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PubMed2003

Surveillance after positive and negative colonoscopy examinations: issues, yields, and use.

As colorectal cancer screening gains acceptance by the public, the use of colonoscopy will increase. The frequency of surveillance examinations after detection of an adenoma is one of the largest contributors to the cost of colorectal cancer screening. Ten years after the publication of the landmark National Polyp Study, the issue of when to perform surveillance examinations and how often to expect advanced findings remains acute. Current guidelines for surveillance vary across specialty organizations. Individuals with advanced adenomas are at increased risk for recurrent advanced adenomas. The impact of multiple nonadvanced adenomas or a single nonadvanced adenoma on subsequent risk of an advanced adenoma or cancer is less clear. Still less is known about findings on repeat examinations after an initial negative examination, whether after colonoscopy or sigmoidoscopy. The yield after a negative examination is an important consideration in determining the recommended interval for screening colonoscopy. For example, the data supporting a 10-yr interval for screening colonoscopy is only indirect. What little we do know about the yield after negative examinations comes from selected, nonrepresentative populations. Of concern, evidence from several polyp prevention trials demonstrates higher yields for subsequent cancer than would be expected, despite a relatively high use of surveillance procedures in follow-up. Further population-based research on the frequency of use and yield of surveillance examinations is needed. Studies that examine the need and the needed timing of subsequent surveillance are essential to containing costs for screening as well as to informing the public better about what endoscopic screening can and cannot accomplish.

Adenocarcinoma↗

PubMed2003

Colonoscopy screening in the elderly: when to stop?

OBJECTIVES: The age to begin colorectal cancer (CRC) screening is based on the risk of neoplasia and is published in screening guidelines. The age to stop screening is unknown but should be based, in part, on the same principle. The purpose of this study was to establish whether the prevalence of neoplasia detected by colonoscopy diminished with advancing age, to warrant ceasing colonoscopic screening. METHODS: The endoscopic and pathology reports of all asymptomatic subjects undergoing colonoscopy for the purpose of CRC screening or an evaluation of abdominal pain or change in bowel habits between 1997 and 2000 were reviewed. A multivariate logistic regression analysis was used to assess the effect of age, gender, and indication for examination on the prevalence of neoplasia, as well as on having more than two adenomas, advanced adenomas (tubulovillous, villous, severe dysplasia, or size > or = 1 cm), and invasive cancers. RESULTS: A total of 915 patients were included. Of these, 50% were male, with a mean age of 65 yr (range 50-100). Neoplasia peaked in the seventh decade, with a fall thereafter (p = 0.009). Numerous adenomas, advanced adenomas, and invasive cancers increased with age. The yield for overall neoplasia, advanced adenomas, and more than two adenomas was higher in the screening group than in the symptomatic group. More invasive cancers were found in the symptomatic group compared with the asymptomatic group, but this did not achieve statistical significance (4 vs 1, p = 0.44). CONCLUSIONS: The prevalence of advanced neoplasia continues to increase with age. Subjects undergoing colonoscopy for screening had a greater risk for neoplasia than did subjects with symptoms. There is no decline in yield of advanced neoplasia to justify stopping screening colonoscopy in the elderly.

Age Factors↗

PubMed2004

Assessment of patients' perceptions of bowel preparation quality at colonoscopy.

AIMS: There is little published literature evaluating the accuracy of patients' perceptions of the quality of their own bowel preparation for colonoscopy. The aim of this article was to compare patients' perceptions of the adequacy of their bowel preparation with the endoscopists' rating at colonoscopy. METHODS: Outpatients undergoing elective colonoscopy completed surveys assessing bowel preparation. Patient responses regarding quality of bowel preparation were compared with endoscopists' assessment of colonic preparation. A residual stool score was also calculated for each subject based on the amount of stool, consistency of residual stool, and percentage of bowel visualized. RESULTS: A total of 474 patients were enrolled. Patients' perceptions of the quality of their bowel preparation were inaccurate when compared to the endoscopists' rating (sensitivity, 75%; specificity, 34%; accuracy, 50%). Overall correlation with endoscopists' rating was low, r = 0.08. Young patient age (<61 yr) was an independent predictor of both adequate bowel preparation ( p= 0.009) and agreement of patient/endoscopist ratings ( p= 0.003). CONCLUSIONS: Patients are unreliable judges of the quality of their own bowel preparation, tending to overestimate the cleanliness of their colon. Conversely, a patient's fear that their preparation is suboptimal is also inaccurate. A colonoscopy should not be canceled on the basis of a patient's perception that the quality of their preparation is poor.

Aged↗

PubMed2005

Premedication with intravenous ketorolac trometamol (Toradol) in colonoscopy: a randomized controlled trial.

OBJECTIVE: We conducted a prospective double-blinded placebo-controlled randomized trial to investigate the effect of ketorolac trometamol (KT) administered intravenously as premedication in colonoscopy. METHODS: One hundred and forty patients undergoing colonoscopy were randomized to receive either 60 mg of KT (KT group (KTG), n=70) or placebo (normal saline group (NSG), n=70) intravenously as premedication 30 min prior to procedure. Patient-controlled sedation (PCS) was used as the mode of sedation. Outcome measures included patient self-assessed pain score in a 10-cm unscaled visual analog scale (VAS), endoscopist assessment of patient pain score in VAS, patient's willingness to repeat colonoscopy, administered and demanded doses of PCS, patient satisfaction score in VAS, and hemodynamic changes during and after the procedure. RESULTS: The mean patient self-assessed pain score (SD) during procedure was significantly lower in KTG than NSG: 5.08 (2.74) vs 6.62 (2.45); p=0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in KTG than NSG as well: 3.99 (2.80) vs 5.28 (2.71); p=0.006. More patients in KTG were willing to repeat procedure as compared with NSG (80.0%vs 57.1%; p=0.004). No significant difference was found in the administered and demanded doses of PCS, mean satisfactory scores and hemodynamic changes in both groups. No serious complication related to intravenous (IV) KT was noted. CONCLUSIONS: Premedication with IV KT (Toradol) improves pain control during colonoscopy with no associated serious complications.

Academic Medical Centers↗

PubMed2006

The case for direct colonoscopy screening for colorectal cancer.

Recent large series of direct colonoscopy screening for colorectal cancer increase our understanding of the advantages of this approach, and have indirectly confirmed efficacy. When performed by well-trained, experienced endoscopists, colonoscopy screening is successful and safe. The prevalence of advanced neoplasia is low under the age of 50 yr but increases substantially with each decade of life thereafter at least until the age of 80 yr. Most detected cancers are at an early, curable stage. A substantial number of proximal advanced neoplasia are detected that would be missed by screening flexible sigmoidoscopy. Widespread population-based colonoscopy screening would markedly decrease the incidence and mortality of this major malignancy. Issues of compliance and capacity related to direct colonoscopy have not yet been adequately addressed.

Adult↗

PubMed1995

Preparing the bowel for colonoscopy.

Bowel preparation methods for total colonoscopy in children generally involve whole gut irrigation with electrolyte lavage solutions, which in most children will require hospitalisation for nasogastric tube administration. The aim of the study was to determine the efficacy of oral bisacodyl combined with a single phosphate enema as a bowel preparation regimen in children. In an open prospective trial, 30 children (aged 18 months-15 years) were given oral bisacodyl on each morning of the two days before colonoscopy. The children were maintained on a normal diet. A phosphate enema was administered on the morning of the procedure. The adequacy of bowel preparation was graded as grade I if no faecal material was encountered, grade II if small amounts of faecal material were present in scattered locations, and grade III if there was poor preparation with faecal material precluding satisfactory visualisation of the bowel mucosa. Eight children (26.6%) had minor abdominal cramps when taking bisacodyl, but all had a previous history of similar pain. Five children (16.6%), all under 5 years of age, cried during the administration of phosphate enema. Bowel preparation was considered excellent (grade I) in 26 (86.6%) and good (grade II) in four (13.3%). In all patients adequate visualisation of the bowel mucosa was obtained. Oral bisacodyl combined with a single phosphate enema provides an ideal method of preparing the bowel for total colonoscopy. This preparation allows colonoscopy to be carried out as a day case procedure in children while maintaining them on a normal diet.

Adolescent↗

PubMed2005

Comparison of magnetic resonance imaging colonography with conventional colonoscopy for the assessment of intestinal inflammation in patients with inflammatory bowel disease: a feasibility study.

AIM: Magnetic resonance imaging (MRI) based colonography represents a new imaging tool which has mainly been investigated for polyp screening. To evaluate this approach for patients with inflammatory bowel disease (IBD), we compared MRI based colonography with conventional colonoscopy for assessing the presence and extent of colonic inflammation. PATIENTS AND METHODS: In 22 consecutive patients with suspected or known IBD, MRI colonography was performed immediately before conventional colonoscopy. After bowel cleansing, a T1 positive contrast agent was applied rectally. In addition to T2 weighted sequences, T1 weighted two dimensional and three dimensional Flash acquisitions as well as volume rendered virtual endoscopy were performed. All images were evaluated with regard to typical MRI features of inflammation. The results were compared with colonoscopy findings. RESULTS: Distension and image quality was assessed as good to fair in 97.4% of all colonic segments. Only four of 154 segments were considered non-diagnostic. With colonoscopy serving as the gold standard, the sensitivity for correctly identifying inflammation on a per segment analysis of the colon was 31.6% for Crohn's disease (CD) and 58.8% for ulcerative colitis (UC). In CD, in most cases mild inflammation was not diagnosed by MRI while in UC even severe inflammation was not always depicted by MRI. Virtual endoscopy did not add any relevant information. CONCLUSION: MRI based colonography is not suitable for adequately assessing the extent of colonic inflammation in patients with IBD. Only severe colonic inflammation in patients with CD can be sufficiently visualised.

Adult↗

PubMed1981

Double contrast enema and colonoscopy in polyp detection.

The diagnostic accuracy of double contrast enema was assessed by colonoscopy of 250 consecutive patients with polypoid lesions that were observed at double contrast enema. The enema method detected 90% of all existing polypoid lesions, and gave false positive results in less than 3.5% Colonoscopy revealed 91% of the lesions. Double contrast enema is suitable as a screening procedure and, when used in combination with colonoscopy, only very few polyps will escape detection. The large number of neoplastic polyps detected in this retrospective series emphasises the necessity for a careful radiographic technique combined with colonoscopy to disclose and treat these potentially malignant lesions of the colon.

Adult↗

PubMed2002

Performance of multidetector computed tomography colonography compared with conventional colonoscopy.

BACKGROUND AND AIMS: This was a prospective blinded study to compare computed tomography (CT) colonography, performed with multidetector arrays CT scan (MDCT), with conventional colonoscopy for the detection of colorectal neoplasia. METHODS: Fifty patients were examined by MDCT after standard bowel preparation and rectal air insufflation in the supine and prone positions. Data sets were examined by one radiologist and one gastroenterologist blinded to the patient's history and colonoscopy results. Patients subsequently underwent colonoscopy on the same day, which served as the gold standard. RESULTS: Nine of 11 lesions >10 mm (82%), 5/15 lesions of 6-9 mm (33%), and 1/42 polyps <5 mm (3%) were detected by MDCT colonography. One false positive result for a structure larger than 10 mm was described. Nineteen of 21 patients who had no lesions during conventional colonoscopy were considered free of lesions by MDCT colonography, yielding a per patient specificity of 90%. CONCLUSION: MDCT colonography provides good data quality and has good sensitivity and specificity for the detection of colonic lesions of 10 mm or more.

Aged↗

PubMed2003

Colonoscopy surveillance of individuals at risk of familial colorectal cancer.

BACKGROUND: Individuals with first degree relatives affected with colorectal cancer (CRC) at a young age, or more than one relative affected but who do not fulfil the Amsterdam criteria for a diagnosis of hereditary non-polyposis colon cancer (HNPCC), are believed to be at an increased risk of CRC. However, there is a paucity of prospective data on the potential benefit of colonoscopic surveillance in such groups categorised by empiric family history criteria. We report a prospective study of 448 individuals seeking counselling about their perceived family history of CRC. PATIENTS AND METHODS: Following pedigree tracing, verification, and risk assignment by genetic counsellors, colonoscopy was undertaken for those at a moderate or high risk (HNPCC). Those classified as low risk were reassured and discharged without surveillance. Here we report our findings at the prevalence screen in the 176 patients of the 448 assessed who underwent colonoscopy. RESULTS: Fifty three individuals had a family history that met Amsterdam criteria (median age 43 years) and 123 individuals were classed as moderate risk (median age 43 years). No cancers were detected at colonoscopy in any group. Four individuals (8% (95% confidence limits (CL) 0.4-15%)) in the high risk group had an adenoma detected at a median age of 46 years and all four were less than 50 years of age. Five (4% (95% CL 0.6- 8%)) of the moderate risk individuals had an adenoma at a median age of 54 years, two of whom were less than 50 years of age. CONCLUSIONS: These findings indicate that the prevalence of significant neoplasia in groups defined by family history is low, particularly in younger age groups. These prospective data call into question the value of colonoscopy before the age of 50 years in moderate risk individuals.

Adult↗

PubMed1992

Colonoscopy in patients aged 80 years or older and its contribution to the evaluation of rectal bleeding.

Colonoscopies performed in patients aged 80 years or older at the Sheba Medical Center were analysed according to the primary indication for the procedure: 101 colonoscopies were performed because of rectal bleeding of at least 2 months duration, and 335 for all other indications. Carcinoma of the large bowel was found in 29 (28.7%) bleeders, with the rectum being the most frequently involved site (12 patients). Among the non-bleeders, the prevalence of cancer was significantly lower (33 cases, 9.8%; P less than 0.001), and rectal carcinoma was less common (five patients, P = 0.04), but proximal tumours were more frequent. Of patients with cancer who had operations, the majority (72%) had a tumour confined to the bowel wall (Dukes A or B). The rate of adenomas was similar for both groups (34% vs 29%). The non-bleeders complained more frequently of abdominal pain or a change in bowel habits as compared to the bleeders, but both groups had similar rates for anaemia and weight loss. In all, 47% of these octogenarians with cancer, and 26% with adenomas were referred for colonoscopy because of rectal bleeding. This procedure was found to be safe in old age, as we recorded only four (0.9%) non-fatal complications among our series, a similar figure to the overall incidence of complications at our Institute. In conclusion, our data indicate that rectal bleeding in octogenarians warrants a complete colonic investigation, preferably by total colonoscopy.

Aged↗

PubMed2000

Randomized trial of oral sodium phosphate compared with oral sodium picosulphate (Picolax) for elective colorectal surgery and colonoscopy.

BACKGROUND: Sodium picosulphate (Picolax) is considered by most British surgeons as standard preparation for colonoscopy and elective surgery. Oral sodium phosphate may be better tolerated and more efficient as bowel preparation. METHODS: A randomized trial was performed to compare oral sodium phosphate (n = 76) with Picolax (n = 77) as bowel preparation for elective colorectal surgery. A parallel study randomized colonoscopy patients to sodium phosphate (n = 51) or Picolax (n = 52). Patient acceptability was measured for seven symptoms with a linear analogue score. Quality of preparation was graded by the surgeon and faecal residue was measured in resection specimens. During colonoscopy, bowel preparation has graded 0-24 using an endoscopic score. RESULTS: Abdominal pain, nausea, vomiting, embarrassment, fear and fatigue did not differ significantly between the groups. Surgeons grade of quality was judged poor or awful in 5 of 76 in the sodium phosphate group (9%) compared with 13 of 73 in the Picolax group (18%, p = 0.084). Mean faecal residue in the resection specimen was 0.1 g/cm after sodium phosphate compared with 0.45 g/cm after Picolax (p < 0.01). The endoscopic score was significantly lower using sodium phosphate (2.0 +/- 2.2) than picolax (3.1 +/- 2.9; p < 0.05). CONCLUSIONS: These results suggest that oral sodium phosphate is well tolerated and superior to Picolax in elective colorectal surgery and colonoscopy.

Administration, Oral↗

PubMed1992

Irritable bowel syndrome: can the patient's response to colonoscopy help with diagnosis?

The irritable bowel syndrome (IBS) is a common disorder estimated to affect up to 20% of adult Caucasians, with only a small percentage requiring investigation. This prospective study was performed to substantiate the impression that patients with IBS experience more pain during endoscopic examination of the colon than do patients with other conditions. Patients with IBS were observed to experience significantly more pain during colonoscopy than did patients without IBS (median observed pain scores 46 and 9, respectively), p < 0.001. The intensity of the pain perceived during examination was significantly higher for patients with IBS than for those without IBS (median 52.5 and 23.5, respectively), p < 0.001. Within the groups, there was no significant difference between flexible sigmoidoscopy and colonoscopy in observed or perceived pain. 64% of the patients with IBS said that the pain experienced at colonoscopy was identical to their presenting pain. This study supports the hypothesis of a lower colonic pain threshold with colonic hyperalgesia in patients with IBS. We have found that hypersensitivity to the endoscopic examination of the colon is a useful clinical adjunct in the diagnosis of the IBS in those selected to undergo colonoscopy.

Colonic Diseases, Functional↗

PubMed2004

Effect of four-day psyllium supplementation on bowel preparation for colonoscopy:A prospective double blind randomized trial [ISRCTN76623768].

BACKGROUND: Patients with new onset constipation or presumed hemorrhoid bleeding frequently require the use of both fiber supplements and diagnostic colonoscopy. We sought to determine whether preliminary fiber supplementation would alter the tolerability or efficacy of a standard bowel preparation for colonoscopy METHODS: A prospective, double blind, randomized trial was designed to compare a short course of a psyllium-based supplement versus placebo prior to a colon lavage. Patients were given an unlabeled canister of powder, and instructed to take 1 tablespoon with 8 oz of water bid for 4 days before colonoscopy. A 4-liter polyethylene based glycol lavage was self-administered over 4 hours on the day prior to colonoscopy. A questionnaire on pre-study bowel habits and side effects was completed. Efficacy of the preparation was visually evaluated on a pre-determined scale. RESULTS: There were no significant differences between the two groups in gender, race, age, pre-study stool frequency or consistency. Tolerability was equivalent but efficacy of the bowel preparation was worse in the psyllium group compared to placebo (P < 0.05). CONCLUSIONS: In non-constipated patients psyllium based fiber supplementation should not be initiated in the few days prior to endoscopy using a polyethylene glycol preparation.

Cathartics↗

PubMedDate not supplied

Outpatient colonoscopy by rural family physicians.

PURPOSE: Five percent of family physicians offer colonoscopy services, either in the office or the hospital, often in rural areas that have no gastroenterologist. Two previous large series have shown the quality and safety of colonoscopy performed by family physicians. The purpose of this study was to verify these findings in an outpatient setting, as well as to obtain patient satisfaction data. METHODS: Data were obtained from 731 colonoscopies performed between 1996 and 2001 in a rural Virginia family practice. These data included patients' age and sex, indications for the procedure, drug dosages for sedation, cecal intubation rates, pathologic findings, complications, and referral correlation findings compared with the original examination. A patient satisfaction survey was done. RESULTS: The adenoma detection rate was 27.2% for men and 21.4% for women older than age 50 years. Six adenocarcinomas and 5 large (>2 cm) villous adenomas were detected, and the patients were referred for definitive surgical resection. A total of 29 patients (4%) were referred: 10 to colorectal surgery and 19 to gastroenterology for resection of large polyps. Correlation of findings at referral with the initial examination was excellent. Cecal intubation rates increased from 89.5% from 1996-1998 to 94.6% from 1999-2001. Minor sedation complications occurred in 5 cases (<1%), and patients responded to supportive care. A high degree of satisfaction was reported by patients, with a mean satisfaction score of 8.8 on a scale from 1 to 10. CONCLUSIONS: Colonoscopy can be performed safely and competently by properly trained family physicians in an outpatient setting with a high degree of patient satisfaction.

Adult↗

PubMed2001

Value of double-contrast barium enema performed immediately after incomplete colonoscopy.

OBJECTIVE: The purpose of this study was to evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy. SUBJECTS AND METHODS: During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult). RESULTS: DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE. CONCLUSION: Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.

Adolescent↗

PubMed1986

Radiation dose in investigations of the large bowel. Comparison of radiation doses in examinations of the colon with double-contrast barium enema with the Welin modification and colonoscopy.

Because of the increasing and repeated application of colonoscopy and double-contrast barium enema with the Welin modification in connection with the checking of patients who have been treated for neoplastic polyps, we have found it valuable to examine the amount of radiation that the patients are exposed to in the two kinds of examinations. The radiation dose in the examination of the colon with the Welin modification (35 examinations) and at colonoscopy (114 examinations) was, on an average, 387 and 10 mSv, respectively. Since colonoscopy gives a possibility not only of diagnosis but also of treatment and also exposes the patients to 40 times less radiation than X-ray examination with the Welin modification, we recommend colonoscopy for diagnosis and treatment of neoplastic colonic polyps.

Adolescent↗

PubMed1988

The diagnostic value of colonoscopy compared with rectosigmoidoscopy in children and adolescents with symptoms of chronic inflammatory bowel disease of the colon.

Seventy-eight young patients with symptoms of chronic inflammatory bowel disease (IBD) of the colon have been investigated to determine to what degree colonoscopy adds important information for the diagnosis of IBD in addition to results of the routine procedures, including rectosigmoidoscopy carried out at the same time. After colonoscopy IBD was established in 4 of 12 patients classified as non-IBD after the routine procedures. Eleven of 18 patients with the routine diagnosis indeterminate colitis (IC) could after colonoscopy be differentiated into UC or probable CC. In 30 of 31 cases classified as UC the routine diagnosis was confirmed by colonoscopy. Routine diagnosis as probable CC was changed to definite CC in 3 of 10 cases. In all cases but one with previously established IBD it was possible to confirm the diagnosis. Thirty-seven of 70 patients with established IBD of the colon had no radiologic evidence of colitis.

Adolescent↗