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PubMed2005

A simulation model for colorectal cancer screening: potential of stool tests with various performance characteristics compared with screening colonoscopy.

OBJECTIVE: Many new stool tests intended to detect neoplastic cells or cell products are developed at present for colorectal cancer (CRC) screening. The aim of this study was to simulate a population-based screening setting to assess and compare the potential for early detection and prevention of CRC of screening based on stool tests with different sensitivity and specificity and of screening with colonoscopy as a primary screening tool. METHOD: A Markov model was developed aimed to estimate the proportion of CRC cases which are early detected or prevented due to screening as well as the number of equired stool tests and colonoscopies per early detected or prevented CRC case. Model outcomes were calculated for the offer of annual stool testing from age 55 to 74 in combination with colonoscopic follow-up of positive test results and for the offer of screening colonoscopy as a primary screening tool at ages 55 and 65. The long-lasting risk reduction of colonoscopy allowing the removal of precancerous lesions was taken into account quantitatively. RESULTS: For a variety of stool tests with different performance characteristics, the proportion of CRC cases early detected or prevented was estimated to be higher for stool testing in combination with colonoscopic follow-up of positive test results compared with screening colonoscopy assuming levels of compliance to be expected for the respective screening scheme. Optimizing performance characteristics of stool tests in terms of detecting precancerous lesions, in addition to those in terms of detecting CRC, seemed to be crucial for maximizing effectiveness of CRC screening with stool tests. CONCLUSION: Screening based on new stool tests with colonoscopic follow-up of positive test results might offer a high potential for early detection or prevention of CRC.

Aged↗

PubMed1999

Virtual colonoscopy: a gastroenterologist's perspective.

Virtual colonoscopy is an exciting new imaging technique with potential to alter current diagnostic approaches to colonic diseases, particularly colonic neoplasms. Although colonoscopy continues to offer the highest sensitivity and specificity for evaluation of the colon, virtual colonoscopy may offer greater safety, less discomfort, and consequently greater patient acceptance. In addition, virtual colonoscopy offers shorter procedure time, more accurate lesion location, and potentially lower cost as a screening test. Limited data are currently available to define virtual colonoscopy's full clinical role. This article describes the technical considerations, current clinical status, limitations, and potential indications of this new and exciting technology which gastroenterologists should not fear but embrace.

Colonoscopy↗

PubMed2004

Colonoscopy and SeHCAT for investigation of chronic diarrhea.

BACKGROUND/AIMS: Chronic diarrhea is a common problem. Colonoscopy is the investigation of choice for diagnosis. Even a macroscopically normal mucosa on endoscopy can have abnormalities such as microscopic colitis and bile acid malabsorption (BAM). The aim of this study was to establish the value of colonoscopy with biopsies in patients with chronic diarrhea and to evaluate the additive value of a SeHCAT test for diagnosing BAM in these patients. METHODS: All patients who underwent a colonoscopy between November 1999 and December 2000 were included. Patient files, colonoscopy and pathology reports and SeHCAT test results were reviewed. RESULTS: 205 patients were included. The most common diagnoses were diarrhea-predominant IBS (n = 76) and IBD (n = 38). 158 patients had non-bloody diarrhea, 113 (72%) of them had a macroscopically normal appearing mucosa. In 40 (35%) of these patients, a histological diagnosis could be made and microscopic colitis was the most common diagnosis (n = 27). SeHCAT test was performed in 36 patients and 15 (42%) of them had BAM. In the 47 patients with bloody diarrhea, IBD was the main diagnosis (n = 23). CONCLUSION: Colonoscopy with biopsies must be performed when investigating chronic diarrhea and BAM should be excluded.

Bile Acids and Salts↗

PubMed2002

Colonoscopy at a combined district general hospital and specialist endoscopy unit: lessons from 505 consecutive examinations.

Provisional reports from the Intercollegiate British Society of Gastroenterology National Colonoscopy audit show completion rates of 57-77% for the procedure and poor levels of training and supervision. We prospectively audited all aspects of colonoscopy performed at a combined district general hospital and specialist endoscopy unit. Details of referral, examination, endoscopist, complications and follow-up were recorded and patients were sent questionnaires for long-term follow-up. 505 patients (246 male) underwent colonoscopy by 27 different endoscopists. Their median age was 57 years (range 13-92) and 93% were outpatients. 64% patients were symptomatic and 36% were having surveillance or follow-up colonoscopy. The overall caecal intubation rate was 93%, with little difference between surgeons, physicians and experienced trainees (89%, 92%, 94%) and specialist endoscopists (98%). In only one case was an inexperienced trainee (<100 procedures) unsupervised. Pain scores estimated by the endoscopist were well matched with those given by the patient-medians 29 and 26 (maximum 100) respectively. Median satisfaction score was 96 (maximum 100). Polyp pick-up rate was 26.9% and there were 11 new cancers. 16 (3%) minor immediate complications were recorded-5 oversedation, 6 vasovagal attacks, 3 polypectomy haemorrhages and 2 mucosal injuries (neither requiring treatment). 3 patients died within 6 months of follow-up but no death was colonoscopy related. Completion rates in this setting were adequate for all endoscopists studied. Patient satisfaction with the procedure was high and very few immediate or long-term complications were encountered.

Adolescent↗

PubMed2006

Intravenous fluid to prevent hypotension in patients undergoing elective colonoscopy.

Colonoscopy may be associated with hypotension during sedation leading to postoperative morbidity. However, no treatment is proven to ameliorate intraoperative hypotension for this procedure. We therefore conducted a randomized trial to determine the effect of intravenous fluid infusion on the incidence of hypotension during sedation for colonoscopy. With institutional approval, 160 patients presenting for elective colonoscopy were randomized to 1.5 ml/kg or 15 ml/kg Hartmann's solution before colonoscopy. All observers were blind to group allocation. The incidence of hypotension during sedation (29% vs 25%; P=0.59) and postoperative morbidity (nausea, vomiting, headache, drowsiness and dizziness) (41% vs 39%; P= 0.75) did not differ between the two groups. Hypotensive patients were older, had a higher baseline systolic blood pressure, and were thirstier after fluid infusion than normotensive patients. This study does not support the use of 15 ml/kg Hartmann's solution to reduce the incidence of hypotension or postoperative morbidity in patients undergoing elective colonoscopy.

Colonoscopy↗

PubMedDate not supplied

Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results?

BACKGROUND: Colonoscopy is becoming increasingly necessary for many patients in screening, diagnosing, and treating colorectal problems. Because the majority of rural doctors are family physicians, providing colonoscopy for the enlarging group of patients with valid indications in rural areas is difficult, unless rural family physicians perform the procedure. Subspecialists in academic settings have been responsible for most of the previously reported studies regarding colonoscopy. We have studied the safety and efficacy of the procedure when performed by rural family physicians. METHODS: A total of 200 sequential colonoscopies performed by family physicians in a rural setting were prospectively collected. Outcomes were measured based on current recommendations and benchmarks, including rate of reaching the cecum, time to reach the cecum, time to completion of the study, pathologic lesions found, and complications. RESULTS: The rate of reaching the cecum was 96.5%, and the average time to the cecum was 15.9 minutes. The average time to study completion was 34.4 minutes. The rate of neoplastic polyps and cancer found was 22.5% and 2.5%, respectively. There were no serious complications. CONCLUSIONS: Adequately trained family physicians can provide safe and technically competent colonoscopy in a rural setting. Their results compare favorably to the currently reported comparative benchmarks from other endoscopists.

Adolescent↗

PubMed2006

Ileoscopy in 39 hematochezia patients with normal colonoscopy.

AIM: To assess the role of retrograde terminal ileoscopy in hematochezia patients with normal colonoscopy. METHODS: Between January 1997 and March 2005, 39 hematochezia patients (males 36, females 3, mean age 44.7 years) with a reported normal colonoscopy underwent a repeat colonoscopy. After reaching the cecum, attempt was made to localize the ileocecal valve and intubate the terminal ileum. Any abnormality in the mucosa of the terminal ileum was carefully recorded and biopsies were obtained from suspicious-looking lesions. RESULTS: During the study period there were 39 patients admitted for hematochezia in whom colonoscopy till cecum did not reveal any abnormality. Full-length colonoscopy till the cecum could be performed in all the patients. The terminal ileum could be intubated in 36 patients. No abnormality was noted in 31 patients. Ileal ulcers were noted in two patients. Nodularity along with ulceration of the ileal mucosa, a Dieulafoy's lesion, and an angiomatous malformation were noted in one patient each. Histological examination of the biopsies obtained from the ulcers revealed typical tuberculous lesion in the patient with nodularity and ulceration. One of the patients had typhoid ulcers and another had non-specific ulcers. CONCLUSION: Retrograde terminal ileoscopy gives limited but valuable information, in patients with hematochezia and should be attempted in all such patients.

Adult↗

PubMed1983

Importance of total colonoscopy in the diagnosis of colonic disorders.

The need for colonoscopic examination of the whole colon was determined by evaluating the accuracy of a barium enema X-ray report with particular reference to the right colon. Long colonoscopies were performed on 108 patients. The reports of the barium enema X-ray examination in these patients were compared with the colonoscopy reports. Over all, the barium enema X-ray report was accurate in 47% of cases. The rate of false negative reports was 10% and that of false positive reports 43%. For lesions of the right colon, the barium enema X-ray report was accurate in only 32% of cases, with 68% false positive and 15% false negative reports. False positive reports of carcinoma or polyps result mainly from imperfect preparation. Of the eight right colonic lesions missed in the barium enema X-ray examination, five were polyps and one was carcinoma. Long colonoscopy, rather than short colonoscopy, or flexible sigmoidoscopy and barium enema X-ray examination, would be accompanied by the greatest diagnostic accuracy. Air-contrast barium enema X-ray examination and long colonoscopy together offer the best methods of diagnosis of occult lesions in the right colon.

Barium Sulfate↗

PubMed2004

Colonoscopy screening for colorectal cancer: the outcomes of two recruitment methods.

OBJECTIVES: To determine the response to colorectal cancer (CRC) screening by colonoscopy, through direct invitation or through invitation by general practitioners. DESIGN AND SETTING: Two-way comparison of randomised population sampling versus cluster sampling of a representative general practice population in the Australian Capital Territory, May 2002 to January 2004. INTERVENTION: Invitation to screen, assessment for eligibility, interview, and colonoscopy. SUBJECTS: 881 subjects aged 55-74 years were invited to screen: 520 from the electoral roll (ER) sample and 361 from the general practice (GP) cluster sample. MAIN OUTCOME MEASURES: Response rate, participation rate, and rate of adenomatous polyps in the screened group. RESULTS: Participation was similar in the ER arm (35.1%; 95% CI, 30.2%-40.3%) and the GP arm (40.1%; 95% CI, 29.2%-51.0%) after correcting for ineligibility, which was higher in the ER arm. Superior eligibility in the GP arm was offset by the labour of manual record review. Response rates after two invitations were similar for the two groups (ER arm: 78.8%; 95% CI, 75.1%-82.1%; GP arm: 81.7%; 95% CI, 73.8%-89.6%). Overall, 53.4% ineligibility arose from having a colonoscopy in the past 10 years (ER arm, 98/178; GP arm, 42/84). Of 231 colonoscopies performed, 229 were complete, with 32% of subjects screened having adenomatous polyps. CONCLUSIONS: Colonoscopy-based CRC screening yields similar response and participation rates with either random population sampling or general practice cluster sampling, with population sampling through the electoral roll providing greater ease of recruitment.

Aged↗

PubMed2004

Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy.

BACKGROUND: Increasing use of colonoscopy for colorectal cancer screening and surveillance of colorectal adenomas after polypectomy has given rise to concerns about the availability of endoscopic resources in the United States. Guidelines recommend surveillance after polypectomy at 3 to 5 years for a small adenoma, and follow-up is not advised for hyperplastic polyps. The intensity of physicians' surveillance is largely unstudied. OBJECTIVE: To survey practicing gastroenterologists and general surgeons about their perceived need for the frequency of surveillance after polypectomy, to compare survey responses to practice guidelines, and to identify factors influencing their recommendations for surveillance. DESIGN: Survey study conducted by the National Cancer Institute. SETTING: A nationally representative study of physicians in the United States. PARTICIPANTS: 349 gastroenterologists and 316 general surgeons. MEASUREMENTS: Questionnaires mailed in 1999 and 2000 assessed physicians' recommendations for surveillance after polypectomy in asymptomatic, average-risk patients. RESULTS: Response rates were 83%. Among gastroenterologists (317 of 349) and surgeons (125 of 316) who perform screening colonoscopy, 24% (95% CI, 19.3% to 28.7%) of gastroenterologists and 54% (CI, 44.9% to 62.5%) of surgeons recommend surveillance for a hyperplastic polyp. For a small adenoma, most physicians recommended surveillance colonoscopy and more than 50% recommended examinations every 3 years or more often. Physicians indicated that published evidence was very influential in their practice (83% [CI, 78.8% to 87.2%] of gastroenterologists and 78% [CI, 72.5% to 86.8%] of surgeons). By contrast, only half of respondents reported that guidelines were very influential. LIMITATIONS: The study was based on physicians' self-reported practice patterns. Results may overestimate or underestimate the performance of surveillance colonoscopy. CONCLUSIONS: Some surveillance colonoscopy seems to be inappropriately performed and in excess of guidelines, particularly for hyperplastic polyps and low-risk lesions such as a small adenoma. These results suggest unnecessary demand for endoscopic resources.

Adenoma↗

PubMed1999

[Time required for training in colonoscopy. Prospective study of 362 consecutive tests].

OBJECTIVES: To assess the time required for training in colonoscopy during one year. MATERIAL AND METHODS: All complete colonoscopies performed under general anesthesia in patients having an intact colon were included. RESULTS: The mean duration of 362 colonoscopies was 23 +/- 12 min. The time required by a senior alone was 19 +/- 9 min (n = 129). There was a significant increase in procedural time (P = 0.001) if a trainee was involved in the case (n = 68) (28 +/- 12 min) and if an assistant carried out the procedure (n = 165) alone (25 +/- 14 min) or with a trainee (27 +/- 9 min). We estimated the time which would have been required for the seniors to perform all the colonoscopies. This time was increased by 24.4% by education of trainees and self-training of assistants. CONCLUSION: The duration of colonoscopy is increased by education, the cost of which should be assessed.

Anesthesia, General↗

PubMed2000

[Conditions of practice and results of colonoscopy in non-university hospitals. Results of a cross sectional, multicenter ANGH study (1)].

OBJECTIVES: The aim of the study was to describe the conditions of practice and results of colonoscopies performed in non university hospital endoscopy units. METHODS: A study was suggested to all members of the National Association of non university Hospital Gastroenterologists (ANGH). During one week a questionnaire was filled out by the gastroenterologists for each colonoscopy. RESULTS: Eighty six hospitals (229 gastroenterologists) took part in this study including 840 explorations. Ninety one percent of them were complete and the result was abnormal in 49%: cancers (3%), polyps > or =1 cm (8%), polyps < 1 cm (20%) and colitis (5%). Colonoscopies were ambulatory in half of the cases. Sedation was used in 95% of the patients, 80% by the anesthesist and 15% by the gastroenterologist (conscious sedation). The recommendations of the French Society of Anesthesia and Intensive Care for ambulatory sedation were not totally respected (15% of patients left the endoscopy unit without assistance). Only 6% of colonoscopies were not well tolerated, because of pain or incidents rarely necessitating intensive care monitoring (5 cases) or prolonged hospitalization (2 cases). CONCLUSION: Colonoscopy provides good diagnostic yield although conditions of use can be improved.

Aged↗

PubMedDate not supplied

[Colonoscopy. Analysis of 2,000 procedures].

BACKGROUND: During the last 3 decades, colonoscopy has become the diagnostic study with greatest sensitivity and acuity in colonic pathology. AIMS: To know the most frequent diagnostic and colonoscopic disorders, and the pathology found, to establish certainty of the colonoscopic procedure. METHOD: Between 1987 and 1997, a descriptive, transversal, retrospective and observational study of the 2,000 colonoscopies that were carried out at on service was done, making a registry of the endoscopic search in colorectal pathology and their characteristics in on patients. RESULTS: Colonoscopies were done in 967 men (47.3%) and 1,053 women (52.6%) with a median age of 55.8 years (10 range (-) 93 years). In 1,780 of them (89.%), it was possible to arrive to cecum; 1,150 (57.5%) were pathologic. The most frequent finding was hemorrhage of the lower digestive tube in 525 (26.2%) patients; in addition cancer in 402 (20.1%), suspicion of intestinal inflammatory disease 292 (14.6%) and colorectal polyps 199 (10%) were found. The most frequent endoscopic diagnosis was colorectal polyps in 405 (35.7%) patients; in additions diverticular disease was found in 404 (35.1%) patients intestinal inflammatory disease in 185 (16%), colorectal cancer in 85 (7.4%), and vascular ectasias in 52 (4.5%) patients. There were four complicated cases (0.25%), three by resolved therapeutic colonoscopy and one diagnostically. CONCLUSION: The most frequent colonoscopic were findings hemorrhage of the lower digestive tube and the finding of cancer. The most frequent diagnoses were colorectal polyps and diverticular disease. Colonoscopy is a safe diagnostic and therapeutic procedure.

Adolescent↗

PubMed2001

Actual colonoscopy: what are the risks of perforation?

Recent studies have suggested that virtual colonoscopy (VC) and actual colonoscopy (AC) have similar efficacy for detection of polyps >6 mm. However, procedural risks with emerging technology such as VC need to be assessed before widespread implementation. We propose to demonstrate complication rates after AC that can be used for a comparative benchmark in VC. From 1994 to 1999 all patients undergoing AC who sustained perforation that required operation were analyzed for the mortality and complications. There were 26,162 consecutive colonoscopies that required 21 operations for perforation. Of these 16,948 (65%) colonoscopies were diagnostic and 9,214 (35%) were therapeutic with 11 (0.06%) and 10 (0.11%) operations respectively. Overall risk for colonoscopic perforation that requires operation was one in 1,246 (one in 1,541 for diagnostic and one in 921 for therapeutic). Five perforations were oversewn, 15 were resected (five with stoma), and one was drained. One patient died. There were two reoperations. Mortality was 0.006 per cent (one in 16,948) for diagnostic and zero for therapeutic colonoscopy. Overall risk for perforation that requires operation or mortality after AC is low. Virtual colonoscopists who propose screening and subsequent therapeutic interventions need to report high volume without complications as the perforation rate requiring operation was one in 1,246.

Colon↗

PubMed2001

Validity of early colonoscopy for the treatment of adenomas missed by initial endoscopic examination.

OBJECTIVE: To determine whether the features of adenomas identified in a first endoscopic examination may predict the presence of polyps with advanced pathological features that may have gone unnoticed and whether early colonoscopy may benefit these patients. MATERIAL AND METHODS: We examined 133 patients with diagnosis of colonic adenomas who had undergone complete colonoscopy and endoscopic polypectomy. All of them underwent colonoscopic follow-up at 3 years. Seventy nine patients underwent colonoscopic follow-up both at 6 months and at 3 years, while 54 patients underwent just colonoscopic follow-up at 3 years and 47 just at 6 months. RESULTS: Fifteen per cent of the patients analyzed developed polyps with pathological features after 6 months. The size and histological analysis of the polyps detected in the initial colonoscopic examination did not affect these results (p < 0.05). The number of polyps was statistically significant: patients with 3 or more polyps in the initial colonoscopic examination presented more polyps with pathological features after six months (25.8 versus 5.8%, p = 0002). This follow-up examination at 3 years did not reveal a higher occurrence of polyps with pathological features in any of the two groups of patients, namely, those who had undergone early colonoscopy and those who had not. CONCLUSIONS: Patients with multiple polyps have greater probability of developing synchronous polyps with some pathological features which may have gone unnoticed. Since early examination has not shown to provide a benefit for these patients, the first follow-up colonoscopy should be performed at 3 years, particularly if the initial colonoscopy is negative.

Adenoma↗

PubMed2002

Improved procedure of colonoscopy under accompanying music therapy.

BACKGROUND: Administration of sedatives and analgetics during colonoscopy includes the risk for arterial hypotension and respiratory depression. The aim of this study was to assess whether music therapy increases patients tolerance and reduces the need of analgo-sedative premedication. METHODS: 146 consecutive patients were examined in a randomized, prospective study. Colonoscopy was performed under intravenous administration with titrated dosages of midazolam and pethidin. Oxygen was given in cases of blood desaturation below values of 90%. Patients younger than 18 and older than 80 years, patients with history of partial colectomy, gastrectomy or hysterectomy and patients with colonic tumorous or inflammatory stenosis were excluded. 60 patients underwent conventional procedure (Group A), whereas 59 patients received additional music therapy (Group B). Time required to reach the cecum (examination time) was measured and the rate of successful colonoscopies was determined. RESULTS: Most of the patients required sedation with midazolam in both groups (97 vs. 93%), whereas more group A patients required analgesia with pethidin than group B patients (43 vs. 31%, p<0.05). Under music therapy the rate of completed colonoscopies was higher (group A 93%, group B 98%) and examination time was significantly accelerated (group A 22.8 +/- 14.6 min, group B 16.8 +/- 11.8 min, p<0.03). CONCLUSIONS: Accompanying music therapy reduces requirement of analgesia during colonoscopy, favours completion of the procedure and shortens examination time. Music therapy seems to promote safer conditions for endoscopical practice and diminishs patients discomfort.

Adult↗

PubMed2002

[Yield of colonoscopy by indication and consequences for colorectal polyp and cancer screening: a prospective survey in Isère, France].

AIM: The aim of this study was to determine yields of colonoscopy by indication, especially after a positive Hemoccult test, in the Isère area in southeastern France where a mass screening campaign for colorectal cancer using the Hemoccult test was conducted in women aged 50 to 69 years. METHOD: This prospective survey was conducted with the participation of all gastroenterologists in the Isère department. Information about indications of all colonoscopies performed and their results were collected. RESULTS: The study involved 1,779 colonoscopies performed for: digestive symptoms (40%), surveillance of colon disease (22%), hematochezia (18%), a family history of colon cancer (10%), anemia, poor general condition or metastasis (4%), and a positive test for blood in the stool (3%). The presence of a pathological colonic condition was significantly related to age (11% of cancers or large polyps after 50 years compared to 3% before), sex (10% of the women with lesions and 15% of the men) and the reason for prescription: after the age 50 a cancer or a large polyp was found in 27% of the cases if the colonoscopy was performed for anemia, metastasis or poor general condition, 21% for hematochezia, 20% for a positive test, 8% for digestive symptoms, and 2% because of a family history. CONCLUSION: Positive Hemoccult tests represent only a small part of the indications for colonoscopies performed in the Isère department. However, the screening program should be extended to develop its use given its yield which is equivalent to that of hematochezia and much higher than that of digestive symptoms or family history.

Adult↗

PubMed2002

Successful colonoscopy; completion rates and reasons for incompletion.

Factors such as poor bowel preparation or obstructing colonic disease may confound the reporting of colonoscopy completion rates, as these factors are outside of the control of the endoscopist performing the procedure. By adjusting for these factors when calculating a colonoscopy completion rate, it may be possible to make a more accurate assessment of a unit's or individuals' competence. Details of two thousand two hundred and sixteen colonoscopies performed by four consultants and their trainees between 1993-2000 were analysed retrospectively from a prospective endoscopy database. Crude (all cases) and adjusted (excluding poor bowel preparation and disease as causes of incompletion) rates were recorded for each sex, and by age according to cause. Overall crude and adjusted completion rates were 77.9% and 85.0% respectively. There was a significant difference between male and female completion rates due to a difference in the incidence of excess looping and intolerance of the procedure (adjusted rate 88.9% in males vs. 81.6% in females, p<0.05). There was a non-significant trend to lower completion rates in patients over 75 years of age compared to younger patients. Completion rates were significantly higher following bowel resection (adjusted rates 93.5% vs. 82.8%, p<0.05). There was no significant difference between completion rates for inpatient and outpatient referrals (P=0.36). Reporting colonoscopy completion rates by adjusting for factors such as poor bowel preparation and obstructing colonic disease allows for direct comparisons of completion rates reported by different units. Reporting completion rates in this way also highlights the effect of inadequate bowel preparation on successful colonoscopy.

Adolescent↗