POST COLONOSCOPY ANAL CANCER

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10/15/23

My last case of 2021… happy new year everyone !

This is a salutary tale of a 69 year old lady who presented 10 months ago with diarrhoea (bowel opening 5x/day, previously 1x/day), urgency, bright red blood PR and anal pain. An urgent (2 week wait) colonoscopy was performed by a consultant gastroenterologist and showed diverticular disease and 2nd degree piles. In addition, mucosal prolapse in the lower rectum was suspected. Photo-documentation of caecum and rectum in retroflexion was performed. The patient continued to have symptoms and a month later, out of desperation, she saw a surgeon privately. The surgeon attempted to examine the patient but digital rectal examination was too painful and not performed and neither was proctoscopy / rigid sigmoidoscopy. However, reassured by the recent unremarkable colonoscopy, the surgeon decided to adopt a conservative approach.
Unfortunately, the patient continued to suffer with ongoing symptoms of diarrhoea, urgency, red blood PR and anal pain. In addition, she lost 10 kg in weight and dropped 2 dress sizes. Her GP referred her for another 2ww colonoscopy and this procedure was performed 10 months after the first one. I performed this second procedure. The initial digital rectal examination proved too painful for the patient and was abandoned. I then applied copious quantities of lignocaine gel and proceeded with the colonoscopy. I was able to reach the terminal ileum without any problems and started the withdrawal process… all was well until the very end…. (see video).
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We are all familiar with the concepts of post colonoscopy colorectal cancer (PCCRC). This is a case of post colonoscopy anal cancer which is a less familiar concept with not much in the literature about it. Previously there was no standardised definition for PCCRC and reported rates varied depending on terminology and calculation methods used. The World Endoscopy Organisation (WEO) recently suggested standardising the terminology, identification, analysis and reporting of PCCRCs and CRCs detected after other whole-colon imaging evaluations (post-imaging colorectal cancers; PICRCs) [1]. Amongst the 21 statements issued by the WEO team, highlights are:

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