A magnified view of the colonic mucosa

With a magnifying colonoscope and dye, another world is revealed. 
WHAT IS SHOWN IN THIS PHOTOGRAPH?

■ Crypt distortion

No, these crypts are MUTATED!

■ Abberant crypt focus

You know your stuff!

■ Small flat adenoma

Histologically, you could be correct!

EXPLANATION

This is an 'aberrant crypt focus'. Aberrant crypt foci are small clusters of mutated crypts (see histology). Fortunately, they are below the detection limit of normal colonoscopes as otherwise a colonoscopy would not doubt take an hour and without any evidence that counting and/or ablating these would make any difference to the risk of dying from bowel cancer. 

In the proximal colon, 50% of these are adenomatous and the rest are hyperplastic. In the distal colon, 85% are hyperplastic and the rest are adenomatous. One paper reported that ACF's in the proximal colon were associated with an increased chance of having adenomatous polyps [Mol Cancer Res 2017;16(3):486-95]. 

​The link between ACF and proximal adenomas, I see as evidence of a colonic “field effect” in which exposure to carcinogenic 'drivers' (dietary, lifestyle, disease and genetic) all work together to prime the colon for the development of cancer. It's for this reason, that endoscopically resecting DALM's (I arbitrarily define DALM's as flat polyps within the colitic field of a patient with >6 yrs of colitis),  then telling patients that they now have nothing to worry about,  is naïve ...