8. Appropriateness of colonoscopy: hematochezia

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.

Endoscopic lesions in low-to average-risk patients with minimal bright red bleeding from midline anal fissures. How much should we go in?

BACKGROUND

Anal fissure is a common condition in young patients, and the main symptoms include anal pain and bleeding. Our aim was to determine the need to perform lower gastrointestinal endoscopy on patients with midline anal fissure who present with minimal bright red rectal bleeding and who are at low risk for colorectal neoplasia.

METHODS

Patients with midline anal fissure who reported small amounts of red blood on toilet paper, toilet bowl or stool after defecation were evaluated. Patients with alarm signs (recently altered bowel habit, weight loss, anemia and family or personal history of colorectal neoplasms) were excluded. A total of 134 patients (80 female and 54 male, aged 35.8+/-11.4 years) were studied. Patients younger than 40 years underwent flexible sigmoidoscopy and colonoscopy was used for older ones.

RESULTS

Fissures were posterior in 106 cases (79.1%) and anterior in 27 cases (20.1%); one patient (0.7%) had both anterior and posterior fissures. The lower gastrointestinal endoscopy was normal in 120 patients (89.6%), and 36 patients (26.9%) had associated internal hemorrhoids. Adenomatous polyps were found in 4 cases (3.0%), ulcerative colitis in 8 (6.0%) and Crohn's disease in one patient (0.7%). There was no case of adenocarcinoma.

CONCLUSIONS

Clinical evaluation plus rectoscopy might be the appropriate evaluation in this selected group of patients, if our results are confirmed by further studies.

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.

Yield of colonoscopy in patients with nonacute rectal bleeding: a multicenter database study of 1766 patients

OBJECTIVE

There are few data to guide the choice between colonoscopy and flexible sigmoidoscopy in patients with nonacute rectal bleeding, especially in younger age groups. Our aim was to determine the yield of colonoscopy for significant proximal large bowel disease in the absence of significant distal disease, with special reference to young patients.

METHODS

This was a retrospective study of data collected prospectively in 1766 patients (median age 57 yr, 711 women). The endoscopic database (GI-Trac) contained 152 discrete fields for data input. Multiple logistic regression analysis was performed to identify variables independently associated with the presence of isolated significant proximal disease.

RESULTS

Young patients had a higher percentage of normal examinations than did older patients. The incidence of diverticular disease, small polyps, large polyps, and cancer rose with increasing age. No patient aged <40 yr had an isolated proximal cancer, but 7% had other significant isolated proximal disease. There was no overall association between age and significant proximal disease in the absence of significant distal disease (p = 0.66). The only variable associated with isolated proximal disease was anemia (odds ratio = 1.81; 95% CI = 1.11-2.93; p = 0.02).

CONCLUSION

The yield of colonoscopy (beyond the range of sigmoidoscopy) for neoplasia is low in patients aged <40 yr, but other significant disease may be missed if age is the only criterion determining colonoscopy use.