Adults

Colorectal cancer (CRC) is a major clinical and public health burden. Screening has been shown to be effective in preventing CRC. In 2021, less than 72% of adult Americans had received CRC screening based on the most recent guidelines. This study examined the relationship between social support and screening colonoscopy or sigmoidoscopy uptake among U.S. adults and the socioeconomic factors that impact the relationship. We conducted a cross-sectional study using the 2021 National Health Interview Survey (NHIS) data for 20,008 U.S. adults to assess the weighted rates of screening colonoscopy or sigmoidoscopy among individuals with strong, some, and weak social support. Adjusted binary logistic regression models were utilized to obtain the weighted odds of receiving a screening colonoscopy or sigmoidoscopy among adults with different levels of social support and socioeconomic status. About 58.0% of adults who reported having colonoscopy or sigmoidoscopy had strong social support, compared to 52.0% who had some or weak social support. In addition, compared to adults with weak social support, the weighted adjusted odds of having colonoscopy or sigmoidoscopy were 1.0 (95% C.I. = 0.994, 0.997; p < 0.001) and 1.3 (95% C.I. = 1.260, 1.263; p < 0.001) for adults with some and strong social support, respectively. Socioeconomic differences were observed in the odds of colonoscopy or sigmoidoscopy uptake based on having strong social support. Having strong social support is an important factor in increasing colonoscopy or sigmoidoscopy screening uptake. Policies and interventions that enhance social support among adults for screening colonoscopy or sigmoidoscopy are warranted.

Lower endoscopy, early-onset, and average-onset colon cancer among Medicaid beneficiaries with and without HIV

BACKGROUND

Studies suggest a lower colorectal cancer (CRC) risk and lower or similar CRC screening among people with HIV (PWH) compared with the general population. We evaluated the incidence of lower endoscopy and average-onset (diagnosed at ≥50) and early-onset (diagnosed at <50) colon cancer by HIV status among Medicaid beneficiares with comparable sociodemographic factors and access to care.

METHODS

We obtained Medicaid Analytic eXtract (MAX) data from 2001 to 2015 for 14 states. We included 41 727 243 and 42 062 552 unique individuals with at least 7 months of continuous eligibility for the endoscopy and colon cancer analysis, respectively. HIV and colon cancer diagnoses and endoscopy procedures were identified from inpatient and other nondrug claims. We used Cox proportional hazards regression models to assess endoscopy and colon cancer incidence, controlling for age, sex, race/ethnicity, calendar year and state of enrollment, and comorbidities conditions.

RESULTS

Endoscopy and colon cancer incidence increased with age in both groups. Compared with beneficiaries without HIV, PWH had an increased hazard of endoscopy; this association was strongest among those 18-39 years [hazard ratio: 1.85, 95% confidence interval (95% CI) 1.77-1.92] and attenuated with age. PWH 18-39 years also had increased hazard of early-onset colon cancer (hazard ratio: 1.66, 95% CI:1.05-2.62); this association was attenuated after comorbidity adjustment. Hazard ratios were null among all beneficiaries less than 50 years of age. PWH had a lower hazard of average-onset colon cancer compared with those without HIV (hazard ratio: 0.79, 95% CI: 0.66-0.94).

CONCLUSION

PWH had a higher hazard of endoscopy, particularly at younger ages. PWH had a lower hazard of average-onset colon cancer. Early-onset colon cancer was higher among the youngest PWH but not associated with HIV overall.

Microscopic Colitis in a Young Male: Unveiling the Rarity

In recent decades, microscopic colitis (MC) has become increasingly recognized as a common contributor to diarrhea and lower gastrointestinal symptoms, particularly among the older demographic. The condition is distinguished by persistent diarrhea with loose watery stools, and endoscopic examination is typically normal with characteristic histopathologic findings. MC is rarely seen under 30 years of age and is less common in males. Our case highlights an exceedingly uncommon clinical setting as it involves a young male who was diagnosed with collagenous colitis. The diagnosis of MC can easily be missed by physicians during initial evaluation. Specifically in irritable bowel syndrome patients with diarrhea predominant symptoms, a colonoscopy should be performed and biopsies should be taken from the entire colon to rule out MC.

An Unusual, Delayed Presentation of a Migrated Intrauterine Contraceptive Device Into the Rectosigmoid Colon

The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.

The value of pre-operative outpatient flexible sigmoidoscopy in patients with deep infiltrating endometriosis

BACKGROUND

Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management.

OBJECTIVES

We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE.

MATERIALS AND METHODS

A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of luminal disease.

RESULTS

102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%.

CONCLUSIONS

Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning.

WHAT IS NEW?

This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Flexible Sigmoidoscopy Utility in the Diagnosis of Pediatric Gastrointestinal Disorders

AIM

 Although flexible sigmoidoscopy (FS) is utilized in children for the diagnosis of pediatric gastrointestinal conditions, such as inflammatory bowel disease and juvenile polyp disorders, the diagnostic yield of FS in pediatric patients is unknown.

MATERIALS AND METHODS

 We retrospectively reviewed FS cases in children under 18 years of age over a five-year period at our institution. Indications for the procedure, endoscopic visual findings, histologic findings, final diagnosis, and any management changes based on FS findings were included.

RESULTS

 A total of 354 cases were included in the analysis for which 40 cases (11.3%) had abnormal visual findings, 48 cases (13.6%) had abnormal histologic findings, and 13 cases (3.7%) had both abnormal endoscopic visual and histologic findings. Of the 88 cases with abnormal visual and/or histologic abnormalities, only the results of 34 of these FS cases led to a change in management based on endoscopic findings (9.6%). Most patients with a non-diagnostic FS had a final diagnosis of functional abdominal pain; most patients with a diagnostic FS had a final diagnosis of colitis, not otherwise specified.

CONCLUSION

 Our findings suggest that FS is not a helpful diagnostic endoscopic intervention in pediatric patients, especially in children with reassuring history and physical exam findings.

Evaluation of Colonoscopy and Sigmoidoscopy Utilization for Colorectal Cancer Screening in Georgia, USA

Colorectal cancer (CRC) is the third most prevalent cancer, and the second most common cancer-related cause of death in the United States (USA). Timely screening reduces both CRC incidence and mortality. Understanding population behaviors and factors that influence CRC screening is important for directing interventions targeted at reducing CRC rates. The 1997-2018 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed for trends in colonoscopy and sigmoidoscopy utilization for CRC screening among adults in Georgia, USA. Overall, in Georgia, there has been an increase in the prevalence of colonoscopy and sigmoidoscopy utilization from 48.1% in 1997 to 71.2% in 2018 (AAPC = 2.30, p < 0.001). Compared nationally, this increase was less pronounced (from 41.0% in 1997 to 73.7% in 2018 (AAPC = 2.90, p < 0.001) overall for USA). Logistic regression analysis of the 2018 BRFSS data, adjusting for sociodemographic factors, shows that sex (female vs. male [aOR = 1.20, C.I. = 1.05, 1.38]); marital status (couple vs. single [aOR = 1.20, C.I. = 1.04, 1.39]); healthcare coverage (yes vs. no [aOR = 3.86, C.I. = 3.05, 4.88]); age (60-69 years [aOR = 2.38, C.I. = 2.02, 2.80], 70-79 [aOR = 2.88, C.I. = 2.38, 3.48] vs. 50-59 years); education (high school [aOR = 1.32, C.I. = 1.05, 1.65], some post high school [aOR= 1.63, C.I. = 1.29, 2.06], college graduate [aOR = 2.08, C.I. = 1.64, 2.63] vs. less than high school); and income ($25,000-$49,999 [aOR = 1.24, C.I. = 1.01, 1.51], $50,000+ [aOR = 1.56, C.I. = 1.27, 1.91] vs. <$25,000) were all significantly associated with colonoscopy and sigmoidoscopy utilization. In Georgia, a significant increase over time in colonoscopy and sigmoidoscopy utilization for CRC screening was observed pertaining to the associated sociodemographic factors. The findings from this study may help guide tailored programs for promoting screening among underserved populations.

Characteristics of non-participants in a randomized colorectal cancer screening trial comparing sigmoidoscopy and faecal immunochemical testing

Public health systems should guarantee universal access to health care services, including cancer screening. We assessed whether certain population subgroups were underrepresented among participants in colorectal cancer screening with sigmoidoscopy and faecal immunochemical testing (FIT). Between 2012 and 2019, about 140 000 individuals aged 50 to 74 years were randomly invited to once‐only sigmoidoscopy or first round of FIT screening. Our study included 46 919 individuals invited to sigmoidoscopy and 70 019 to FIT between 2012 and 2017. We used logistic regression models to evaluate if demographic and socioeconomic factors and use of certain drugs were associated with participation. Twenty‐four thousand one hundred and fifty‐nine (51.5%) individuals attended sigmoidoscopy and 40 931 (58.5%) FIT screening. Male gender, young age, low education and income, being retired or unemployed, living alone, being an immigrant, long driving time to screening centre, and use of antidiabetic and psychotropic drugs were associated with low participation in both screening groups. Many of these factors also predicted low acceptance of colonoscopy after positive FIT. While male gender, young age and living alone were more strongly associated with nonparticipation in FIT than sigmoidoscopy, low education and income, being retired or immigrant and long driving time were more strongly associated with nonparticipation in sigmoidoscopy than FIT. In conclusion, participation was lower in sigmoidoscopy than FIT. Predictors of nonparticipation were similar between arms. However, low socioeconomic status, being an immigrant and long driving time affected participation more in sigmoidoscopy screening, suggesting that FIT may guarantee more equal access to screening services than sigmoidoscopy.

Optimal Strategies for Colorectal Cancer Screening

Colorectal cancer (CRC) imposes significant morbidity and mortality, yet it is also largely preventable with evidence-based screening strategies. In May 2021, the US Preventive Services Task Force updated guidance, recommending screening begin at age 45 for average-risk individuals to reduce CRC incidence and mortality in the United States (US). The Task Force recommends screening with one of several screening strategies: high-sensitivity guaiac fecal occult blood test (HSgFOBT), fecal immunochemical test (FIT), multi-target stool DNA (mt-sDNA) test, computed tomographic (CT) colonography (virtual colonoscopy), flexible sigmoidoscopy, flexible sigmoidoscopy with FIT, or traditional colonoscopy. In addition to these recommended options, there are several emerging and novel CRC screening modalities that are not yet approved for first-line screening in average-risk individuals. These include blood-based screening or “liquid biopsy,” colon capsule endoscopy, urinary metabolomics, and stool-based microbiome testing for the detection of colorectal polyps and/or CRC. In order to maximize CRC screening uptake in the US, patients and providers should engage in informed decision-making about the benefits and limitations of recommended screening options to determine the most appropriate screening test. Factors to consider include the invasiveness of the test, test performance, screening interval, accessibility, and cost. In addition, health systems should have a programmatic approach to CRC screening, which may include evidence-based strategies such as patient education, provider education, mailed screening outreach, and/or patient navigation, to maximize screening participation.

Reduction in Standard Cancer Screening in 2020 throughout the U.S

Cancer screening is an important way to reduce the burden of cancer. The COVID-19 pandemic created delays in screening with the potential to increase cancer disparities in the United States (U.S.). Data from the 2014-2020 Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed to estimate the percentages of adults who reported cancer screening in the last 12 months consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation for cervical (ages 21-65), breast (ages 50-74), and colorectal cancer (ages 50-75) prior to the pandemic. Cancer screening percentages for 2020 (April-December excluding January-March) were compared to screening percentages for 2014-2019 to begin to look at the impact of the COVID-19 pandemic. Screening percentages for 2020 were decreased from those for 2014-2019 including several underserved racial groups. Decreases in mammography and colonoscopy or sigmoidoscopy were higher among American Indian/Alaskan Natives, Hispanics, and multiracial participants, but decreases in pap test were also highest among Hispanics, Whites, Asians, and African-Americans/Blacks. Decreases in mammograms among women ages 40-49 were also seen. As the 2020 comparison is conservative, the 2021 decreases in cancer screening are expected to be much greater and are likely to increase cancer disparities substantially.

A single-center experience and review of literature

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a curative therapy used to treat high-risk hematological malignant disorders and other life-threatening nonmalignant diseases. Gastrointestinal (GI) symptoms post-HSCT might be due to GI graft-versus-host disease (GVHD) or GI infections or both. GI endoscopy with biopsies is safe and beneficial in guiding the management of GI symptoms in children after HSCT, justifying the therapeutic management and contributing to improved outcomes.

METHODS

A retrospective cohort study including 16 children with malignant and nonmalignant diseases that underwent allogeneic HSCT who had 24 ileo-colonoscopies performed for GI symptoms. To facilitate an evidence-based approach to the endoscopic evaluation of GI symptoms in pediatric patients post HSCT, we examined whether a full ileo-colonoscopy, which includes right colon and terminal ileum (TI), as opposed to a limited sigmoidoscopy, was more accurate in the evaluation of GI symptoms in pediatric patients post HSCT.

RESULTS

Specific findings on the right colon/TI were found in nine out of 24 ileo-colonoscopies (38%, CI = 19%-59%). The macroscopic findings on ileo-colonoscopy were compared with the histopathologic findings. When macroscopic findings were present, there were matching histopathologic findings in 100% of cases. However, even in the absence of any macroscopic findings on ileo-colonoscopy, there were histopathological findings in 29% of the cases (p-value = .016).

CONCLUSIONS

This cohort favors ileo-colonoscopy over sigmoidoscopy, with systematic biopsy sampling, in evaluating GI symptoms in pediatric patients post HSCT.

Routine Endoscopy After Acute Sigmoid Diverticulitis: Would a Sigmoidoscopy be Sufficient?

Background: Current guidelines suggest that patients should undergo colonoscopy after CT confirmed acute diverticulitis to outrule colorectal cancer (CRC). The aim of this study was to determine if flexible sigmoidoscopy (FS) could be a viable alternative to full colonoscopy following acute sigmoid diverticulitis.

Methods: A retrospective study of 271 patients was performed who were diagnosed with acute sigmoid diverticulitis by CT and subsequently underwent full colonoscopy. Medical records, CT reports, endoscopy reports, and histopathological reports were reviewed.

Results: Sigmoid diverticulosis was confirmed on colonoscopy in all patients. No colorectal malignancies were detected. Adenomatous polyps were found in 16 (5.9%) patients, of which three had polyps detected beyond the sigmoid colon. The overall proportion of abnormalities found beyond the sigmoid colon was 1.1% (n=3).

Conclusion: The detection of CRC cancer in patients undergoing full colonoscopy following an episode of acute sigmoid diverticulitis is rare. Despite this, current guidelines still advocate for endoscopy due to the potentially serious consequences of a missed malignancy. However, given that the area of concern in these cases is the sigmoid colon, FS may be a feasible means of outruling malignancy in the absence of red flag features that would necessitate a full colonoscopy. Our results support this approach, with no CRC detected and a polyp detection rate equivalent to that of the general population. This offers numerous advantages to a full colonoscopy for the patient and health service by being a quicker, cheaper, safer procedure without the need for full bowel preparation or IV sedation.

The role of sex and rurality in cancer fatalistic beliefs and cancer screening utilization in Florida

BACKGROUND

People's fatalistic beliefs about cancer can influence their cancer prevention behaviors. We examined the association between fatalistic beliefs and breast and colorectal cancer screening among residents of north-central Florida and tested whether there exists any sex or rural-non-rural disparities in the association.

METHODS

We conducted a cross-sectional, random digit dialing telephone survey of 895 adults residing in north-central Florida in 2017. Using weighted logistic models, we examined the association between (1) respondents' sociodemographic characteristics and cancer fatalistic beliefs and (2) cancer fatalistic beliefs and cancer screening utilization among screening eligible populations. We tested a series of sex and rurality by fatalistic belief interactions.

RESULTS

Controlling for sociodemographics, we found the agreement with "It seems like everything causes cancer" was associated with a higher likelihood of having a mammogram (odds ratio [OR]: 3.34; 95% confidence interval [CI]: 1.17-9.51), while the agreement with "Cancer is most often caused by a person's behavior or lifestyle" was associated with a higher likelihood of having a blood stool test (OR: 1.85; 95% CI: 1.12-3.05) or a sigmoidoscopy or colonoscopy among women (OR: 2.65; 95% CI: 1.09-6.44). We did not observe any rural-non-rural disparity in the association between fatalistic beliefs and cancer screening utilization.

CONCLUSIONS

Some, but not all, cancer fatalistic beliefs are associated with getting breast and colorectal cancer screening in north-central Florida. Our study highlights the need for more research to better understand the social and cultural factors associated with cancer screening utilization.

Rectal Invasion by Metastatic Prostate Adenocarcinoma

In men, prostate cancer is the second most diagnosed cancer worldwide. Typical sites for metastasis include bone, lung, and liver. Prostate cancer with gastrointestinal involvement, particularly rectal, has been rarely reported in the literature. As patients with prostate cancer with rectal invasion may present with symptoms similar to those of other gastrointestinal pathologies, such as anal fissures and rectal carcinoma itself, misdiagnosis and delays in care can result. Direct visualization of the rectum via endoscopy, along with biopsy, allows clinicians to make an accurate and timely diagnosis in patients with prostate cancer with rectal involvement, which in turn leads to broader available treatment options.

Endoscopic and clinical correlation with dose to sigmoid colon in carcinoma cervix patients treated with radical radiotherapy

Context

Sigmoid colon, due to its close proximity to central tandem in intracavitary brachytherapy (BT), is at risk of receiving high dose, the clinical significance of which is not documented.

Aim

This study was designed to assess the dose received by sigmoid colon following radical treatment and to correlate clinically with the sigmoid mucosal changes seen on sigmoidoscopy.

Settings and Design

This is a prospective study.

Subjects and Methods

Thirty histologically proven carcinoma cervix patients treated with radical radiotherapy were accrued. A baseline sigmoidoscopy was done and repeated at 6 months following completion of BT. The dose-volume parameters (DVP) were used to calculate the dose received by the sigmoid colon and correlate with symptoms along with the sigmoid mucosal changes.

Statistics

The following were the statistical methods used: frequency; percentages; and descriptive statistics such as mean ± standard deviation, Chi-square test, Kolmogorov-Smirnov test, and independent sample t-test. P < 0.05 was considered statistically significant.

Results

The dose of the sigmoid colon in patients with a sigmoidoscopy score of ≥2 was significantly high compared to that of patients with a score of <2 for DVP such as D0.1cc, D1cc, D2cc, D5cc, and mean dose, whereas max dose was not significantly high.

Conclusions

The dose received by the sigmoid colon is directly proportional to the mucosal changes and hence possibly a higher morbidity. Tighter dose-volume constraints, better optimization techniques, and close follow-up sigmoidoscopy will help in the prevention and early treatment of long-term morbidity.

Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven-years' experience

BACKGROUND

Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal.

METHODS

From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed.

RESULTS

There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal.

CONCLUSION

This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

EVIDENCE FACTORS IN A CASE-CONTROL STUDY WITH APPLICATION TO THE EFFECT OF FLEXIBLE SIGMOIDOSCOPY SCREENING ON COLORECTAL CANCER

As in any observational study, in a case-control study a primary concern is potential unmeasured confounders. Bias, due to unmeasured confounders, can result in a false discovery of an apparent treatment effect when there is none. Replication of an observational study, which tries to provide multiple analyses of the data where the biases affecting each analysis are thought to be different, is one way to strengthen the evidence from an observational study. Evidence factors allow for internal replication by testing a hypothesis using multiple comparisons in a way that the comparisons yield independent evidence and differ in the sources of potential bias. We construct evidence factors in a case-control study in which there are two types of cases, "narrow" cases which are thought to be potentially more affected by the exposure and "marginal" cases which are thought to have more heterogeneous causes. We develop and study an inference procedure for using such evidence factors and apply it to a study of the effect of sigmoidoscopy screening on colorectal cancer.

Patient participation in gastrointestinal endoscopy - From patients' perspectives

Background

Patient participation is associated with satisfaction and improved health‐related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.

Objective

To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.

Methods

Semi‐structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19‐80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.

Results

Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff ‘invited’ patients in decision making.

Discussion

This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.

Conclusions

Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.

Iatrogenic rectal injury associated with fleet enema administration masquerading as Fournier's Gangrene

Rectal injuries secondary to fleet enemas are the result of a chemical irritation as well as mechanical trauma causing localized perforation and mucosal necrosis. These injuries can be managed expectantly. Fournier’s Gangrene is a life-threatening, fulminant soft tissue infection of the genito-perineal region commonly secondary to a perianal infection, requiring extensive debridement of all affected tissue and judicious antibiotic therapy. This distinction is critical in the management of the current case, allowing for limited debridement and judicious observation without a resection of the injured rectum. A diverting colostomy allows for effective faecal management and minimizes contamination of the perineal wound.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Colorectal cancer in young patients: a retrospective cohort study in a single institution

BACKGROUND

Young onset colorectal cancer is on the rise, with a disproportionate increase in incidence among young people, both in Australia and internationally. Current national guidelines for bowel cancer screening in average risk individuals include only patients greater than 50 years of age. It is well recognized that colorectal cancer is a highly treatable malignancy when detected at an early stage, and timely diagnosis yields a greater than 90% chance of cure and survival. The aims of this study were to define the clinical presentations leading to colonoscopy in young patients and assess the incidence of malignancy in this group.

METHODS

This is a retrospective cohort study including all patients ≤35 years of age without any baseline indication for early bowel cancer surveillance that underwent colonoscopy at Caboolture Hospital from January 2017 to April 2018.

RESULTS

A total of 224 patients underwent colonoscopy in the study period. A total of 210 (93.8%) had symptoms including rectal bleeding (51.7%), altered bowel habit (25.9%), abdominal pain (10.3%) and symptomatic anaemia (6.7%) prior to colonoscopy. Two cases of invasive adenocarcinoma were identified (0.89%, P < 0.01), both of which were symptomatic and were defined as stage IIIB disease on histopathology.

CONCLUSION

In a theoretically low-risk population, the incidence of malignancy was nearly 1%. More advanced disease at diagnosis may be due to a delay in investigating these patients due to an overall low suspicion of cancer in young individuals. As such, investigation should be offered early to young patients presenting with any warning symptoms.

Effectiveness of sigmoidoscopy for assessing ulcerative colitis disease activity and therapeutic response

Ulcerative colitis (UC) typically begins in the rectum and progresses proximally in a contiguous fashion without skip lesions. Post-treatment inflammation distribution can change over time. Colonoscopy is unpleasant for the patient and clinical trials often use sigmoidoscopy for evaluation of disease severity. The aim of this study is to evaluate whether sigmoidoscopy is adequate to assess disease activity and therapeutic response as colonoscopy.We retrospectively reviewed patients who underwent colonoscopy for the initial diagnosis and follow-up by evaluating their mucosal inflammation in our hospital from January 2012 and December 2017.A total of 69 patients were analyzed. During follow up, the inflamed segment changed post-treatment in 62% (43/69). Extensive UC was common in the changed disease extent group (P < .01). Patients treated with oral mesalazine had a higher rate of changed disease extent (P < .01). The sigmoid segment was the most commonly involved segment, and the rectum was the severely inflamed segment during initial diagnosis and follow-up. According to Mayo endoscopic subscore (MES) in the most severely inflamed colonic and rectosigmoid segment, there were high degrees of correlation in the initial UC diagnosis (r = .90, P < .01) and follow-up (r = .74, P < .01).Our findings suggest that sigmoidoscopy is effective as colonoscopy for detecting disease activity and evaluating therapeutic response in UC patients during follow-up.

Population-based assessment of the performance of sigmoidoscopy in the detection of colorectal cancer: implications for future screening recommendations

Current North American guidelines endorse the use of flexible sigmoidoscopy every 10 years as an alternative to fecal testing for the screening of colorectal cancer (CRC). The present study aims to evaluate its performance in a hypothetical population-based scenario, using data from the Surveillance, Epidemiology and End Results (SEER)-18 database. We explored the SEER database with the SEER*stat software. All cases diagnosed as colorectal carcinoma within the age group of 50-74 years during the year 2010 were included. Cases were considered either accessible or non-accessible to detection by screening sigmoidoscopy by virtue of their anatomic location. For example, cases within the rectum, sigmoid or descending colon were considered accessible whereas cases within other colorectal sub-sites were considered non-accessible. Assuming that all eligible United States' citizens underwent screening sigmoidoscopy and assuming that all CRC cases within accessible sites were correctly identified by sigmoidoscopy, true positive, true negative, and false negative cases were calculated. False positive cases, however, were non-calculable. Sensitivity and negative predictive value (NPV) of screening sigmoidoscopy were derived accordingly. A total of 18,794 patients aged between 50-74 years were diagnosed in 2010. The total United States' population covered by the SEER-18 registry in the same year and within the same age group was 21,613,411 individuals. A total of 10,786 CRC patients (57.4%) were diagnosed in sigmoidoscopy-accessible sites, 7,532 CRC patients (40.1%) were diagnosed in sigmoidoscopy-non-accessible sites, and an additional 476 patients (2.5%) were identified as unknown sub-sites. This translated into 2,853 CRC-related deaths at 5 years for sigmoidoscopy-accessible tumors versus 2,126 CRC-related deaths for sigmoidoscopy-non-accessible tumors. Based on the study's assumptions, sensitivity of screening sigmoidoscopy would be 58.8% and NPV would be 99.9%. Flexible sigmoidoscopy has an unacceptably low sensitivity for the detection of right-sided CRC; therefore, its use as a first-line screening modality should be questioned. Additional studies on alternative screening options for right-sided CRC are warranted.

Capability of four sigmoidoscopy-based screening strategies to predict proximal neoplasia in an asymptomatic Chinese population

BACKGROUND AND AIM

A proper colonoscopy referral criterion is essential for flexible sigmoidoscopy-based colorectal cancer screening. We aimed to compare the predictive capability of four existing criteria to detect proximal neoplasia (PN) and advanced proximal neoplasia (APN) in a Chinese population.

METHODS

Asymptomatic Chinese participants aged 50-75 years, who received screening colonoscopy, were consecutively recruited. The four criteria included (i) UK flexible sigmoidoscopy; (ii) Italian Screening for COlon REctum; (iii) NORwegian Colorectal Cancer Prevention trial; and (iv) US clinical index. The sensitivity, specificity, positive/negative predictive value, and the number of subjects needed to screen (NNS)/refer (NNR) to detect one APN/PN were examined. The area under receiver operating characteristic curve was evaluated.

RESULTS

Among 5833 subjects, 749 (12.8%) and 151 (2.6%) cases were found to have PN and APN, respectively. US criteria achieved the highest sensitivity for PN (49%) and APN (66%), while UK criteria attained the highest specificity (93%) for PN/APN. The lowest NNS was required by US criteria for PN (16 vs 19-38) and APN (58 vs 69-86), while the lowest NNR was required by UK criteria for PN (3.2 vs 4.0-4.8) and APN (7 vs 10-16). The receiver operating characteristic of all four criteria was 0.57-0.61 for PN and 0.68-0.70 for APN.

CONCLUSIONS

Among all the four criteria, US criteria had the highest sensitivity and lowest NNS, while UK criteria achieved the highest specificity and lowest NNR. Their limited discriminatory capability highlighted the need for a new score to predict PN/APN in Chinese populations.

Detection of serrated lesions in proximal colon by simulated sigmoidoscopy vs faecal immunochemical testing in a multicentre, pragmatic, randomised controlled trial

Background

The diagnostic yield of the faecal immunochemical test and sigmoidoscopy in detecting proximal serrated polyps in a colorectal cancer screening programme has not been fully assessed.

Aim

We determined the detection rate of proximal serrated polyps by simulated sigmoidoscopy and faecal immunochemical test compared with total colonoscopy in a population-based, multicentre, nationwide, randomised controlled trial (ColonPrev study).

Methods

Sigmoidoscopy yield was simulated based on the UK-Flexible Sigmoidoscopy Trial for total colonoscopy referral. Definitions were: proximal serrated polyp (proximal serrated polyp): sessile serrated polyp or hyperplastic polyp of any size and proximal at-risk serrated polyp (at-risk proximal serrated polyp): sessile serrated polyp of any size or hyperplastic polyp ≥ 10 mm, both located proximally to the splenic flexure.

Results

A total of 10,611 individuals underwent faecal immunochemical test and 5059 underwent total colonoscopy and were evaluated by simulated sigmoidoscopy. Sigmoidoscopy and faecal immunochemical test were less accurate in detecting proximal serrated polyps (odds ratio: 0.13; 95% confidence interval: 0.10-0.18 and 0.13; 0.09-0.18, p < 0.0001, respectively). Both tests were inferior to colonoscopy in detecting at-risk proximal serrated polyps, and sigmoidoscopy was inferior to faecal immunochemical test in detecting these lesions (odds ratio: 0.17; 95% confidence interval: 0.10-0.30 and 0.25; 0.17-0.37, p < 0.0001, respectively).

Conclusion

Sigmoidoscopy and faecal immunochemical test are less accurate in detecting proximal serrated polyps than colonoscopy, particularly in women.

Cost-effectiveness of colorectal cancer screening programmes using sigmoidoscopy and immunochemical faecal occult blood test

OBJECTIVE

Several European countries are implementing organized colorectal cancer (CRC) screening programmes using faecal immunochemical test (FIT) and/or flexible sigmoidoscopy (FS), but the cost-effectiveness of these programmes is not yet available. We aimed to assess cost-effectiveness, based on data from the established Piedmont screening programme.

METHODS

Using the Piedmont programme data, a Markov model was constructed comparing three strategies in a simulated cohort of 100,000 subjects: single FS, biennial FIT, or sequential strategy (FS + FIT offered to FS non-responders). Estimates for CRC incidence and mortality prevention were derived from studies of organized screening. Cost analysis for FS and FIT was based on data from organized programmes. Incremental cost-effectiveness ratios (ICER) between the different strategies were calculated. Sensitivity and probabilistic analyses were performed.

RESULTS

Direct costs for FS, and for FIT at first and subsequent rounds, were estimated as €160, €33, and €21, respectively. All the simulated strategies were effective (10-17% CRC incidence reduction) and cost-effective vs. no screening (ICER <€1000 per life-year saved). FS and FS + FIT were the only cost-saving strategies, with FS least expensive (€15 saving per person invited). FS + FIT and FS were the only non-dominated strategies. FS + FIT were more effective and cost-effective than FS (ICER €1217 per life-year saved). The residual marginal uncertainty was mainly related to parameters inherent to FIT effectiveness and adherence.

CONCLUSIONS

Organized CRC screening programmes are highly cost-effective, irrespective of the test selected. A sequential approach with FS and FIT appears the most cost-effective option. A single FS is the least expensive, but convenient, approach.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Full colonoscopy in patients under 50 years old with lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal (GI) bleeding is a common clinical problem in young patients. The management of this disease in patients is challenging. The aim of this study is to compare sigmoidoscopy with full colonoscopy in these patients.

MATERIALS AND METHODS

In this cross-sectional study, 120 eligible patients under 50 years old with acute rectal bleeding were enrolled. After cleaning the colon, initially the patients underwent sigmoidoscopy. Pain, the comfort of the test by physician and patient, duration of the procedure, and pathologic findings were recorded. The procedure continued until the splenic flexure passed in the ileocecal valve, and this stage was considered as proximal colonoscopy. Pain, easy performance by physician and the patient, duration of procedure, and pathologic findings were recorded in this stage too. The variables in the two stages were compared with each other.

RESULTS

There were 66 women (55%) and 54 men (45%) and the mean of age was 41 ± 7.9 years. Proximal colonoscopy from splenic flexure to reach cecum was relatively easier for the physician and the patient than sigmoidoscopy (P < 0.001). Furthermore, the time spent to carry out proximal colonoscopy was less than the time taken for sigmoidoscopy (P < 0.001). Pathologic findings recorded in full colonoscopy were more than sigmoidoscopy (P < 0.001). Therefore, full colonoscopy that includes sigmoidoscopy and proximal colonoscopy is relatively easier than sigmoidoscopy for patients, and it also proves more advantageous than sigmoidoscopy for physicians to perform in Iranian patients because of more tortuous and elongated sigmoid colon in these patients.

CONCLUSION

It is advised to perform full colonoscopy than sigmoidoscopy in young patients with lower GI bleeding.

Evaluation of the benefits, harms and cost-effectiveness of potential alternatives to iFOBT testing for colorectal cancer screening in Australia

The Australian National Bowel Cancer Screening Program (NBCSP) will fully roll-out 2-yearly screening using the immunochemical Faecal Occult Blood Testing (iFOBT) in people aged 50 to 74 years by 2020. In this study, we aimed to estimate the comparative health benefits, harms, and cost-effectiveness of screening with iFOBT, versus other potential alternative or adjunctive technologies. A comprehensive validated microsimulation model, Policy1-Bowel, was used to simulate a total of 13 screening approaches involving use of iFOBT, colonoscopy, sigmoidoscopy, computed tomographic colonography (CTC), faecal DNA (fDNA) and plasma DNA (pDNA), in people aged 50 to 74 years. All strategies were evaluated in three scenarios: (i) perfect adherence, (ii) high (but imperfect) adherence, and (iii) low adherence. When assuming perfect adherence, the most effective strategies involved using iFOBT (annually, or biennially with/without adjunct sigmoidoscopy either at 50, or at 54, 64 and 74 years for individuals with negative iFOBT), or colonoscopy (10-yearly, or once-off at 50 years combined with biennial iFOBT). Colorectal cancer incidence (mortality) reductions for these strategies were 51-67(74-80)% in comparison with no screening; 2-yearly iFOBT screening (i.e. the NBCSP) would be associated with reductions of 51(74)%. Only 2-yearly iFOBT screening was found to be cost-effective in all scenarios in context of an indicative willingness-to-pay threshold of A$50,000/life-year saved (LYS); this strategy was associated with an incremental cost-effectiveness ratio of A$2,984/LYS-A$5,981/LYS (depending on adherence). The fully rolled-out NBCSP is highly cost-effective, and is also one of the most effective approaches for bowel cancer screening in Australia.

Comparison of Flexible Sigmoidoscopy Screening in Average Risk Patients Performed by Nurses Versus Gastroenterologists

Background

Screening sigmoidoscopy is effective in reducing mortality from colorectal cancer. In 2009, Cancer Care Ontario (CCO) launched a nurse-performed screening flexible sigmoidoscopy program at Hotel Dieu Hospital, Kingston, Ontario. Prior to this program, there was a pilot sigmoidoscopy screening program by gastroenterologists in a similar average risk cohort.

Aim

To compare neoplasia detection rates and associated costs of screening sigmoidoscopy performed by nurses and gastroenterologists.

Method

A retrospective chart review was conducted on flexible sigmoidoscopies performed as part of two average risk screening programs performed by gastroenterologists and nurse-endoscopists. Detected polyps were categorized as hyperplastic, low-risk adenomas or high-risk adenomas. Average cost per procedure was estimated based on physician fee for service charges, nurse wage and benefits, physician supervisory fees, pathology costs and administrative expenses.

Results

There were 538 procedures performed by nurses and 174 by physicians. Adenomas were detected in 18% of nurse-performed procedures versus 9% in physician-performed procedures (p=0.003), with the higher adenoma detection rate restricted to low risk adenomas. One cancer was found in the physician group. Seven physicians performed the 174 sigmoidoscopies, with one physician performing the majority. This physician’s adenoma detection rate was 4.5%, whereas detection rate for the remaining physicians combined was 16.5%. Nurses biopsied more polyps per case (0.96 versus 0.18). Average estimated cost per case was greater for nurses ($387.54 versus $309.37).

Conclusion

Well-trained nurse-endoscopists can provide an effective service for colorectal cancer screening, but as currently structured in Ontario, the associated cost is higher for nurse-performed procedures.

[Prospective study to determine the diagnostic sensitivity of sigmoidoscopy in bowel endometriosis]

INTRODUCTION AND AIM

In the treatment of colorectal endometriosis a multidisciplinary laparoscopic resection is suggested, for this reason the correct selection of bowel infiltration is essential before surgery.

PATIENTS AND METHOD

Between 2009 and 2015, 383 sigmoidoscopies were performed in patients with endometriosis. Where mucosal invasion was absent secondary signs (wall rigidity, impression, kinking, pain during the examination, suffusion) were analysed. In endoscopically confirmed cases multidisciplinary surgery was performed, the remaining patients were operated by a gynecologic team only.

RESULTS

Endometriosis was endoscopically confirmed in 224 patients (58.49%), 108 of them underwent multidisciplinary operation, the negative 135 cases received gynaecological surgery. Bowel endometriosis was confirmed in 103 out of 108 cases intraoperatively, while in 8 cases of the sigmoidoscopically negative patients bowel infiltration was diagnosed intraoperatively by the gynaecological team. Complete sigmoidoscopy was performed in 43.47% of the cases. Intraluminal endometriosis was found in 4.91%, secondary signs as rigidity in 38.39%, impression in 45.54%, kinking in 57.14%, pain (in cases of examination without narcosis) in 26.06% and suffusion in 3.82% of the cases was found during sigmoidoscopy. Sigmoidoscopic examination has a 92.8% specificity and 96.2% sensitivity in cases of bowel endometriosis.

CONCLUSION

Sigmoidoscopy performed by an experienced gastroenterologist is a highly sensitive examination for the diagnosis of bowel endometriosis. Orv. Hetil., 2017, 158(7), 264-269.

A Management Algorithm for Retained Rectal Foreign Bodies

Few authors have proposed therapeutic protocols to manage retained rectal foreign bodies (RFBs). All patients with retained RFBs in hospitals across Trinidad and Tobago over 5 years were identified. Hospital records were retrieved and manually reviewed to extract the following data: demographics, history, foreign body retrieved, clinical signs at presentation, management strategy, duration of hospitalization, and morbidity and mortality. There were 10 patients with RFBs over the study period. The annual incidence of this phenomenon was 0.15 per 100,000 population. All patients were men at a mean age of 50.6 years (range: 27-83; SD = 15.3) who presented after a voluntary delay of 1.4 days (range: 0.5-2.5; SD = 0.7). Only one patient gave an accurate history on presentation, but all eventually admitted to self-insertion for sexual gratification. At presentation, one patient had a spontaneous rectal perforation (10%). The remaining nine patients had attempts at bedside transanal extraction, which was unsuccessful in 89% (8/9) of cases. The RFB was pushed beyond the grasp of forceps, making removal under anesthesia unsuccessful in 62.5% (5/8) cases. These patients required more invasive extraction methods including transanal minimally invasive surgery (1), laparoscopic-assisted advancement with transanal retrieval (1), and open surgery with transmural extraction and anastomoses (3). A management algorithm is proposed for the management of RFBs. Important points in this algorithm are the importance of clinician-patient rapport, early surgical referral, avoidance of bedside extraction in the emergency room, early examination under anesthesia, and the inclusion of emerging therapies such as transanal minimally invasive surgery.

Identifying the optimal strategy for screening of advanced colorectal neoplasia

BACKGROUND AND AIM

To guide selection of optimal screening strategies for advanced colorectal neoplasia (ACRN), we evaluated the screening performances of sigmoidoscopy, fecal immunochemical test (FIT), and the Asia-Pacific Colorectal Screening (APCS) system, as well as combinations of these techniques.

METHODS

We reviewed the records of participants who had undergone a colonoscopy and FIT as part of a comprehensive health-screening program. Results of sigmoidoscopy were estimated from lesions under colonoscopic examination. The screening strategies were classified as sigmoidoscopy-based, FIT-based, and APCS-based. The sensitivity and reduction of number needed to colonoscope (NNScope) of each screening strategy were assessed.

RESULTS

Of 23 023 participants, 398 (1.7%) had ACRN. To predict the presence of ACRN, sigmoidoscopy was the most effective method (odds ratio [OR]: 22.96, 95% confidence interval [CI]: 18.26-29.07), followed by FIT (OR: 7.18, 95% CI: 5.28-9.68) and APCS (high risk [≥4] OR: 2.59, 95% CI: 1.87-3.58; moderate risk [2-3] OR: 1.66, 95% CI: 1.28-2.17). Regarding sigmoidoscopy-based strategies, "sigmoidoscopy positive alone" and "sigmoidoscopy positive or APCS ≥4" were optimal strategies (reduction of NNScope: 79-86%; sensitivity: 73-78%). In the case of FIT-based strategies, "FIT positive or APCS ≥4" was the optimal strategy (reduction of NNScope: 72%; sensitivity: 37%). With regard to the APCS system only, "APCS ≥2" and "APCS ≥4" were recommended as sensitivity-preferred and reduction in NNScope-preferred strategies, respectively.

CONCLUSIONS

The performance in ACRN prediction differs among screening methods (sigmoidoscopy, FIT, and APCS). Among the various single or combined screening strategies, several specific strategies can be chosen depending on medical resources, financial budgets, and screenee preference.

Does lower gastrointestinal endoscopy during pregnancy pose a risk for mother and child? - a systematic review

BACKGROUND

Gastrointestinal endoscopy plays a crucial role in the diagnosis and management of gastrointestinal disorders. When endoscopy is indicated during pregnancy, concerns about the effects on pregnancy outcome often arise. The aim of this study was to assess whether lower gastrointestinal endoscopies (LGEs) across all three trimesters of pregnancy affects pregnancy outcomes.

METHODS

A systematic literature search was performed using Embase (including MEDLINE), Medline OvidSP, Cochrane Central Register of Controlled Trials, Web-of-Science, Google scholar and Pubmed. All original research articles from 1990 until May 2014 involving pregnant women who underwent LGE for any indication were included. Adverse pregnancy events like spontaneous abortion, preterm birth and fetal demise were assessed for a temporal and etiological relation with the LGE.

RESULTS

In total, 5514 references were screened by two independent reviewers. Eighty-two references met the inclusion criteria and were selected. Two retrospective, controlled studies, one uncontrolled study and 79 case reports were identified. In the three studies, birth outcomes did not differ between women undergoing LGE during pregnancy, compared to women that had an indication for LGE but in whom LGE was not performed because of pregnancy. In 79 case reports, 92 patients are described who underwent 100 LGE's during pregnancy. LGEs performed in all trimesters (n = 32, 39 and 29) were both temporally and etiologically related to 1, 3 and 2 adverse events, respectively.

CONCLUSION

Based on the available literature, this review concludes that lower gastrointestinal endoscopy during pregnancy is of low risk for mother and child in all three trimesters of pregnancy.

Long-term effectiveness of endoscopic screening on incidence and mortality of colorectal cancer: A randomized trial

BACKGROUND

Due to few randomized trials, there is uncertainty about the long-time effect of endoscopic screening on colorectal cancer (CRC) incidence and mortality.

AIM

To evaluate the long-term effect of endoscopic screening on CRC incidence and mortality, we performed a population-based randomized controlled trial in Norway.

MATERIALS AND METHODS

In 1983, 799 Norwegian men and women, age 50-59 years were drawn from the population registry and randomly assigned to flexible sigmoidoscopy screening (400 individuals), or no screening (399 individuals). Colonoscopy surveillance was offered after two and six years for all polyp-bearers in the screening group. In 1996, both groups were offered colonoscopy. Only individuals with advanced adenomas at colonoscopy in 1996 were recommended surveillance. All individuals were followed through Norwegian registries until 2008. Hazard ratios (HR) for CRC incidence, and CRC and overall mortality rates were calculated.

RESULTS

During 26 years of follow up (17,327 person-years), 26 colorectal cancers were observed: seven in the screening group and 19 in the control group (HR in screening group 0.40, 95% CI 0.17-0.95, p = 0.04). Eight individuals died of colorectal cancer; one in the screening group and seven in the control group (HR 0.16, 95% CI 0.02-1.28, p = 0.08).

CONCLUSIONS

This first randomized trial on the long-term effect of endoscopic screening shows reduced CRC incidence and mortality if screening is combined with rigorous surveillance for individuals with polyps. Colonoscopy screening without such surveillance may not be effective.

Not only hysterectomy but also cesarean section can predict incomplete flexible sigmoidoscopy among patients with prior abdominal or pelvic surgery

BACKGROUND

Flexible sigmoidoscopy (FS) is a safe and effective method for colorectal cancer (CRC) screening. Several studies have demonstrated that individuals who have undergone surgery are at a greater risk of having incomplete FS. This study explored predictors of incomplete FS and reduced polyp detection rates for participants who had undergone abdominal or pelvic surgery.

METHODS

From January 2009 to December 2009, individuals participating in health examinations and who had undergone abdominal or pelvic surgery were invited to participate in this investigation. Four experienced gastroenterologists performed examinations using a 60-cm Olympus video sigmoidoscope. Factors associated with incomplete FS insertions and reduced polyp detection rates were analyzed using logistic regression models.

RESULTS

Overall, 106 eligible individuals were analyzed, and 45 (42%) incomplete FS insertions were reviewed. Fifty participants (47%) had undergone pelvic surgery, and the other 56 (53%) had undergone abdominal surgery. Pelvic surgeries were cesarean section (25%) and hysterectomy (15%); appendectomy (36%) was the most common abdominal surgery. The main pathological FS findings were hemorrhoids (54%) and adenomatous polyps (18%). Multivariate analysis indicated that only prior pelvic surgery [odds ratio (OR), 3.54; p = 0.01] was an independent risk factor for incomplete FS insertion. Incomplete examinations were inversely related to adenomatous polyp detection rates (OR, 0.23; p = 0.03).

CONCLUSION

Prior pelvic surgery, particularly cesarean section and hysterectomy, is an independent factor for incomplete FS insertion in a selected adult population. In addition, incomplete FS can increase the risk of missing polyps, particularly in individuals who underwent pelvic surgery.

Endoscopy in the diagnosis of intestinal graft-versus-host disease: is lower endoscopy with biopsy as effective in diagnosis as upper endoscopy combined with lower endoscopy?

BACKGROUND

Graft-versus-host disease (GvHD) causes morbidity and mortality in recipients of hematopoietic stem cell transplantation (SCT). This study assessed the distribution of GvHD in gastrointestinal (GI) biopsies from the upper and lower GI tract in pediatric patients who had undergone SCT and evaluated if there was correlation between biopsy findings and possible extra-intestinal manifestations of GvHD.

PROCEDURE

We performed a retrospective chart review for all patients diagnosed with GvHD, who underwent both upper and lower endoscopy. We also reviewed pathology and clinical reports to determine which biopsy sites were diagnostic of GvHD and to evaluate for the possible presence of extra-intestinal manifestations GvHD at the time of biopsy.

RESULTS

Twenty patients were identified who had undergone both upper and lower endoscopy for evaluation of GvHD. Patients with GvHD diagnosed on upper endoscopy also had GvHD identified in the sigmoid colon region 100% of the time (positive predictive value [PPV] = 1). In patients that were found to have underlying liver disease, GvHD was diagnosed in the sigmoid colon region 90% of the time (PPV = 0.9).

CONCLUSION

Use of sigmoid biopsy for GvHD diagnosis is effective, safe, and less expensive compared to other endoscopic interventions.

Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer

BACKGROUND & AIMS

Colorectal cancer (CRC) screening guidelines recommend screening schedules for each single type of test except for concurrent sigmoidoscopy and fecal occult blood test (FOBT). We investigated the cost-effectiveness of a hybrid screening strategy that was based on a fecal immunological test (FIT) and colonoscopy.

METHODS

We conducted a cost-effectiveness analysis by using the Archimedes Model to evaluate the effects of different CRC screening strategies on health outcomes and costs related to CRC in a population that represents members of Kaiser Permanente Northern California. The Archimedes Model is a large-scale simulation of human physiology, diseases, interventions, and health care systems. The CRC submodel in the Archimedes Model was derived from public databases, published epidemiologic studies, and clinical trials.

RESULTS

A hybrid screening strategy led to substantial reductions in CRC incidence and mortality, gains in quality-adjusted life years (QALYs), and reductions in costs, comparable with those of the best single-test strategies. Screening by annual FIT of patients 50-65 years old and then a single colonoscopy when they were 66 years old (FIT/COLOx1) reduced CRC incidence by 72% and gained 110 QALYs for every 1000 people during a period of 30 years, compared with no screening. Compared with annual FIT, FIT/COLOx1 gained 1400 QALYs/100,000 persons at an incremental cost of $9700/QALY gained and required 55% fewer FITs. Compared with FIT/COLOx1, colonoscopy at 10-year intervals gained 500 QALYs/100,000 at an incremental cost of $35,100/QALY gained but required 37% more colonoscopies. Over the ranges of parameters examined, the cost-effectiveness of hybrid screening strategies was slightly more sensitive to the adherence rate with colonoscopy than the adherence rate with yearly FIT. Uncertainties associated with estimates of FIT performance within a program setting and sensitivities for flat and right-sided lesions are expected to have significant impacts on the cost-effectiveness results.

CONCLUSIONS

In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand.

Colorectal cancer screening: the northern trust experience

OBJECTIVE

Colorectal cancer (CRC) is the third most common type of cancer with resulting major mortality. In a bid to reduce the mortality, bowel cancer screening has been established in the United Kingdom. The screening programme was commenced in Northern Ireland in 2010 within the Northern Health and Social Care Trust, following its implementation in England and Scotland. This study aimed to look at early outcome data for bowel cancer screening in Northern Ireland and compare data with other regions in the UK.

DESIGN

A retrospective analysis was conducted of patients who tested faecal occult blood (FOB) positive and attended for pre-assessment between May 2010 and May 2011. Data was also collected from the computerised endoscopy database (Endoscribe®). Patient demographics, colonoscopic depth of insertion, findings and complications were documented. Subsequent surgical management, pathological staging and final outcome were also noted.

RESULTS

182 patients attended for pre-assessment in the time frame and 178 patients proceeded to colonoscopy. The commonest pathology encountered was polyps, identified in 95 (52.7%) patients. Macroscopically 13 cancers were seen on endoscopy and a further two were found on post-operative histology of polyps that were not amenable to endoscopic resection. In addition, 5 malignant polyps were found on histological analysis of the excised polyps. The staging of cancers was favourable with 35% being Dukes' A stage.

CONCLUSION

Outcomes from the first year of colorectal cancer screening in the Northern Trust are in keeping with early results from previous studies in terms of cancer detection rates per colonoscopy and proportion of early stage cancers. However, the adenoma detection rate was higher than anticipated.

Computed tomography findings of bowel wall thickening: its significance and relationship to endoscopic abnormalities

INTRODUCTION

The aim of this study was to conduct retrospective analysis of abdominopelvic computed tomography (CT) reports, identifying those patients in whom bowel wall thickening (BWT) was observed, and to correlate these reports with subsequent endoscopic evaluation.

METHODS

Formal reports for all patients undergoing abdominopelvic CT between February 2007 and September 2009 were reviewed. Where patients were identified as having colorectal 'wall thickening', results of subsequent endoscopic evaluations were documented. Only those patients with a report of BWT who had follow-up endoscopy (colonoscopy, sigmoidoscopy) were included in the analysis.

RESULTS

A total of 165 patients were included. Abnormalities on endoscopy at the exact site of the BWT on CT were found in 95 patients (57.58%); in 36 cases (21.82%) this was a malignant lesion. BWT of the transverse colon was significantly more likely to correspond to an endoscopic finding of cancer than other sites (p=0.034). Rectal bleeding was reported significantly more often in patients with BWT and neoplastic disease on endoscopy compared with those with normal endoscopy (p=0.04). Excluding patients with inflammatory/diverticular lesions, 59.02% of Caucasians had a neoplastic lesion at the site of reported BWT, significantly higher than the other ethnic groups (p=0.008). There were 38 patients (23.03%) who did not present with bowel symptoms and, of these, 6 were diagnosed subsequently with colorectal cancer.

CONCLUSIONS

This study supports endoscopic evaluation to investigate patients with CT evidence of BWT, especially in cases involving the transverse colon, in Caucasian patients or in association with symptoms of rectal bleeding.

Cost-effectiveness of colorectal cancer screening - an overview

There are several modalities available for a colorectal cancer (CRC) screening program. When determining which CRC screening program to implement, the costs of such programs should be considered in comparison to the health benefits they are expected to provide. Cost-effectiveness analysis provides a tool to do this. In this paper we review the evidence on the cost-effectiveness of CRC screening. Published studies universally indicate that when compared with no CRC screening, all screening modalities provide additional years of life at a cost that is deemed acceptable by most industrialized nations. Many recent studies even find CRC screening to be cost-saving. However, when the alternative CRC screening strategies are compared against each other in an incremental cost-effectiveness analysis, no single optimal strategy emerges across the studies. There is consensus that the new technologies of stool DNA testing, computed tomographic colonography and capsule endoscopy are not yet cost-effective compared with the established CRC screening tests.

Healthy colon, healthy life (colon sano, vida sana): colorectal cancer screening among Latinos in Santa Clara, California

Colorectal cancer (CRC) screening rates are low among Latinos. To identify factors associated with CRC screening, we conducted a telephone survey of Latino primary care patients aged 50-79 years. Among 1,013 participants, 38% were up-to-date (UTD) with fecal occult blood test (FOBT); 66% were UTD with any CRC screening (FOBT, sigmoidoscopy, or colonoscopy). Individuals less than 65, females, those less acculturated, and patients of female physicians were more likely to be UTD with FOBT. CRC screening among Latinos is low. Younger patients, women, and patients of female physicians receive more screening.

Endoscopic evaluation of the colorectum in patients presenting with haematochezia at korle-bu teaching hospital accra

SUMMARY BACKGROUND

Colorectal endoscopy is the gold standard investigation of the large bowel in patients with rectal bleeding and is employed as a means of secondary prevention of colorectal cancer.

AIM

To determine the frequency of benign lesions and carcinomas in patients who underwent colorectal endoscopy because of rectal bleeding and to evaluate the role of endoscopy in secondary prevention of colorectal carcinoma in our centre.

METHOD

A retrospective study was undertaken on patients who underwent colorectal endoscopy between January 1995 and December 2000 for rectal bleeding.

RESULTS

Five hundred and ninety six (596) patients were studied. Males were 403 and females 93, mean age 50.9 (SD 7.07). Three hundred and ten patients (52%) had rigid proctosigmoidoscopy, flexible sigmoidoscopy 105 (17.6%) and colonoscopy 181 (30.4%). Of those who had colonoscopy complete examination of the colon was achieved in 55 patients (30.4%). Those in whom colonoscopy was incomplete had double contrast barium enema. Haemorrhoids were the commonest disease diagnosed, 316 patients (53%). Colorectal carcinoma 39 patients (6.7%), non-specific colitis 34 patients (5.7%), diverticular disease 27 patients (4.5%) and adenomatous polyps 17 patients (2.9%) were the next common disease. Less common conditions were ulcerative colitis, rectal schistosomiasis and angiodysplasia. In 125 patients (21.0) the cause of bleeding could not be found.

CONCLUSION

An appreciable number of the patients with rectal bleeding had serious pathology that was diagnosed early by endoscopy confirming the important role of endoscopy in secondary prevention of colorectal carcinoma. The low success rate of full colonoscopy underscores the need for training in this procedure.

Reasons for noncompliance with five-yearly screening flexible sigmoidoscopy

OBJECTIVE

To determine factors influencing the low return rate observed in a program of flexible sigmoidoscopy for average risk screening for colorectal carcinoma.

METHODS

Flexible sigmoidoscopy-based screening of average risk 55-64 yr olds has been ongoing since 1995. Greater than 3400 primary and 1000 follow up screening examinations have been performed. Participants with a primary screen in 1997-1999 and eligible for rescreening in 2002-2004 were studied. A questionnaire assessing possible reasons for noncompliance was sent to subjects who did not attend the five year repeat screening.

RESULTS

1672 primary screening flexible sigmoidoscopies were performed in 1997-1999 with 1362 being normal or having hyperplastic polyps only. The return rate was 45%: 48% of eligible males and 39% of eligible females had returned (p = 0.001 for difference). 709 questionnaires were mailed with a 50% response rate and 162 requests for repeat flexible sigmoidoscopy were generated. 27% of all respondents had undergone further bowel evaluation since the original normal sigmoidoscopy. Of eligible subjects who refused further screening, 65% did so because of concerns over procedural pain.

CONCLUSIONS

Reasons for nonattendance relate to uptake of other bowel investigations and pain felt at initial screening. Return rate can be raised with ongoing prompting to attend screening.

Predicting colorectal cancer risk in patients with rectal bleeding

BACKGROUND

Rectal bleeding is an important symptom of colorectal cancer but has low predictive value in primary care.

AIM

To determine which characteristics of rectal bleeding, along with other factors, are predictive of colorectal cancer.

DESIGN OF STUDY

Observation study of patients with rectal bleeding referred to an open-access diagnostic clinic.

SETTING

Primary care, southern England.

METHOD

Symptom data were collected, using a self-completed questionnaire. Logistic regression techniques were used to determine predictors of colorectal cancer.

RESULTS

There were 604 patients in the study and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms.

CONCLUSION

Patient-reported type of rectal bleeding as an isolated symptom has insufficient diagnostic value to be useful in general practice. By studying referred patients, we may even have overestimated its value. At best, it could be useful as a component of a composite symptom score to guide referral decisions.