you could point to exercise, you could point to all sorts of environmental risk factors that might be in play. But I think the short answer is we don't know. So

Speaker 2: 9:06

If you're average risk, you're in your mid forties, it's time to start thinking about it. I

Speaker 3: 9:10

Think that's a safe thing to say. Yeah.

Speaker 2: 9:11

What about if you are mom or your dad or your brother, your sister had problems in their colon?

Speaker 3: 9:16

If you have a, a family history of colon cancer and the, the most important family history is, is in your first degree relatives. And, and by that we mean mom, dad, or siblings, uh, then you should start screening earlier, how much earlier? Depends on what they had, when they had it, and how many of them had it. So it's a bit of a complex discussion, but definitely worth bringing up with your primary care provider if that is an issue for you. Once you get out to second degree relatives, grandparents, aunts, uncles, cousins, that can be important. But it, it only is germane if it involves multiple family members in that second tier. So if you do have a family member with, uh, colon cancer or colon polyps, it's definitely worth mentioning to your, uh, primary care provider because it, it will impact your risk. But whether it changes the recommendations really depends on the particulars of your, your situation.

Speaker 2: 10:08

So you've mentioned the word polyp in addition to the word cancer. What's the difference? So

Speaker 3: 10:14

A polyp is a small growth coming off the lining of the colon. It is the thing that over time grows and eventually turns into colon cancer. So polyps are the precursors to colon cancer. And in people who do not have underlying inflammatory conditions of their colon, we believe that it is the sole pathway for the development of colon cancer. Oh,

Speaker 2: 10:36

So they don't, cancers don't arise from anything else, correct. From the polyps,

Speaker 3: 10:40

Yeah. So, so by identifying polyps, which we can again, do either with stool-based tests or with colonoscopy, and by taking them out, which we can do with colonoscopy, we can protect you from getting colon cancer.

Speaker 2: 10:51

So you can prevent it. We

Speaker 3: 10:53

Can, and again, the, the, the strategy is not a hundred percent effective, but you know, as we were talking about earlier, it is highly effective at reducing your risk and preventing you from developing colon cancer.

Speaker 2: 11:04

We're gonna take a quick break, and when we come back, we'll resume our conversation with Dr. Jake Matlock, director of the division of Gastroenterology at Hennepin Healthcare, and one of the best medical educators I know. When we come back, we're gonna resume the conversation. Stay with us.

Speaker 1: 11:20

You are listening to the Healthy Matters podcast with Dr. David Hilton. Got a question or comment for the doc, email us at Healthy Matters hc m e d.org, or give us a call at six one two eight seven three talk. That's 6 1 2 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 2: 11:44

Jake. Um, I was thinking about a couple more things that came to mind about polyps. Do all polyps turn into cancer? So like when you tell a patient, yep, I took out some polyps. Should that patient automatically assume that those polyps were destined to become cancer? That's

Speaker 3: 12:01

A good question, and it's a hard one to answer. Uh, as you can imagine, you, you'd be really hard to study that question because you, to

Speaker 2: 12:08

Study, you believe some of them,

Speaker 3: 12:09

You'd have to leave them behind and see what happens. And I, I don't know anybody who would sign up for that study. Uh, I've been told, and I don't know if this is an apocryphal story or not, that, that there was a study done in the fifties in a Indiana prison population where they followed polyps, uh, over time and found that really small ones sometimes do go away. I've never been able to find this study, so I don't know if that's true. However, the current belief about the polyps based on studying the biology and the genetics of, of the tissue in polyps is that once they reach a certain size and, and most people say about a centimeter, they're committed, they're gonna become cancer. If not, if not removed, how

Speaker 2: 12:50

Long? Like, what's the timeframe? So

Speaker 3: 12:53

That's another very important point. I think, you know, when, when we do a colonoscopy and we take polyps out today, we're not protecting you from colon cancer next week. We're c we're protecting you from colon cancer several years down the road. And so the time horizon of the benefit that you get is measured in years, not weeks or, or even months. And that's important. I think a lot of people, when they have a positive stool test or when they just get a recommendation from their provider to get a colonoscopy, that it, it introduces a great deal of anxiety and pressure. I gotta get this done right away. My opinion on that or my, my counsel on that would be, it's important not to let it slide, not to forget about it, but I wouldn't rearrange your life around it. Mm-hmm. You know, get it done soon, but it's not an emergency.

Speaker 2: 13:37

That's reassuring actually. What do you tell people about the chance that the day after their colonoscopy, they're growing another polyp? And if you wait 10 years, aren't you missing out on something?

Speaker 3: 13:47

So that's a question that actually comes up a lot, uh, in the colonoscopy suite. And what I think it's important to keep in mind with any screening evaluation, and this is true of colon cancer or anything else, is what we're doing is we're trying to change the odds that you are gonna get sick. So if you come in at 45 or 50, uh, you don't have any risk factors for colon cancer and we don't find any polyps in your colon, what we can say is, you know, you've lived four and a half to five decades of your life without forming polyps. And so that, that puts you in an even lower risk group for the formation of polyps in the future. It's not zero. And that's among the reasons that the screening, uh, strategy doesn't reduce that risk, uh, over your lifetime, all the way to zero. That problem is that how often you want to have a colonoscopy, you know, you want to get, do you wanna do it every month just to

Speaker 2: 14:39

Be safe? Like never safe

Speaker 3: 14:40

<laugh>, uh, you know, so at some point there's a balance that has to be struck and, and there's been enormous population studies done with thousands of patients over several decades that that suggests that 10 years for the average risk population seems to be a, a reasonable interval that balances the benefit that you're gonna get from the test against the risk and the, the inconvenience of doing it. What

Speaker 2: 15:03

About when you do find a polyp and you remove it? Is it still 10 years?

Speaker 3: 15:07

No. Uh, so the, that's an area that, that is also in evolution. So we do remove all polyps that we see. We send any polyps that we remove down to the pathology lab so that somebody can look at it under the microscope and tell us what it looks like and what its risk is, uh, of progression over time. But the number, size and appearance of the polyps that we find dictate when we recommend that you come back. And usually, not always, but usually it is a shorter interval, and that shorter interval can be as, as long as five to seven years or as little as three months. Uh, you know, again, depending on how many you have, how big they are and how bad they look under the microscope. Just

Speaker 2: 15:49

In general, can you just see'em? Are you just looking at'em, say, yep, there's one. Yeah.

Speaker 3: 15:54

I mean, I, I think that, uh, you know, I, I could offer all sorts of descriptors of what a polyp looks like, but I, it's, it's kind of like trying to describe your Aunt Martha, you know, or when you see her mm-hmm.<affirmative>, uh, and, and I might be able to, to describe to you,

Speaker 2: 16:07

Hopefully she doesn't look like a poly

Speaker 3: 16:08

<laugh>, well,

Speaker 2: 16:09

<laugh>, but,

Speaker 3: 16:12

Uh, they do have a fairly characteristic appearance. Um, you know, as we were talking about earlier, the, the, the polyps that we're looking for are quite small. You know, once they're, once they're a centimeter, they're, they're committed, but we're looking for things as small as one or two millimeters. And so it is important that we have a good clean colon to, to look at. So

Speaker 2: 16:31

Let's let, that's a good segue. So you need a clean colon<laugh>. Okay. Folks, your colons are generally filled with your stool. That's what the prep's about, is giving a clean colon. Talk about the importance of the prep, and is there anything other than drinking for quartz of that stuff? So

Speaker 3: 16:49

The, the importance of the prep is, is the thing that keeps me up at night because it, quite frankly, it's the most important quality determinant for the colonoscopy. And it is the thing that is completely out of my control. Mm-hmm.<affirmative>, because it's all done before you arrive for your colonoscopy. You know, again, we're looking for things that can be quite small, and so we need your colon completely cleaned out in order to see it. And in order to clean your colon out, we basically have to create a tidal wave that runs through your colon. Mm-hmm.<affirmative>, uh, you alluded to drinking for liters of, uh, prep. Uh, the most common prep that's used is this stuff called golightly, which, uh,

Speaker 2: 17:25

<laugh> which the, whoever named that. Come on.

Speaker 3: 17:28

Somebody with a very good sense of humor, I guess. But I

Speaker 2: 17:30

Think everybody in your line of work has to have a pretty good sense of humor. Oh,

Speaker 3: 17:33

Yeah.<laugh>, you know. Yeah. I mean, you

Speaker 2: 17:34

Guys,

Speaker 3: 17:36

Uh, yeah, us and the urologist<laugh>. Um, so the, the Golightly prep, uh, although challenging is probably the, the preferred prep for most gastroenterologists. And the reason for that is that it is the least likely to fail it, it's the most reliable prep. Uh, it's also the safest, uh, because it is neutral in terms of fluid balance and electrolyte balance. So it, it travels through you, it doesn't get absorbed into your bloodstream, so it doesn't interfere with any of your medicines, any of your physiologic processes. It just runs right through you carries,

Speaker 2: 18:12

It's the tidal wave you're looking for.

Speaker 3: 18:13

Yeah. And, and so that, that method of producing the tidal wave by drinking the ocean is effective and safe.

Speaker 2: 18:20

But it's a bummer. It is

Speaker 3: 18:22

A bummer<laugh>. And there, there are,

Speaker 2: 18:24

Yeah. Listen, admit it. There,

Speaker 3: 18:25

There are methods that's just nasty. Yeah. There are def, there are definitely other methods and, and, and for some people they are, uh, reasonable options. And the, the other methods, uh, which may involve lower volumes of fluid, or even there are some pill based preps that are out there, that challenge with those is that they rely on stealing fluid from your bloodstream Oh. To create that tidal wave. And so you're ability to maintain your hydration or pay attention to the maintenance of your hydration is much more important. Uh, your ability to keep your electrolytes in balance, which relies on your kidney function, is also much more important. So those options exist and they are definitely good for the right person. But that's something you'd need to discuss with your doctor about whether or not that's the right answer for

Speaker 2: 19:10

You. So what we've learned so far, get your colon cancer screening at the appropriate age, usually age 45 or 50 if you're at average risk, get the follow up depending on what they find and the importance of a prep. Uh, those are some key take home points so far. Yeah. I know colonoscopy is safe, but no procedure is 100% risk free. And in people often worried about, what are the chances of you popping a hole in my colon?

Speaker 3: 19:35

Yeah. So you're right. There isn't, and there's nothing in medicine or life that's completely without risk. Uh, the risks associated with colon cancer are principally bleeding and perforation are popping a hole in the colon, as you said. Uh, both of those differ depending upon what we do when we're in there. So if you have a colonoscopy and I remove a really large polyp, now I say something, you know, a centimeter and a half or two centimeters, your chances of having bleeding after that are about one in 500. And by bleeding, I mean bleeding significant enough to need to come to the doctor to need to get a blood transfusion. So it happens mm-hmm.<affirmative>, uh, but not as commonly as you might think. Uh,

Speaker 2: 20:17

Yeah. That, that isn't as much as I might think. Yeah. And it's usually for the bigger

Speaker 3: 20:21

Polyps, and that's, yeah. And that's in somebody who's got, you know, a, a larger polyp that we've removed. Perforation, I think is the dreaded complication of colonoscopy. Uh, and, uh, it, it dreaded by both patients and, and colonoscopist mm-hmm.<affirmative>, uh, none, nobody wants that to happen. That also is usually, uh, something that occurs with the removal of large polyps, and it's dreaded because it's something that produces a need for immediate surgery. Uh, in most cases, we can sometimes close perforations with the scope if we recognize them quickly enough, but

Speaker 2: 20:55

That's because the contents of your colon, which are not sterile, are

Speaker 3: 20:59

Spilling out, spilling into the, into your abdominal cavity where they don't belong. Right. And, and so, you know, what I, what I tell people, uh, is that your risk of getting a perforation with a colonoscopy is about one in five to 10,000. Again, depending on the studies that you look at, depending on what we do. So it's low but not zero. It is usually, uh, when I have made a judgment call that, you know, this polyp that I'm gonna try to take out is big, but needs to come out. And the balance of the risk is, do I take the risk and take it out now and give you a, a small chance that you'll need surgery because of what I've done, versus just taking photographs of it and guaranteeing that you'll need surgery,

Speaker 2: 21:40

Then you for sure gonna have to have a surgery to take it

Speaker 3: 21:42

Out now. Yeah. So it, it, it's not risk free, but it's typically the lower risk path.

Speaker 2: 21:47

We've had a great conversation here about the, the, the real truth about your colon, your colon health and colon cancer with Dr. Jake Matlock. To wrap it up, if you could tell people three things about their colon health, what would they be?

Speaker 3: 22:00

So the most important thing is get screened for colon cancer. Uh, and, and, uh, I hope that people take away from this, that how you get screened is less important than that. You get screened and, uh, you know, I think that myself, my colleagues all carry a bias towards colonoscopy. We try not to, uh, let that bias come out because the most important thing is that you do something to get screened.

Speaker 2: 22:26

The best screening test is the one you're gonna do.

Speaker 3: 22:28

Absolutely. Okay. And, and, and they, all of the available screening tests are effective if used correctly. So please get your screening done. The second thing that I would emphasize is that if you do have things about your colon health, things about the function of your colon that interfere with your life, talk to somebody about it. You know, it is not the case that we can make things perfect for everyone, that that would be foolish to even suggest, but we can usually make things better with some work. Uh, and that, that work may involve changes in your diet, changes in your lifestyle, occasionally, medication therapies that can help to bring your bowel function more in line with, uh, what you're hoping for. Um, I like

Speaker 2: 23:09

That

Speaker 3: 23:09

Tip. Yeah. I mean, it, it, you know, that's what we're here for mm-hmm. Is, is to try to help. And again, we can't always make it perfect. I, I'm too old to promise perfection to anyone anymore, but<laugh>, but we can usually make it better. The third thing, I guess I would say is if you do have colon problems, as difficult as it is, let your family know, cuz again, that that risk for colon cancer is, uh, increased in first degree relatives of people with problems. So if you have polyps, if you've had colon cancer and you have family members you care about, let'em know cuz it changes their risk.

Speaker 2: 23:43

Awesome tips. We've been talking to Dr. Jake Mattlock, the director of the Division of Gastroenterology here at Hennepin Healthcare in downtown Minneapolis. I've known Jake for, I dunno, how long have we known each other? Some 20 some years. 22 years. 22 years, something like that. And all the way since we trained together here at this very institution. I wanna thank you, Jake, for coming on the show and, uh, talking us through this. Yeah, thanks David. It's fun. It's been great to have you on the show. Listeners, I hope you've picked up some tips for your own health as I have, and I hope you'll join us for the next episode. And in the meantime, be healthy and be well.

Speaker 1: 24:17

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden. To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. You got a question or a comment for the show? Email us at Healthy Matters hc m e d.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. And finally, if you enjoy the show, please leave us a review and share the show with others. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan Comito and Christine Hill. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.