March was Colon Cancer Awareness Month…

Today being March 31st, this is the last day of the month, and the last day of this Colon Cancer Awareness Blog.

I’d like to thank you for taking the time to read this blog.

My understanding is that the link will remain active, so if you know someone who should read the information contained in this blog, you can still direct them to:

blogs.bellinghamherald.com/ColonCancerAwareness

Many thanks to the Bellingham Herald for their support of this blog.

Thank you also to contributing authors, to individuals who proof-read the content before it was published, to readers who posted comments, and to individuals who shared their comments with me on the side.

Please help spread the Facts, not the Myths of colorectal cancer.

If you have additional questions about colorectal cancer, polyps, screening, or other gastrointestinal issues, please speak to a qualified medical professional.  Please do not let embarrassment get in the way of your health.

If you need help finding a gastroenterologist in your area, some resources include:

The American Society for Gastrointestinal Endoscopy

The American College of Gastroenterology

The American Gastroenterological Association

 

My goal this month has been to help educate the community about the facts

of colon & rectal cancer, and to dispel myth.

 

The ASGE website www.screen4coloncancer.org is full of very useful, reliable information.

 

Have a look at their Myth vs. Fact section, which also includes informative videos.

To answer today’s question, I turn the blog over to my colleague, Dr. Kelly McCullough:

 

Dr. McCullough was born and raised in Seattle, Washington.  He attended the University of Washington School of Medicine, stayed at the University of Washington for Internal Medicine residency, and completed his training with a three year Gastroenterology fellowship also at the University of Washington.  He is board certified in Internal Medicine and Gastroenterology.  Dr. McCullough joined Northwest Gastroenterology in 2005.  He is married and has two amazing children.  

 

 

Unlike major surgery where patients may receive a “general anesthetic”, colonoscopy is generally performed with patients receiving moderate conscious sedation.

Versed and fentanyl are given together at doses which make a patient feel quite sleepy and comfortable, but able to respond to questions. 

Versed is a sedative related to valium.  Fentanyl is a narcotic related to morphine. 

These medications are fairly quick to act and quick to wear off, allowing sedation during the procedure and steady post-procedure recovery.

These medications are given repeatedly through a procedure to maintain patient comfort.  Both medications have antidotes or reversal agents, which can be used to reverse sedation if needed.

During colonoscopy, air is used to inflate the colon, allowing inspection.  That air can feel like gas, and at times, gas pains.  Sedation helps block these gas pains. 

Maintaining patient comfort is essential to quality colonoscopy, as it allows us time to thoroughly inspect the colon lining. 

During the first portion of the exam, the colonoscope is advanced to the cecum, or beginning of the colon, the area of attachment to the small intestine.   This is the time sedation is most helpful in  preventing pain. 

As the colonoscope is withdrawn, or pulled back toward the rectum, the exam becomes less and less stimulating (less uncomfortable) so sedation is allowed to begin wearing off. 

Often patients may be somewhat awake for the last few minutes of the exam and are often quite curious. “Is that me?” is not an uncommon question.  “Yes” is the answer.

Can colonoscopy be done without sedation?

Yes, colonoscopy can be done without sedation but it can hurt.  People with any abdominal pain should not consider unsedated colonoscopy- it tends to be pretty miserable.  It is generally hard to predict how patients will tolerate an exam without sedation. 

During colonoscopy, the goal is to be very thorough.  If a patient is uncomfortable and asking “how much longer”, this is not ideal and risks compromising the exam.  You don’t want to ask your doctor to hurry.

Will I remember anything?  Will I be totally out?

The goal is for patients to be comfortable - without pain, anxiety, or stress.  Sedation is given during colonoscopy to maintain comfort.  The sedative, Versed, may limit memory of the procedure - in fact, at the end of a colonoscopy some patients ask when we are going to begin. 

There are times when deeper or more profound sedation is appropriate - these circumstances are generally identified and discussed during a pre-operative appointment.

Gastroenterologists were being asked this question by patients about this time last year, when the New York Times published this story about flat polyps.  If you haven’t already read it, it’s worth reading.

A “flat polyp” is, well, flat.  Refer back to my March 4th blog entitled “What is a Polyp Anyway?” where I describe the shapes of polyps as principally either “sessile” (mushroom cap) or “pedunculated” (on a stem, like a lollipop).

Add to this that sometimes the “sessile” ones are actually “flat” - or hardly raised… or could even be sunk-in a bit, “depressed.”   See diagram.

While colonoscopy is currently the “gold standard” (i.e. “best we have”/”most recommended”) test to screen for colon cancer and pre-cancerous polyps, admittedly it, like everything else in life (and therefore science & medicine) is not perfect… things can rarely be missed.

Thankfully it is under 1% of cases in which a person still develops colon cancer within a few years of having had a colonoscopy.

How can this happen?

Since we believe that most, if not all, colon cancer comes from “pre-cancerous polyps,” it may be the case when this happens that either:

1. A polyp was missed on the prior colonoscopy, which therefore grew and transformed into colon cancer, or
2. A new polyp emerged and quickly transformed into colon cancer

In the case of a polyp being missed, admittedly these “flat polyps” can be subtle, hard to find, and could be missed.  For example, see how subtle the below flat polyp is (especially compared to some of the other polyps I’ve shown pictures of this month):

 You can see the polyp here because you can sense the change of “texture” of the tissue - not because it has any significant “raised” 3-D quality.  This, by the way, is one of the concerns gastroenterologists have for  “Virtual Colonoscopy,” which I suspect  would have missed this sizeable pre-cancerous polyp.

The answer to the original question is “Yes, a skilled ‘endoscopist’ (someone who does colonoscopies) does look for, and remove, flat polyps.” 

Now you see it….

It is should not come as a surprise then that it has been shown that doctors are more skilled at colonoscopy (and thus identifying hard to reach or hard to find polyps) when colonoscopy comprises a significant portion of their medical practice and they do many (hundreds) of colonoscopies each year…

 

This question has come to the front because of a recent update in Colorectal Cancer Screening guidelines from the U.S. Preventive Services Task Force, which were updated/published October 2008 in the Annals of Internal Medicine (click here for full article).

Among other things, this guideline recommended against routine screening for adults over the age 0f 75.  They state that there is “moderate certainty” to this recommendation. 

It is important to understand that this recommendation was clearly couched with terminology.  The use of the word “routine” was intentional so as to say ” not every” person over 75.  Also, the “Grade C” aspect of their recommendation says in the fineprint “offer or provide this service only if other considerations support the offering or providing the service in an individual patient.”

Unfortunately, some newspapers reported this recommendation in an unclear way, spreading the misinformation that if you are over 75 there is no benefit to having a colonoscopy and you do not need to worry about colon cancer any longer.  Some other articles were more clear though….

What should be understood is that EVERY person over 75 MAY NOT benefit from the procedure.   MANY do benefit, however.

The critical question is how healthy the person is. 

If the person’s health is not that good and they don’t have a 5+ year life-expectancy due to other medical problems, they may not benefit from a colonoscopy.

However, if they are in reasonably good health, and one can anticipate them living another 5 years, they should strongly think about having a colonoscopy to prevent their life from being shortened by colorectal cancer.

The factors that I discuss with someone over the age of 75 who is considering whether or not to have a colonoscopy are:

1. How is your overall health?  Can we reasonably anticipate you might live at least another 5 years?
2. What is the history of longevity in your family?  How did that seem to you?
3. How long do you hope to live?
4. How would you feel about having your life shortened by colorectal cancer - especially if it were preventable?
5. If  you were to have colon cancer right now, would you want to know about it?  What would you do with that information?
6. If  you had a colonoscopy and we found colon cancer, would you at least consider meeting with a surgeon to talk about having surgery to remove it?

Depending on one’s answers to these question, a more informed decision can be made about whether this person over age 75 should have a colonoscopy…. 

 Although the U.S. Preventive Services Task Force recommendations often strongly influences Medicare (and thus other private insurance companies)’s policies, I don’t see this particular guideline taking away coverage for patients over the age of 75.  To do so would clearly be ageist.

 Moreover, insurance companies are always looking at the bottom $$$, and being hospitalized for colon cancer, even if you are over age 75, is still costly for them!   Just recently the Agency for Healthcare Research and Quality (AHRQ) reported that:

 “two thirds of individuals hospitalized for colorectal cancer in 2006 were age 65 and older.. [and that] older patients with colorectal cancer are not specifically hospitalized for cancer treatment, those diagnosed with the disease are likely to be admitted for complications from the cancer, such as intestinal blockage and pneumonia. Colorectal cancer is the third most common cancer for men and women.” The analysis showed “that cancer treatment accounted for about 152,000 hospitalizations in 2006, while treatment for complications totaled about 420,000 hospitalizations the same year.”

BOTTOM-LINE: 

Care for a patient over the age of 75 must be individualized. 

The word on the street may not always tell the full story….

Talk to a qualified medical professional if you have concerns or questions about your situation.

I know that this is a bit off the topic of colorectal cancer, but it seems important to address this because it so often comes up when someone has blood in the stool (or tissue paper or toilet bowl)…. see also yesterday’s blog topic…   To cover this topic, we again turn the blog over to my colleague, Dr. Schoenecker.…

What is a hemorrhoid?

Hemorrhoids are enlarged cushions above the anus. These cushions are made up of a complex of small arteries and veins which are important in preventing leakage from the anus.  Anatomically there are three.

[Click for Graphic]

What causes a hemorrhoid?

The cause of hemorrhoids is anything that increases intra-abdominal pressure over time such as constipation or diarrhea or obesity or heavy lifting.

Lack of soluble fiber, insufficient water, and straining for a long time on the toilet are major factors in causing hemorrhoids and their complications. Airplane travel can flair hemorrhoids as well. The best advice is to take a fiber supplement for several days prior to the trip, drink lots of water, and avoid alcohol on the plane. Also try to walk about as much as you can on the airplane. This is also important to prevent blood clots in your legs from sitting too long in an uncomfortable seat.

Pregnancy is a good example of a short period of increased pressure, relieved when the baby is delivered and this type of hemorrhoid may resolve on its own.

What’s the big deal?

Hemorrhoids get larger with time and may bleed or itch at the beginning but later may come out transiently or even stay out all the time. Tags can form on the outside and sometimes the hemorrhoids can develop a clot inside (thrombose)  and become very painful. When there are large tags it may be difficult to keep the area clean and there may be a discharge and itching or irritation.

Can my hemorrhoids be treated?

After age 50 half of people will have haemorrhoids but only 1% will need treatment each year.

The best treatment is prevention. Increasing dietary fiber with 2 tablespoons of bran or Psyllium (Metamucil) or flax or Benefiber in addition to 7 to 8 glasses of water per day is very helpful. Avoid obesity and exercise regularly.

Early hemorrhoids usually respond to the above suggestions, plus an over-the-counter hemorrhoid cream helps. Another important suggestion is not spending longer than 2 minutes on the toilet to have a bowel movement. Stop and wait, then go back a few hours later and try again for two minutes.

What if that do-it-at-home stuff doesn’t work?

If hemorrhoids persist specialty care may be needed. The most important issue is to be sure that hemorrhoids are the only problem…other causes such as inflammatory bowel disease, fissure (a tear) or even colon cancer may need to be excluded. 

Laser, injection of sclerosant, infrared, or surgery are available techniques to treat hemorrhoids, but the vast majority can be treated easily by “rubber band ligation.”

Rubber band ligation?

Hemorrhoids can be shrunk by applying an elastic band about an inch above the anus where there is no pain sensation. This restores the cushions to normal size but doesn’t remove them completely. This technique has been around since the 1960’s and recently modified with the O’Regan Ligator. 

A few patients with very advanced hemorrhoids (grade 4) may require surgery because of the large amount of hemorrhoid protruding through the anus.

“… MUST BE A HEMORRHOID.”   These are dangerous words that get said far too often.

One of the many myths about colorectal cancer is that it doesn’t occur in young people.

The truth is that while 80% of cases DO occur in those at/over the age of 50, that still leaves 20% occuring in individuals who are under age 50…  like Erika who was 22 years old when she was diagnosed!

The problem with a healthy 20, 30 or 40 year old who suddenly gets blood in their stool is that they often delay seeking medical attention… and even when they do, sometimes there can be a delay in diagnosis because all involved parties are thinking and hoping the same thing, “must just be a hemorrhoid.” 

Blood in the stool can be lots of things - sure, might be a hemorrhoid; might be a tear (anal fissure); might be an infection; might be inflammatory bowel disease, like Ulcerative Colitis or Crohn’s Disease; and it could be colorectal cancer.

Until the person has had a proper evaluation (i.e. endoscopy), you don’t know which of the above it is!

Early diagnosis is the key…

Learn more about young people, like Erika, affected by colorectal cancer and read their stories of survival at www.colondar.com…  (it’s a colon, no it’s a pin-up calendar… no it’s a colondar….)

Unfortunately, there are often NO symptoms of colon or rectal cancer when it is in its earliest stages.  The tumor often needs to grow to a bigger, more advanced status before symptoms start to show up.  This is why it is is called “screening” - - in other words, looking for trouble BEFORE there are symptoms.

Below, however, are a list of symptoms that should be taken seriously because they MAY be a sign of colon or rectal cancer:

1. A change in bowel habits.  This means that you used to go to the bathroom for a bowel movement a certain way, and this changed in a significant way.  Maybe you used to go daily and fully, and now you only go once every few days or feel that “incomplete sense of evacuation” afterwards.  Maybe you are suddenly having more loose, diarrhea-like stools.  Maybe they are now flattened or narrowed.  You get the idea…  
2. Bleeding.  This can be blood seen in the stool, around the stool, in the toilet bowel or even simply on the tissue paper.   Generally, but not always, the lower down towards the rectum that the tumor is, the more likely you’ll see blood around the stool, or simply in the toilet bowel or tissue paper (this is why in this situation, people often first think it is simply a hemorrhoid).  The blood could be dark, marroon or clotted.  Blood that comes from the far end of the colon (the “proximal” side nearest the small bowel) can look black by the time that it comes out - - this is called melena.  You know that doctors will quiz you about your stools, so use that as your justification - go ahead, turn the lights on in the bathroom and look at your stools.  It’s amazing how many people don’t.
3. Abdominal pain.  We’re not talking that few second cramping twinge that you’ve been getting the past decade - - we’re talking something new and different.
4. Unexplained weight loss.  If you are on a Weight Watchers program, good for you for losing that weight.  But if you aren’t trying to lose weight and are… you should see a doctor.
5. Anemia.   This means that your red blood cell count is low.  The symptom of anemia most commonly is fatigue.  It may have occurred slowly, though, without you even noticing it.  This symptom would prompt your doctor to check bloodwork, which would then show that you are anemic.
6. A lump or hardness in your belly that doesn’t belong.  When the tumor gets really big, your doctor MAY be able to feel it.  It is more often the case, however, that it can not be felt on examination of the abdomen even by a skilled professional.  If, however, you feel something, make sure you have it examined.  This goes for ANY part of your body!  (This last point reminds me to mention that because the cancer grows on the inside of the colon, one should not be falsely reassured by a standard doctor’s examination of the belly, by an xray of the abdomen, or even a standard CT scan of the abdomen… all could easily miss the cancer)
7. Other:  you name it and in retrospect it may have been a symptom - - new gassy-ness, new ache, new nausea, new mucous, new urgency….  the bottom-line here is that if the ol’ car makes a new clunking sound, get it checked out sooner, rather than later….

To address today’s topic, I’d like to introduce my oncology colleague, Dr. Kominsky.  Dr. Kominsky is one of those doctors you hope you’ll never meet - - but you’re grateful he’s there if you do NEED to meet him.

 

Dr. Andrew Kominsky graduated from Skidmore college with a degree in Mathematics, and then earned his MD from Tufts University School of Medicine in 1997.  He then trained in medicine for four years at Tulane University in New Orleans before going on to Dartmouth in New Hampshire for specialty training.  He is board certified in Internal Medicine, Hematology, and Oncology.  He has been practicing in Bellingham for the past three years, and works for the Peace Health Medical Group.

 

So some of you have been through a colonoscopy, followed by a fairly major surgery, and have started to feel your regular self, kind of like a car after a major overhaul…

And of course the biggest thing on your mind these last few weeks has been: is it over?

For many people it is.  Surgery (or colonoscopy alone) has been successful at preventing a life threatening cancer from running its course. This is not something to be taken lightly, understanding that colon cancer is in the top 3 cancer killers among both men and women.  

[Click here for Graphic]  

What an amazing thing, to be able to screen for a cancer and be able to cure it before it ever had the chance to cause trouble! We have found, over the years, that our best method of curing cancer is to stop it as early as possible.

If you can’t get rid of the risk factor (example: smoking) then screen for the cancer and remove it as early as possible.  This works superbly for cancers such as cervical, nicely for breast and colon, not so well for lung, and terribly for those such as pancreatic and ovarian. 

 For colon, we assume screening works not only because it makes sense logically, but because death rates and advanced stage presentations continue to decline steadily over the past two decades just as the endoscopy rates continue to rise.

[Click here for Graphic]

 So depending on the extent of the findings at surgery, you may at this point be referred to an Oncologist.  We specialize in the medical management of cancer. 

What does that mean? 

Actually it took me all of medical school, residency, and part of my fellowship (10 years) to answer this question with any insight.  Basically, though, we help people through the process of cancer, including anything from diagnosis, staging, and treatment to education, surveillance, and counseling. 

Sometimes this means just meeting for a simple conversation…sometimes it is more involved.

Get to the point. 

Ok, you have been sent to see the Oncologist after your surgery.  My first job when meeting someone who has gone through this process is to evaluate the extent of the disease.  This process is called staging and it is the most important determinant of risk of recurrence.  After all, this is the million dollar question, “have I been cured of the cancer or is there a risk that it can come back?”  

Actually there are two ways that cancers recur: either locally or at a distant site. 

Locally means at the area where it was removed (and thus followup colonoscopies are important down the road), but the distant recurrences are the ones that we are most concerned about.

Distant sites are most usually the liver and the lungs in colon cancer. Although sometimes people that have disease in these sites can be cured, more often this means that the cancer has taken hold.  Not that there are not options for treatment, our therapies for advanced colon cancer have come a long way, but cure is not the rule. 

What I am going to cover below, the adjuvant treatment of colon cancer, is aimed at preventing this.

But first, how do we stage colon cancer? 

Depending on how concerned we are, this can include a CT scan of the abdomen and pelvis (the red arrows pointing to a colon cancer), usually obtained prior to surgery, and either a plain or CT film of the chest. 

[Click here for Graphic] 

A newfangled technology that you may have heard of called a PET scan is typically not used because of its unproven efficacy in this setting.  Also, a blood test is drawn, the CEA (short for medical-speak carcinoembryonic antigen) which is a tumor marker may be used but is often not helpful. 

Rectal cancer, probably to be included in this conversation, is the same cancer found closer to the bottom end (considered different because of its richer blood supply and therefore high risk for recurrence; also different because it is tacked down as opposed to floating around, and therefore able to be targeted by radiation). 

Staging in rectal cancer might also include an endoscopic ultrasound, which is a probe from the inside that gives us a better picture than CT alone in this setting.  This is all called clinical staging, which is not as accurate as pathologic staging, or the information we get from the surgery. 

So all of this information together paints an overall picture, and we use this to predict risk for recurrence.

[Click here for Graphic]

Can you be more specific? 

Well, no one characteristic is used alone to predict risk.  First we look at the cancer itself, which starts from the middle of a circle, grows from the inside, and works its way outward.  If you consider the colon like a tire, then if it is just involving the inner tube then this is less concerning then if it gets to the treads.  We also look at its capacity to leave the colon and involve other areas such as the lymph nodes, which could be considered the oil filter.  The blood test mentioned before, the CEA, if it doesn’t come back to normal value once the cancer is removed is also considered.  Finally, if there are complications during or before the surgery, such as perforation (where the colon wall loses its integrity) or obstruction (it is completely blocked off) or if there are other areas seen on the CT scan, then these help contribute as well. 

At this point, we are able to form an educated opinion as to whether or not this cancer is likely to cause problems down the road, and to at least start to consider heading it off at the pass. 

This is the case for the minority of people with colon (or rectal, or grouped together as “colorectal”) cancer, as many people are considered cured with colonoscopy or surgery alone. 

 

However, there are some people that are not so lucky. 

Many are apt to blame themselves if they get to this point because of diet or lifestyle, or not getting their colonoscopy quickly enough, but I think this is a totally wrong way of thinking about this.  I digress, but I wanted to put in a few words at this point about cancer as a whole. 

The word I like to use to best describe cancer is insidious.  Cancer hides, sneaks about, and catches us by surprise. 

Now I don’t have the keys to the kingdom of knowledge, and maybe it makes me more the fool than anything else to tell you that I have been in school from the age of 5 to 35, but my feeling is that many of us have the wrong idea when it comes to cancer (including the head of the National Cancer Institute who not so many years ago announced that all cancer would be cured in ten years). 

Cancer is not an infectious disease, meaning we do not catch it from someone else, and our immune systems are not effective at destroying it.  Usually a single drug will not make it go away like penicillin will with a strep infection. 

And although genetics and environment can play a role as to why we develop cancer, cancer is for the most part a natural process. 

Those sound like fighting words, I know. 

But cancer cells are really our own cells, slightly different in some way but not to the point where our body recognizes it as foreign.  I think of it as an endpoint of natural breakdown, or perhaps entropy (the tendency of all things toward disorder).

Not to harp on cars, but if you have a car long enough things will start to go wrong.  You can drive your car too hard, and not get frequent enough checkups, or use the wrong kind of oil, or even have a lemon to begin with, but you don’t see a lot of model T’s still out there on the road.  So don’t blame the car because it had a break down.

 [Click here for Graphic]

So all the disease has been removed, the scans are negative, and I feel fine.  Why should I consider going through more treatment? 

Unfortunately, in order for us to see something 1 cm on a scan, billions of cells need to be present.  Something smaller would then be missed, and these are the areas, microscopic untraceable deposits of disease, that may be seeds for future growth.

What then is high enough risk to consider more therapy? 

In general, people that have had a large tumor, obstruction or perforation, or have had disease in other areas (usually meaning the lymph nodes), all are candidates for more treatment.  This doesn’t mean everyone meeting these requirements should get therapy, though, as there are many other factors to consider at this point (other illnesses and age, to name a couple).

You may have heard of the term adjuvant therapy. 

Adjuvant by definition means treatment in the absence of disease.   We know, through trials involving thousands of patients, that by administering treatment in high risk individuals that some will not only have the disease stay away, but also for many, will not die, because they received the treatment.  In general, the higher the risk going in the greater the chance that they would benefit.  This is not only done in patients with colon cancer, but also breast, lung, and melanoma to name a few.

 [click here for Graphic]

“Does that mean chemotherapy?  I would never do that.  I know someone that did horribly with chemo.” 

This is a very frequent conception that I think deserves attention here.  It is true.  Not so many years ago we had only a few drugs that were largely ineffective, and very little in terms of supportive treatments to combat side effects.  So you would see many people not only dying of cancer, but dying horribly in our attempts at trying to treat them.  But we are entering a more modern age.  Now that we have done so well against the major killers of the last century, infectious disease early on…and heart disease once we started to prosper and live longer…now the majority of research dollars are spent fighting the next frontier, cancer. 

We have many options, for example prior to the last decade we had 2 drugs to combat colon cancer, but in the last several years 5 new drugs have been approved. 

And we are much better at treating side effects.  This is not to say that everyone feels just fine on therapy, or that everyone that is treated benefits.  But we are much better prepared to now sit down and have a rational discussion about the potential risks and benefits of treatment. 

Thousands of lives are saved every year because of it.

To answer today’s question, I’d like to introduce you to one of my surgical colleagues, Dr. Pietro.

 

Dr. Michael Pietro graduated from the University of Chicago with a degree in Biology, and then earned his MD at Vanderbilt Medical School in Tennessee in 1985.  His clinical training in Surgery was accomplished through a five year program at Virginia Mason Medical Center in Seattle.  His is Board-Certified in Surgery.  Dr. Pietro worked in Maine and West Africa before coming to Bellingham in 1991.

 

 

All colon cancers should be removed surgically if possible. 

This can usually be done with a laparoscope which minimizes postoperative pain and recovery time.  This requires several small puncture incisions for instruments and a single incision 2 or 3 inches in length to remove the piece of bowel containing the tumor.

Usually a laxative is taken on the day prior to surgery to empty the colon.  The surgery itself takes from 90 minutes to 3 or more hours, depending on the location of the tumor. 

The great majority of the time, the ends of the colon will be reconnected and bowel function will resume normally. 

Occasionally a temporary “stoma” may be necessary, where the end of the intestine is brought up to the skin and waste is collected in a bag.  Only rarely, when a tumor is so close to the anus that the anus itself must be removed, is a “permanent stoma” necessary.

Following surgery, most patients can start eating again within a day or two.  The hospital stay ranges from 2 to 7 days.  Patients can go home once they are able to eat and tolerate oral medications.

Following discharge from the hospital, there are no restrictions on diet or activity.  In general, the more exercise, the better. 

It usually takes about one month for appetite and energy level to return to normal, and most people lose some weight during this time.