History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up

Low level of antibodies to the oral bacterium Tannerella forsythia predicts bladder cancers and Treponema denticola predicts colon and bladder cancers: A prospective cohort study

This study explores the risk for cancer by level of antibodies to the anaerobe oral bacteria of periodontitis Tannerella forsythia (TF), Porphyromonas gingivalis (PG), and Treponema denticola (TD) all three collectively termed the red complex, and the facultative anaerobe bacterium Aggregatibacter actinomycetemcomitans (AA). The prospective cohort, the Oslo II-study from 2000, the second screening of the Oslo study of 1972/73, has been followed for 17 ½ years with regard to cancer incidence and mortality. A random sample of 697 elderly men comprised the study cohort. The antibody results measured by enzyme linked immunosorbent assay (ELISA) were used in the Cox proportional hazards analyses, and quartile risk on cancer incidence in a 17 ½ years follow-up. Among the 621 participants with no prior cancer diagnoses, 221 men developed cancer. The incidence trend was inverse, and the results are shown as 1^st quartile of highest value and 4^th as lowest of antibody levels. The results of the Cox proportional regression analyses showed that TF inversely predicts bladder cancer (n = 22) by Hazard Ratio (HR) = 1.71 (95% CI: 1.12, 2.61). TD inversely predicts colon cancer (n = 26) by HR = 1.52 (95% CI: 1.06, 2.19) and bladder cancer (n = 22) by HR = 1.60 (95% CI: 1.05, 2.43). Antibodies to two oral bacteria, TF and TD, showed an inverse risk relationship with incidence of specific cancers: TF bladder cancer, TD bladder and colon cancer. Lowered immunological response to the oral infection, periodontitis, is shown to be a risk factor in terms of cancer aetiology.

A rational approach to the patient with hematochezia

PURPOSE OF REVIEW

Hematochezia is a common clinical presentation, with significant morbidity and economic burden. These patients often require costly interventions including hospitalization, blood transfusions, and radiologic or endoscopic procedures. The purpose of this review is to give a rational, concise approach to the patient with hematochezia, with special consideration of recent advances in the literature.

RECENT FINDINGS

Recent studies pertaining to hematochezia have evaluated risk stratification, endoscopic intervention, evaluation of small bowel bleeding, and management of anticoagulation.

SUMMARY

A step-wise approach to hematochezia helps determine the cause and provide the appropriate management of these patients. We propose five steps beginning with hemodynamic assessment and risk stratification, then focused history and physical examination, endoscopic intervention when warranted, and consideration of small bowel bleeding in selected instances.

The fecal occult blood test as a tool for improved outpatient qualification for colonoscopy. A single-center experience and 10-year follow-up survey

PURPOSE

Colonoscopy is not widely and easily available in all countries, even for symptomatic patients. This is one of the causes of tumors not being diagnosed until an advanced stage. The aim of this study was to estimate the efficacy of the fecal occult blood test (FOBT) in the diagnostic work-up of outpatients referred to a colorectal unit due to indistinct abdominal symptoms.

PATIENTS/METHODS

Among 10418 consecutive symptomatic individuals referred to the outpatient clinic, an immunochemical FOBT (Hem-Check 1^®) was recommended for 9432 patients with indistinct symptoms as a tool for qualifying them for colonoscopy. All the subjects were treated according to their diagnosis and followed-up for the next 10 years.

RESULTS

Colorectal cancer (CRC) was diagnosed in 535 individuals: 393/986 (39.9%) among patients with red-flag symptoms, and 142/951 (14.9%) of individuals with indistinct symptoms and a positive FOBT. In the latter group, less-advanced tumors, classed as such using Dukes' classification, were twice as common and more advanced CRC occurred twice as seldom than in the former. Cancer recurrence-free and overall survival periods after surgical treatment for CRC were significantly longer in patients with indistinct symptoms who qualified for diagnostic procedures on the basis of a positive FOBT.

CONCLUSIONS

Patients with symptoms suggesting organic colon disease had a worse prognosis compared to individuals with non-specific symptoms. If bowel endoscopy is not widely and easily available, qualification for colonoscopy on the basis of alarm symptoms and a positive FOBT seems to be an effective strategy in early CRC diagnosis.

Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category

BACKGROUND

The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms.

OBJECTIVE

To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort).

DESIGN

Retrospective controlled cohort study.

SETTING

Teaching hospital.

PATIENTS

Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years.

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

Prevalence of advanced neoplasia.

RESULTS

During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neoplasia in patients with rectal bleeding was comparable with that in the screening controls: 28 of 472 (5.9%) versus 113 of 1638 patients (6.9%) (P = .459). Furthermore, 10 patients (2.1%) with rectal bleeding were newly diagnosed with inflammatory bowel disease. In contrast, other symptoms that commonly lead to colonoscopy, such as abdominal pain, changes in bowel habits, and weight loss, were associated with much lower risks for neoplasia. As a result, the overall prevalences of neoplasia and advanced neoplasia were significantly higher in the screening cohort than in the diagnostic cohort: 467 of 1638 patients (28.5%) versus 179 of 1266 patients (14.1%), and 113 patients (6.9%) versus 48 patients (3.8%), respectively (both P < .001).

LIMITATIONS

No data on duration of symptoms; discrepant sex ratios between cohorts.

CONCLUSION

The threshold for diagnostic colonoscopy in symptomatic young adults should be individualized for each symptom category. Rectal bleeding warrants colonoscopy to detect advanced neoplasia or inflammatory bowel disease in most young patients, especially those aged 40 to 49 years, whereas non-bleeding symptoms, including some traditionally regarded as "alarm" symptoms, were associated with a much lower risk for neoplasia compared with the risk in screening patients aged 50 to 54 years.

Diagnostic value of rectal bleeding in predicting colorectal cancer: a systematic review

This study aimed at summarizing published study findings on the diagnostic value of rectal bleeding (RB) and informing clinical practice, preventive interventions and future research areas. We searched Medline and Embase for studies published by September 13, 2013 examining the risk of colorectal cancer in patients with RB using highly inclusive algorithms. Data for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and positive predictive value (PPV) of RB were extracted by two researchers and analyzed applying Meta-Disc (version 1.4) and Stata (version 11.0). Methodological quality of studies was assessed according to QUADAS. A total of 38 studies containing 5,626 colorectal cancer patients and 73,174 participants with RB were included. The pooled sensitivity and specificity were 0.47 (95% CI: 0.45-0.48) and 0.96 (95% CI: 0.96-0.96) respectively. The overall PPVs ranged from 0.01 to 0.21 with a pooled value of 0.06 (95% CI: 0.05-0.08). Being over the age of 60 years, change in bowel habit, weight loss, anaemia, colorectal cancer among first-degree relatives and feeling of incomplete evacuation of rectum appeared to increase the predictive value of RB. Although RB greatly increases the probability of diagnosing colorectal cancer, it alone may not be sufficient for proposing further sophisticated investigations. However, given the high specificity, subjects without RB may be ruled out of further investigations. Future studies should focus on strategies using RB as an "alarm" symptom and finding additional indications to justify whether there is a need for further investigations.

Disparities in evaluation of patients with rectal bleeding 40 years and older

BACKGROUND & AIMS

Rectal bleeding is associated with colorectal cancer. We characterized the evaluation of patients aged 40 years and older with rectal bleeding and identified characteristics associated with inadequate evaluation.

METHODS

We conducted a retrospective review of records of outpatient visits that contained reports of rectal bleeding for patients aged 40 years and older (N = 480). We studied whether patient characteristics affected whether or not they received a colonoscopy examination within 90 days of presentation with rectal bleeding. Patient characteristics included demographics; family history of colon cancer and polyps; and histories of screening colonoscopies, physical examinations, referrals to specialists at the index visit, and communication of laboratory results. Data were collected from medical records, and patient income levels were estimated based on Zip codes.

RESULTS

Nearly half of the patients presenting with rectal bleeding received colonoscopies (48.1%); 81.7% received the procedure within 90 days. A history of a colonoscopy examination was more likely to be reported in white patients compared with Hispanic or Asian patients (P = .012 and P = .006, respectively), and in high-income compared with low-income patients (P = .022). A family history was more likely to be documented among patients with private insurance than those with Medicaid or Medicare (P = .004). A rectal examination was performed more often for patients who were white or Asian, male, and with high or middle incomes, compared with those who were black, Hispanic, female, or with low incomes (P = .027). White patients were more likely to have their laboratory results communicated to them than black patients (P = .001).

CONCLUSIONS

Sex, race, ethnicity, patient income, and insurance status were associated with disparities in evaluation of rectal bleeding. There is a need to standardize the evaluation of patients with rectal bleeding.

The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review

BACKGROUND

Over 37,000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care.

AIM

To conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer.

DESIGN

Systematic review.

METHOD

MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool.

RESULTS

Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥ 50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding.

CONCLUSION

The findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.

Hematochezia in the young patient: a review of health-seeking behavior, physician attitudes, and controversies in management

Hematochezia, defined as the passage of blood or clots from the rectum, is common and can be quite alarming. Few patients in general consult their physicians for this symptom. Various reasons have been explored for this behavior. Physician attitudes also shed some light onto why some patients are referred and others are not. Hematochezia may be associated with an anal cause in most healthy young adults (<50 years of age), but some may end up being diagnosed with colorectal cancer (CRC). Many studies have looked at the usefulness of clinical presentation in helping to decide which patients need further evaluation and what the optimal mode of investigation should be. Of note, studies on patients less than 50 years of age presenting with rectal bleeding have been few and far between. The results of these studies have been contradictory to the point where, today, there is no single set of consensus guidelines on the approach to hematochezia in young patients. In this review, the value of clinical symptoms and the underlying risk of CRC in guiding this clinical decision will be discussed.

Diagnostic accuracy systematic review of rectal bleeding in combination with other symptoms, signs and tests in relation to colorectal cancer

Background:

Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care.

Methods:

Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated.

Results:

Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3–15.4%, median: 8.1%). Age ⩾60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00–3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03–3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54–3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively ‘rule in’ the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30–10.35), specificity 0.95 (95% CI: 0.93–0.96), but still only generates a post-test probability of 21.6%.

Conclusions:

In patients with rectal bleeding who present to their general practitioner, additional ‘red flag’ symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines.

Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study

PURPOSE

Rectal bleeding is considered an important sign of colonic disease, particularly colorectal cancer. The epidemiology of rectal bleeding in the community is poorly understood. Moreover, there is little information as to whether individuals seek health care for this problem. This study aimed to determine the prevalence of rectal bleeding and levels of healthcare seeking amongst an Australian population.

METHOD

A community sample of adults aged above 18 years of Penrith (a Sydney suburb representative of the Australian population) selected randomly from the electoral roll. The survey consisted of a self-administered questionnaire sent out to 440 residents stratified for equal numbers of men and women.

RESULTS

The response rate was 77% (n = 338; mean age 46 years; SD: 16; range: 18-90; 55% women). Blood in the stools in the previous 12 months was reported by 18% (95% CI: 14-23). Colour of the blood in bowel movements was reported as bright (72%), dark (7%), bright and dark (10%), 11% did not know. Only 31% (n = 21/68) of respondents with rectal bleeding had visited a physician primarily about the presence of blood in the bowel movement within the previous 12 months. The majority (90%) who consulted about the presence of blood were aged between 30 and 60 years. Blood in the stools was independently associated with younger age (OR = 0.97, 95% CI: 0.95-0.99, P = 0.01), feelings of incomplete rectal evacuation (OR = 3.42, 95% CI: 1.66-7.08, P = 0.001), self-reported injury or tear (OR = 3.45, 95% CI: 1.53-7.69, P = 0.002), and surgery (OR = 2.70, 95% CI: 1.03-7.14, P = 0.04) to the perianal region.

CONCLUSIONS

Rectal bleeding is common in the general population. Only one-third of those with rectal bleeding consults a physician about their condition. Rectal bleeding occurs in younger individuals, those who suffer from incomplete evacuation and among individuals who have had an injury, tear or surgery to the anus.

Colonoscopic evaluation of minimal rectal bleeding in average-risk patients for colorectal cancer

AIM: To assess the prevalence of clinically significant lesions in patients with minimal bright red bleeding per rectum (BRBPR).

METHODS: Consecutive outpatients prospectively underwent colonoscopy at Loghman Hakim Hospital, Tehran. Minimal BRBPR was defined as small amounts of red blood after wiping or in the toilet bowl. Patients with the following alarm signs were excluded: Positive personal history of colorectal neoplasms or inflammatory bowel disease (IBD), positive first degree family history of colorectal neoplasms, history of altered bowel habits, recent significant weight loss, and presence of iron deficiency anemia. Neoplastic polyps, colorectal carcinoma, and IBD were defined as significant lesions.

RESULTS: A total of 402 patients (183 female and 219 male, aged 43.6 ± 15.7 years) were studied. Hemorrhoids (54.2%), anal fissures (14.2%) and ulcerative colitis (14.2%) were the most common lesions and colonoscopy was normal in 8.0%. Significant lesions were found in 121 (30.1%) patients, including 26 patients (6.5%) with adenocarcinoma and 30 (7.5%) with adenomatous polyps. Almost all patients with significant lesions had at least one lesion in the distal colon; an adenocarcinoma and an adenomatous polyp in the proximal colon were found in 2 patients with hemorrhoids.

CONCLUSION: Flexible sigmoidoscopy appears to be sufficient for the evaluation of average risk patients with minimal BRBPR. Rigid sigmoidoscopy may be used as an alternative in patients less than 40 years of age in settings where the former is not available. The choice of colonoscopy over flexible sigmoidoscopy in patients aged over 50 years should be individualized.

Videoanoscopy: useful technique in the evaluation of hemorrhoids

BACKGROUND AND AIM

Rigid proctoscopy, the gold standard for detecting hemorrhoids, has become a neglected procedure in the era of flexible endoscopy. Evaluation of hemorrhoids is often done with the retroflexed fiberoptic colonoscope. The aim of this study was to evaluate the technique of videoanoscopy in comparison with retroflexion of colonoscope in the rectum to detect hemorrhoids and to correlate objective findings of hemorrhoids and their relation to bleeding.

METHODS

In total, 544 patients were screened and 358 patients were evaluated by the technique of videoanoscopy and retroflexion of colonoscope in the rectum. The video images of both the procedures were independently analyzed by two observers for the presence or absence of hemorrhoids. The videoanoscopy images were also analyzed for number of columns of hemorrhoids, size and presence of red-color sign.

RESULTS

Videoanoscopy detected hemorrhoids in a significantly higher number of subjects when compared with retroflexion of colonoscope in the rectum by both observers (P < 0.05). The average kappa value was 0.637 and 0.779 for retroflexed colonoscopy and videoanoscopy, respectively. Red-color sign was present in 80.5% of patients with bleeding compared with only 30.3% in the non-bleeding group. The majority (71%) of patients in the bleeding group had larger hemorrhoids. Red-color sign and size of hemorrhoidal columns correlated with bleeding (P < 0.05).

CONCLUSION

Videoanoscopy is a simple technique with increased sensitivity to detect hemorrhoids compared with intrarectal retroflexion of colonoscope and yields valuable objective information about the presence and condition of hemorrhoids. It should be performed as an extension of standard colonoscopy.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome

BACKGROUND

The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment.

METHODS

This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival.

RESULTS

A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment.

CONCLUSIONS

Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

Colonoscopic evaluation of hematochezia in low and average risk patients for colorectal cancer: A prospective study

AIM: To relate the endoscopic findings in patients with hematochezia with regard to age in “low and average risk” for colorectal cancer (CRC) and to localize significant lesions in order to identify patients who need sigmoidoscopy or total colonoscopy.

METHODS: This prospective study was performed in an open access GI endoscopy unit. Out of 4322 consecutive patients undergoing colonoscopy, 918 reported hematochezia. The final study group comprized 180 patients aged below 45 and 237 over 45. Main exclusion criteria were a 1^st-degree family history of colorectal carcinoma, patients reporting blood mixed with stools and/or progressive colonic symptoms, or patients who had undergone colon surgery for neoplastic lesions.

RESULTS: Total colonoscopy could be performed in 96% of patients. Abnormal findings were observed in 34.3% of the younger and in 65.7% of the older ones. Findings were the presence of polyps in the distal colon (n = 2) and IBD in the proximal colon (n = 29) in the group of the younger patients, and polyps (n = 15), IBD (n = 13), and carcinoma (n = 6, 4 of the lesions were located proximal to the splenic flexure) in the elderly. Our findings suggest that the diagnostic potential of total colonoscopy in patients younger than 45 referring scant hematochezia, is not mandatory. By exploring only the distal tract of the colon we have misdiagnosed two cases of IBD located in the ascending colon. In this group of patients additional risk factors must be identified before performing a total colonoscopy. Regarding the patients older than 45 yr, the exploration of the distal colon would have led to our overlooking a carcinoma, two neoplastic polyps and one IBD located in the proximal colon.

CONCLUSION: Young patients with scant hematochezia but without risk factors for neoplasia do not need a total colonoscopy, whereas is mandatory performing a total colonoscopy in older patients even in the presence of anal pathology.

Utilization of colonoscopy in the United States: results from a national consortium

BACKGROUND

To assess capacity for colonoscopy, we need to understand current utilization of colonoscopy in diverse clinical practice settings. The objective of this study was to determine the utilization of colonoscopy in diverse clinical practice settings.

METHODS

The Clinical Outcomes Research Initiative (CORI) data repository, which receives endoscopy reports from 73 diverse adult practice sites in the United States was used. Colonoscopy reports from January 2000 to August 2002 were analyzed to determine the demographic characteristics of adult patients who received a colonoscopy and the procedure indication. The relationship of age, race, gender, and procedure indication was analyzed.

RESULTS

Results of colonoscopies in 146,457 unique patients were analyzed. Of the reports, 68% came from nonacademic settings. Patients less than 50 years of age accounted for 20% of colonoscopies. The most common indications were rectal bleeding (33.6%), irritable bowel symptoms (23.8%), or screening because of a positive family history of colorectal cancer (22.4%) and screening with a primary colonoscopy or a fecal occult blood test (FOBT) (12.8%). In patients 50 years and older, asymptomatic screening (average-risk screening colonoscopy, positive family history, or FOBT positivity) accounted for 38.1% of all colonoscopies. Surveillance colonoscopy in patients with previous cancer or polyps accounted for 21.9% of colonoscopies performed in this age group. Differences in utilization were noted, based on gender and race.

CONCLUSIONS

Colonoscopy utilization varies based on age, gender, and race. Colonoscopy often is performed in patients less than 50 years old for irritable bowel symptoms; rectal bleeding; or average-risk screening, for which benefits are uncertain. In patients older than 50 years, surveillance after polyp removal is a common indication and may be overused. Understanding utilization can lead to further study to determine outcomes, to optimize utilization, and to provide a basis for shifting limited resources.

The evaluation of rectal bleeding in adults. A cost-effectiveness analysis comparing four diagnostic strategies

BACKGROUND

Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown.

OBJECTIVE

To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding.

DESIGN

Cost-effectiveness analysis using a Markov decision model.

DATA SOURCES

Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry.

TARGET POPULATION

Patients over age 40 with otherwise asymptomatic rectal bleeding.

TIME HORIZON

The patient's lifetime.

PERSPECTIVE

Modified societal perspective.

INTERVENTIONS

Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy.

OUTCOME MEASURES

Incremental cost-effectiveness ratio.

RESULTS OF BASE-CASE ANALYSIS

The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was 5,480 dollars per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy.

RESULTS OF SENSITIVITY ANALYSES

The cost of colonoscopy was reduced to 1,686 dollars per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above 34,000 dollars.

CONCLUSIONS

Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.

Predictive value of rectal bleeding for distal colonic neoplastic lesions in a screened population

The aim of this study was to determine the diagnostic value of rectal bleeding for distal colorectal cancer (CRC), or large (> or =10 mm) adenomas among an average-risk population. A cross-sectional survey was conducted among individuals aged 55-64 years, who attended sigmoidoscopy (FS) screening in the context of a multicentre randomised trial of FS screening for CRC. Sensitivity, specificity and positive predictive value (PPV) of rectal bleeding for large distal adenomas or CRC were calculated. Rectal bleeding was reported by 8.8% of 8507 patients examined (15% of those with large adenomas and 29% of those with CRC). The risk of CRC was increased when bleeding was associated with an altered bowel habit: odds ratio (OR)=10.42; 95% Confidence Interval (CI): 4.08-26.59; the corresponding OR for isolated bleeding was 5.29 (95% CI: 2.28-12.30). Rectal bleeding carries an increased risk of distal neoplastic lesions. However, most lesions are detected among asymptomatic subjects. This finding suggests that screening represents the optimal strategy to detect CRC or large adenomas in the distal colon in the targeted age range.

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding

OBJECTIVE

This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding.

METHODS

One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus.

RESULTS

In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids.

CONCLUSIONS

In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.