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PubMedDate not supplied

Profile of lower gastrointestinal bleeding in children from a tropical country.

Eighty five children were evaluated endoscopically for recurrent lower gastrointestinal (GI) bleeding. The male: female ratio was 2.4:1 with a mean age of 6 years (range 8 months to 2 years). After adequate bowel preparation endoscopic evaluation was done using olympus CF 101 colonoscope. Sedation was given only in two patients. Full length colonoscopy had been done in 16 cases only, to look for extent of disease in 8 cases and to ascertain site of bleeding when no lesion could be seen on sigmoidoscopy. Juvenile polyps were seen in 40 cases, amoebic ulcer in 20, solitary rectal ulcer in 4 and polyposis syndrome in 5 cases. Sigmoidoscopy alone could establish the diagnose in 76 cases. We conclude that flexible sigmoidoscopy alone is safe and adequate in ascertaining the cause of prolonged recurrent lower GI bleeding.

Child↗

PubMed1998

A randomized, placebo-controlled trial of low-dose alpha-difluoromethylornithine in individuals at risk for colorectal cancer.

DFMO is an irreversible inhibitor of ornithine decarboxylase (ODC), the key enzyme in mammalian polyamine biosynthesis. The goal of this study was to determine the effects of DFMO 0.5 g/m2/day as a single oral dose on polyamine and ODC levels in rectal, rectosigmoidal, and cecal colonic mucosae of individuals at risk for colon cancer because of a personal history of adenomatous polyps of the colon or a family history of colon cancer in at least one first-degree relative. A second goal was to determine toxicity of this treatment given over 1 year. Forty-five randomized subjects had a flexible sigmoidoscopy with no preparation and a colonoscopy after lavage preparation at baseline, a sigmoidoscopy with no preparation after 3 months, and both procedures (as at baseline) after 12 months, with mucosal biopsies taken from the rectosigmoid area (sigmoidoscopy) or rectal and cecal areas (colonoscopy) for evaluations of ODC and polyamine levels. Significantly decreased levels of putrescine and spermidine were found in rectosigmoid colonic mucosae of DFMO-treated (n = 24) compared with placebo (n = 21) subjects at 3 months (P = 0.03 and 0.04) and 12 months (P = 0.005, P = 0.004). Similar trends, none reaching statistical significance, were found for individual polyamine levels in rectal and cecal mucosae. No significant differences in ODC levels were detected marginally. There was evidence of global suppression of ODC and polyamine levels in the treatment group (P = 0.035). Three DFMO recipients (12.5%) developed clinically noticeable and audiologically demonstrated hearing loss, which was reversible and attributed to DFMO after 3 months (two subjects) and 12 months (one subject). The tissue polyamine changes demonstrated in this study are consistent with findings in other studies in colon and other tissues. The ototoxicity findings here suggest that investigation of other DFMO schedules, such as ones with a drug "holiday," will be a necessary step before Phase III chemoprevention studies can be pursued.

Adult↗

PubMed1993

Diagnostic and screening procedures in family practice. Past, present, and future use.

OBJECTIVE: This report documents the experience, current practices, and plans of family physicians regarding their use of clinical procedures in diagnosis, screening, and prevention. DESIGN: A mailed survey of family physicians asked who offered or planned to add a variety of clinical procedures in their practices. PARTICIPANTS: Active members of the Washington Academy of Family Physicians. MAIN OUTCOME MEASURES: Does the physician include the procedure in his or her current practice or plan to add it in the future? RESULTS: Questionnaires were returned by 790 (82%) of 963 physicians, with 750 usable responses. Eighty-four percent of respondents were male and 68% had trained for at least 3 years. The median age of respondents was 40 years. Procedures performed by most respondents included the following: Papanicolaou's smear (97%), electrocardiography (80% performed it and 71% interpreted the results), endometrial biopsy (66%), pulmonary function test (61%), rigid sigmoidoscopy (58%), chest roentgenogram interpretation (54%), flexible sigmoidoscopy (52%), performing chest roentgenography (51%), and endocervical curettage (51%). Procedures most often planned to be added by respondents included flexible sigmoidoscopy (59%), colposcopy (30%), endometrial biopsy (23%), pulmonary function test (18%), smoking cessation groups (16%), exercise tolerance test (14%), and fine-needle aspiration biopsy (14%). Forty-two percent of respondents volunteered to teach these procedures to their colleagues. CONCLUSIONS: Family practice includes a wide variety of procedures used in diagnosis, screening, and prevention. Family physicians are eager to add procedures to their practices and to teach their colleagues the procedures they know.

Adult↗

PubMed1999

Colorectal carcinoma screening attitudes and practices among primary care physicians in counties at extremes of either high or low cancer case-fatality.

BACKGROUND: To the authors' knowledge, physician attitudes and reported practices regarding colorectal carcinoma screening have not been studied in areas of highest risk for cancer death. METHODS: Medicare claims were used to calculate colorectal carcinoma 2-year case-fatality rates for counties with >100 incident cases of colorectal carcinoma between 1991-1993. All 2682 practicing primary care physicians in 20 counties with the lowest case-fatality rates (mean of 29.9%) and 19 counties with the highest case-fatality rates (mean of 47.8%) were surveyed regarding their screening procedures and attitudes. RESULTS: Among the 972 respondents (36.1%), the reported use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy was similar in the low and high case-fatality counties. However, physicians who practiced in the high case-fatality counties were less likely to be trained in and to perform sigmoidoscopy themselves (37.0% vs. 45.6%; P<0.01). Moreover, practitioners in the high case-fatality counties were more likely than the other physicians to consider or plan enhanced FOBT and sigmoidoscopic screening in the near future. FOBT and sigmoidoscopy screening rates at the county level were associated negatively with cancer incidence rates, case-fatality rates, and metastatic disease rates, suggesting a potentially protective effect. CONCLUSIONS: Geographically targeted interventions are a potentially cost-effective strategy for focusing additional screening services on the highest risk populations. The primary care clinicians in these high risk areas are logical partners for these interventions by virtue of their high degree of readiness to change their current screening practices.

Attitude to Health↗

PubMed1988

Early cancer detection. Colorectal cancer.

Persons with symptoms or signs suggestive of colorectal cancer require complete exam of the large bowel either by sigmoidoscopy, preferably flexible, with barium enema, or by total colonoscopy. A test for fecal occult blood (FOBT) is not necessary here. In asymptomatic persons at average risk for colorectal cancer, the following screening recommendations are made: from age 40, annual digital rectal exam and FOBT; and, from age 50, sigmoidoscopy, preferably flexible, every 3 to 5 years after two negative annual exams. If there is a family history of colorectal cancer in one or more first-degree relatives, annual digital rectal exam and FOBT should begin at age 40, with either barium enema and sigmoidoscopy or total colonoscopy every 3 to 5 years. Persons with a history of chronic ulcerative colitis, polyposis syndromes, or prior colorectal adenomas or cancer merit special attention.

Colonoscopy↗

PubMed1993

Infectious complications of endoscopic procedures in bone marrow transplant recipients.

The prevalence of clinically relevant bacteremia after endoscopic procedures in bone marrow transplant recipients was assessed retrospectively. Bacteremia, within 24 hr of procedure, was defined as positive blood cultures, while hypotension and temperature greater than 38 degrees C were taken as possible indicators of bacteremia. Sixty-seven procedures were performed in 53 endoscopic sessions (upper endoscopy 37, flexible sigmoidoscopy 7, upper endoscopy + flexible sigmoidoscopy 8, colonoscopy 1). Twenty-five endoscopic sessions were performed in patients receiving broad-spectrum antibiotics and 28 sessions in patients not receiving antibiotics. Both groups were comparable with respect to patient characteristics, procedures performed, and immune status. No patient in either group developed hypotension. One patient developed fever after flexible sigmoidoscopy; no source of fever was identified. We conclude that: (1) there were no episodes of clinically relevant bacteremia attributable to endoscopic procedures, and (2) not all bone marrow transplant recipients require routine antibiotic prophylaxis prior to endoscopic procedures.

Adolescent↗

PubMed1983

Comparison of the rigid sigmoidoscope and the flexible sigmoidoscope in conjunction with colon x-ray for detection of lesions of the colon and rectum.

A series of 1007 patients was randomly divided into two groups, one a group of 499 patients who underwent rigid sigmoidoscopy and the other a group of 508 patients who had flexible sigmoidoscopy. Contrast barium enema studies were subsequently performed in all patients. Eighteen per cent of the patients had a neoplasm. We concluded that, given the amount of colon surveyed by rigid and flexible sigmoidoscopy in conjunction with contrast barium enema, there was no difference in the rate of detection between the two endoscopic techniques.

Barium Sulfate↗

PubMed2006

Screening tests for colorectal cancer: a menu of options remains relevant.

Until the early 1990s, no evidence was available to show that screening for colorectal cancer (CRC) by any means actually saved lives. Subsequently, sufficient evidence for the efficacy of fecal occult blood testing (FOBT) and flexible sigmoidoscopy allowed the US Preventive Services Task Force to publish guidelines for CRC screening. Since that time the major organizations in the United States concerned with screening guidelines have recommended a menu of screening test options including FOBT, flexible sigmoidoscopy, flexible sigmoidoscopy plus FOBT, barium enema, and colonoscopy. No organization, except for the American College of Gastroenterology, has designated any one of these options as "preferred." Nevertheless, the lay press and many gastroenterology opinion leaders have encouraged Americans to have only one test--colonoscopy. In this review we discuss the rationale for caution in designating one screening test as "the best" and present information on how new stool and serum tests can be used effectively to screen for CRC.

Biomarkers, Tumor↗

PubMed2006

Temporal trends in colorectal procedure use after colorectal cancer resection.

BACKGROUND: After curative cancer resection, routine colon surveillance is recommended. It is not known whether trends over time in cancer survivors parallel that of the general population. OBJECTIVE: Our purpose was to describe temporal changes in the use of posttreatment procedures. DESIGN: Retrospective cohort study. SETTING: Linked tumor registry and Medicare claims data. PATIENTS: Medicare beneficiaries >65 years old who were diagnosed with local or regional stage colorectal cancer from 1992-2002 and who underwent surgical resection. MAIN OUTCOME MEASUREMENTS: Use of colonoscopy, sigmoidoscopy, or barium enema within 1 year, 18 months, or 3 years of diagnosis. RESULTS: A total of 62,882 patients were followed up for 1 year and 35,784 for 3 years. Colonoscopy within 1 year was performed in 25.9%, within 18 months in 53.8%, and within 3 years in 70.3%. Corresponding rates for sigmoidoscopy were 7.4%, 10.2%, and 14.9%, respectively, and were 3.4%, 5.1%, and 7.9%, respectively, for barium enema. There was a decrease over time in the receipt of colonoscopy within 1 year of diagnosis (31.3% in 1992 to 20.6% in 2002), no change in 18-month rates, and a smaller increase in colonoscopy use within 3 years (66.5% to 72.3%). The use of sigmoidoscopy and barium enema declined over time. Overall procedure use within 1 year and 18 months also decreased and 3-year rates were essentially unchanged. These differences were maintained in multivariate analyses. LIMITATIONS: Accuracy of procedure coding and indications for tests could not be measured. CONCLUSIONS: Temporal trends in procedure use in cancer survivors were consistent with the general population. Importantly, despite guideline recommendations and Medicare reimbursement, 25% of patients who undergo curative treatment do not receive surveillance examinations and this was unchanged over time.

Adenocarcinoma↗

PubMed2000

A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults.

OBJECTIVES: Guidelines for colorectal cancer screening and surveillance in people at average risk and at increased risk have recently been published by the American Gastroenterological Association. The guidelines for the population at average risk were evaluated using cost-effectiveness analyses. METHODS: Since colorectal cancers primarily arise from precancerous adenomas, a state transition model of disease progression from adenomatous polyps was developed. Rather than assuming that polyps turn to cancer after a fixed interval (dwell time), such transitions were modeled to occur as an exponential function of the age of the polyps. Screening strategies included periodic fecal occult blood test, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Screening costs in 1994 dollars were estimated using Medicare and private claims data, and clinical parameters were based upon published studies. RESULTS: Cost per life-year saved was $12,636 for flexible sigmoidoscopy every 5 years and $14,394 for annual fecal occult blood testing. The assumption made for polyp dwell time critically affected the attractiveness of alternative screening strategies. CONCLUSIONS: Sigmoidoscopy every 5 years and annual fecal blood testing were the two most cost-effective strategies, but with low compliance, occult blood testing was less cost-effective. Lowering colonoscopy costs greatly improved the cost-effectiveness of colonoscopy every 10 years.

Aged↗

PubMed1998

Screening endoscopy and risk of colorectal cancer in United States men.

OBJECTIVES: The purpose of this study was to describe the effect of screening endoscopy (sigmoidoscopy or colonoscopy) on colorectal cancer incidence and mortality. METHODS: We used data from a prospective cohort study of 24,744 men aged 40 to 75 years in 1986, free from cancer and colon polyps, followed until 1994. The outcomes are diagnosis of colorectal cancer and death from colorectal cancer. RESULTS: Screening endoscopy in 1986-87 was associated with a lower risk of all colorectal cancer (multivariate relative risk [RR] = 0.58, 95 percent confidence interval [CI] = 0.36-0.96); cancer in the distal colon or rectum (multivariate RR = 0.40, CI = 0.19-0.84); Dukes stage A&B (multivariate RR = 0.66, CI = 0.35-1.25); and Dukes stage C&D (multivariate RR = 0.50, CI = 0.20-1.26) colorectal cancer; and death from colorectal cancer (multivariate RR = 0.56, CI = 0.20-1.60), after adjusting for age and a wide range of colon cancer risk factors. Screening endoscopy in 1988-87 appeared to provide strong protection against distal stage C&D cancers (age-adjusted RR = 0.16, CI = 0.02-1.23) but no protection against proximal stage C&D cancers (age-adjusted RR = 0.96, CI = 0.32-2.91). CONCLUSIONS: This study provides strong evidence for a protective effect of screening sigmoidoscopy on colorectal cancer incidence and mortality and supports recommendations for screening sigmoidoscopy as an approach to colon cancer prevention.

Adult↗

PubMed2006

Prospective endoscopic evaluation for gastrointestinal graft-versus-host disease: determination of the best diagnostic approach.

The best endoscopic diagnostic strategy for gastrointestinal (GI) graft-versus-host disease (GVHD) is unknown. Over a 48-month period, all patients with unexplained diarrhea at risk for acute gastrointestinal GVHD were prospectively identified. Acute GVHD was defined as symptoms and histologic evidence of GVHD occurring within 100 days of transplant or donor lymphocyte infusion (DLI). Colonoscopy was performed with multiple biopsies of the ileum, right colon and rectosigmoid colon. Next, upper endoscopy with duodenal and random gastric biopsies of both antrum and body were performed. All biopsies were evaluated for GVHD by an experienced GI pathologist. Over the study period, 24 patients (mean age 37 years; 62.5% male) were evaluated. The median time from transplantation or DLI was 30.5 days. The biopsy site with the highest yield was the distal colon (82%). A combination of upper endoscopy with sigmoidoscopy and colonoscopy with ileal biopsies were equivalent ( approximately 94%). In patients with diarrhea at risk for GVHD, biopsies of the distal colon had the highest diagnostic yield suggesting the importance of sigmoidoscopy and biopsy. Colonoscopy and ileoscopy or flexible sigmoidoscopy plus upper endoscopy had the highest diagnostic yields.

Adolescent↗

PubMed2001

Nurse endoscopists in United Kingdom health care: a survey of prevalence, skills and attitudes.

OBJECTIVES: To assess the prevalence and potential benefits of attitudes towards nurse endoscopy in the United Kingdom (UK). DESIGN: Postal questionnaire. SUBJECTS: All hospitals in the UK with accident and emergency, general medical and general surgical services in October 2000. MAIN OUTCOME MEASURES: Number of teaching or district general hospitals employing nurse endoscopists, range of diagnostic and therapeutic endoscopic skills and potential benefits to the endoscopy unit and patients. RESULTS: Seventy-six hospitals employed 102 nurse endoscopists. Forty-four nurse endoscopists performed both oesophago-gastroduodenoscopy (OGD) and flexible sigmoidoscopy with solitary OGD and flexible sigmoidoscopy performed by 17 and 31, respectively. Three performed full colonoscopy while seven could perform all three procedures. Nurse endoscopists were found to provide good patient care in the majority of endoscopy units with no compromise in safety. Lead clinicians were keen to restrict nurse endoscopy to diagnostic OGD and flexible sigmoidoscopy only in the majority of units. CONCLUSIONS: Nurse endoscopy is widely practised in the UK and is not limited to one procedure or solely for diagnostic purposes. Benefits include good patient acceptability, improved care and safety. Most clinicians predict an important but restricted role for nurse endoscopy in contributing to endoscopic services.

Attitude to Health↗

PubMed2000

Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures.

BACKGROUND: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists. OBJECTIVE: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists. DESIGN: Retrospective cohort study. PATIENTS: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists). MEASUREMENTS: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression. MAIN RESULTS: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6). CONCLUSIONS: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities.

Aged↗

PubMed1999

Colon polyp registries and colorectal cancer control.

This cohort of 252 subjects in the Roger Williams Hospital Polyp Registry who had adenomatous polyps removed in 1990, was followed for 6 years. Thirty subjects died during that period. Follow-up rate for the 222 living patients (88.1% of total) was 85%. New adenomatous polyps were found in 59% of the endoscoped subjects. Risk factors for new polyps included family history of colorectal carcinoma (p = 0.00079), right-sided location (p = 0.0108), and (probably) prior adenomatous polyps (p = 0.0595). In addition, three colorectal carcinomas, two of which were Dukes stage A, were found 1, 1, and 6 years after index polypectomy. If, as is common practice, the two first-year cancers are excluded, the observed incidence of metachronous colorectal cancer was 0.8/1000 patient years, which is substantially less than the expected incidence of such carcinomas in reference populations. Compared to the 1984 and 1987 cohorts in the polyp registry, colonoscopy was used more frequently and sigmoidoscopy less so for surveillance. Within the sigmoidoscopy group, the flexible instrument continued to rise in popularity as compared with rigid sigmoidoscopy. In addition to helping reduce the incidence of metachronous colorectal carcinomas, the polyp registry also serves the educational function of sensitizing physicians and their patients to the need to detect and treat these premalignant lesions. Enrollees in the registry also provide a source for studies designed to evaluate possible inhibitory effects of dietary, chemopreventive, and other agents on colorectal neoplasias.

Adenomatous Polyposis Coli↗

PubMed2002

Prevalence of Barrett's esophagus in asymptomatic individuals.

BACKGROUND & AIMS: The incidence of esophageal adenocarcinoma in the western world has been linked to chronic heartburn, regurgitation, and the development of the premalignant epithelium of Barrett's esophagus (BE). However, up to 40% of esophageal adenocarcinomas occur in patients without prior reflux symptoms. We prospectively screened for the presence of BE in asymptomatic subjects older than 50 years of age undergoing screening sigmoidoscopy for colorectal cancer. METHODS: Subjects undergoing sigmoidoscopy for colorectal cancer (CRC) screening were invited to undergo upper endoscopy. Exclusion criteria included symptoms of gastroesophageal reflux disease (GERD) more than once a month, use of medications for GERD, or previous endoscopy. BE was classified as long-segment BE (LSBE), short-segment BE (SSBE), and microscopic specialized intestinal metaplasia of the esophagogastric junction (SIM-EGJ). RESULTS: Of 408 potential study candidates, 110 subjects were screened; 9 were women. The mean (+/-SD) age was 61 +/- 9.3 (range, 50-80) years, most of them (73%) Caucasian. Intestinal metaplasia (IM) extending above the EGJ was detected in 27 (25%) subjects; 8 (7%) had LSBE, and 19 (17%) had SSBE. Patients with BE were no more likely to be obese, consumers of tobacco or alcohol, report a family history of GERD, show association with toxic exposure, or use antacids more than once a month, compared with those without BE. CONCLUSIONS: BE was detected in 25% of asymptomatic male veterans older than 50 years of age undergoing screening sigmoidoscopy for CRC.

Aged↗

PubMed2000

Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer.

BACKGROUND: Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known. METHODS: Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures. RESULTS: One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers. CONCLUSIONS: There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines.

Age Distribution↗

PubMed2004

Do benefits and barriers differ by stage of adoption for colorectal cancer screening?

In 2003, over 148,300 people were expected to be diagnosed and 56,000 to die from colorectal cancer (CRC). First-degree relatives (FDRs) of people with colon cancer have a two- to eight-fold increased risk for CRC. Despite evidence that screening is effective, adherence with screening recommendations in this at-risk population is low. This study's purposes were to (1) identify perceived benefits and barriers of fecal occult blood testing (FOBT), sigmoidoscopy and colonoscopy, and (2) compare demographic characteristics and perceived benefits and barriers by stage of adoption for CRC screening. Participating FDRs (n = 257) completed a 40-min structured telephone interview. Despite high rates of agreement with the benefits of screening, most FDRs were not contemplating being screened. Of those 50 and older, most were in precontemplation for FOBT, sigmoidoscopy and colonoscopy. Older age was related to stage for FOBT and sigmoidoscopy, but not colonoscopy. Lack of provider recommendation also was related to stage. Consistent with theoretical predictions, precontemplators had (1) higher rates of endorsement of specific barriers to screening and (2) lower rates of endorsement of benefits than contemplators or actors. For morbidity and mortality reduction, participation in routine, periodic screening is imperative. These findings can guide development of screening-promoting interventions.

Age Factors↗