9. Appropriateness of colonoscopy: lower abdominal pain or constipation

Comparative analysis of diagnostic colonoscopy in symptomatic young adults from South Korea and the United States

To date, not much is known about ethnic differences in the prevalence of colorectal neoplasia in symptomatic young patients with lower gastrointestinal symptoms. This study sought to compare diagnostic colonoscopic findings in symptomatic young patients from South Korea and the United States. Results from the first diagnostic colonoscopies in symptomatic 18- to 49-year-old patients were compared between the United States and Korean cohorts. The US cohort data were collected at Virginia Mason Medical Center in Seattle, Washington between January 2007 and January 2010, and the Korean cohort data were collected at 14 university hospitals in Korea between June 2006 and June 2015.The prevalence of advanced neoplasias was similar in both cohorts for bleeding and nonbleeding symptoms (P = .966 and P = .076, respectively). In a subgroup analysis for 40- to 49-year-old patients, the prevalence of advanced neoplasias was similar for bleeding symptoms; however, nonbleeding symptoms were significantly higher in the Korean cohort than in the US cohort (6.2% vs 2.6%, P < .001). In an age subgroup analysis for 18- to 39-year-old patients, the prevalence of advanced neoplasias was similar for bleeding and nonbleeding symptoms in both cohorts. Multivariate analysis showed that lower gastrointestinal symptoms were not associated with the risk of any type of advanced neoplasia in young Korean patients.Ethnic disparities in the prevalence of advanced neoplasia on diagnostic colonoscopy were not noticeable between Korean and US young patients. However, 40- to 49-year-old patients with nonbleeding symptoms require more attention to detect advanced neoplasia in Korea than similarly aged patients in the United States.

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.

A risk profile for advanced proximal neoplasms on diagnostic colonoscopy

The capacity for colonoscopy is limited and a method to prioritize patients for diagnostic colonoscopy is needed in health care centers. A retrospective cross-sectional cohort study was carried out in county and community endoscopy centers, which included 1,065 county and 279 community patients aged > or = 40 years undergoing diagnostic colonoscopy. We constructed a risk profile for proximal advanced neoplasms on diagnostic colonoscopy at the county center based on the size of the regression coefficients for independent risk factors from logistic regression. An advanced neoplasm was defined as one of size > or = 1 cm or containing villous histology, high-grade dysplasia, or cancer. In our county colonoscopy population (n = 929 after exclusions), the stepwise logistic regression analysis identified age > or = 60 years (adjusted odds ratio [AOR]: 2.60; 95% confidence interval [CI]:1.14, 6.14), iron deficiency anemia (AOR: 4.74; 95% CI: 2.07, 11.34), and an advanced neoplasm in the recto-sigmoid (AOR: 6.01; 95% CI: 2.02, 16.00) as the statistically significant predictors of an advanced proximal neoplasm. In the county population, the prevalence rates of an advanced proximal neoplasm and proximal high-grade dysplasia/cancer in the low-risk group were 0.71% (95% CI: 0.15, 2.05) and 0.24% (95% CI: 0.01, 1.31), respectively. Avoiding colonoscopy in this group would increase the capacity for colonoscopy by 46% in the higher risk groups. In a disparate community population (n = 237 after exclusions), this scoring system had a goodness-of-fit test showing high concordance (P = 0.51). This clinical profile stratified the risk for an advanced neoplasm proximal to the sigmoid in patients undergoing diagnostic colonoscopy. It identified a large subset of low-risk patients.

The yield of lower endoscopy in patients with constipation: survey of a university hospital, a public county hospital, and a Veterans Administration medical center

BACKGROUND

The role of endoscopy in the evaluation of constipation is controversial. The aim of this study was to clarify the yield of lower endoscopy in patients with constipation.

METHODS

Endoscopic databases from 3 diverse hospitals were searched for procedures with constipation as an indication. Detection of neoplasia was the main outcome of interest.

RESULTS

Among 19,764 sigmoidoscopies or colonoscopies, constipation was a procedure indication for 563 patients (mean age 61 [16] years, 52% women); 58% had procedure indications in addition to constipation. Colorectal cancer was diagnosed in 8 (1.4%), adenomas in 82 (14.6%), and advanced lesions (cancer or adenoma with malignancy, high-grade dysplasia, villous features, or size > or = 10 mm) in 24 (4.3%). In the 358 patients who underwent colonoscopy, cancer was detected in 1.7%, adenomas in 19.6%, and advanced lesions in 5.9%. Two patients with cancer were less than 50 years of age. In as many as 6 patients with cancer, the tumor may have caused partial obstruction.

CONCLUSIONS

The range of neoplasia in patients with constipation evaluated with lower endoscopy was comparable with what would be expected in asymptomatic subjects undergoing colorectal cancer screening. Although chronic constipation alone may not be an appropriate indication for lower endoscopy, age-appropriate colorectal cancer screening should be pursued when patients with constipation seek medical care.