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PubMed2000

Overuse and underuse of colonoscopy in a European primary care setting.

BACKGROUND: Efforts to decrease overuse of health care may result in underuse. Overuse and underuse of colonoscopy have never been simultaneously evaluated in the same patient population. METHODS: In this prospective observational study, the appropriateness and necessity of referral for colonoscopy were evaluated by using explicit criteria developed by a standardized expert panel method. Inappropriate referrals constituted overuse. Patients with necessary colonoscopy indications who were not referred constituted underuse. Consecutive ambulatory patients with lower gastrointestinal (GI) symptoms from 22 general practices in Switzerland, a country with ready access to colonoscopy, were enrolled during a 4-week period. Follow-up data were obtained at 3 months for patients who did not undergo a necessary colonoscopy. RESULTS: Eight thousand seven hundred sixty patient visits were screened for inclusion; 651 patients (7.4%) had lower GI symptoms (mean age 56.4 years, 68% women). Of these, 78 (12%) were referred for colonoscopy. Indications for colonoscopy in 11 patients (14% of colonoscopy referrals or 1.7% of all patients with lower GI symptoms) were judged inappropriate. Among 573 patients not referred for the procedure, underuse ranged between 11% and 28% of all patients with lower GI symptoms, depending on the criteria used. CONCLUSIONS: Applying criteria from an expert panel of nationally recognized experts indicates that underuse of referral for colonoscopy exceeds overuse in primary care in Switzerland. To improve quality of care, both overuse and underuse of important procedures must be addressed.

Colonoscopy↗

PubMed1998

Colonoscopy without sedation.

Colonoscopy is routinely performed with conscious sedation. We wanted to determine if colonoscopy can be successfully completed without sedation and to assess patient tolerance and acceptance. One hundred nine consecutive patients undergoing colonoscopy were examined. The risks and benefits of colonoscopy with or without sedation were explained in a standard format. Patients were then given the option of having colonoscopy without premedication. After the procedure, as well as 2 to 5 days later, patients rated on an analog scale (0, no pain; 5, severe) the severity of pain and willingness to undergo colonoscopy in the future without sedation. Eighty patients underwent colonoscopy without prior sedation. Only 6% (n=5) required sedation to complete the examination. When questioned, 5% experienced no pain, 41% slight or mild pain, 34% moderate pain, and 20% severe pain. Seventy-three percent (n=58) were willing to undergo repeat colonoscopy without sedation, 10% (n=8) were undecided, and 18% (n=14) would request sedation. Pain severity was a strong predictor (p=0.001) of future sedation preference. Colonoscopy without sedation may be completed successfully in most patients and does not undermine many patients' willingness to undergo a similar procedure in the future. Sedation by choice is more cost-effective, may be safer, and should be offered as an alternative to routine intravenous sedation.

Analgesics, Opioid↗

PubMed2001

The utility of urgent colonoscopy in the evaluation of acute lower gastrointestinal tract bleeding: a 2-year experience from a single center.

OBJECTIVE: Urgent colonoscopy is often recommended to evaluate acute rectal bleeding. However, it may not identify a source because of blood in the lumen or inadequate preparation. Our aim was to determine the utility of urgent colonoscopy as the initial test for acute rectal bleeding. METHODS: This was a retrospective chart review of all patients discharged in 1997 and 1998 with an International Classification of Diseases, 9th Revision, code for hematochezia or rectal bleeding. RESULTS: We identified 514 charts but excluded 424 because of inaccurate coding. In the 90 with confirmed acute rectal bleeding, colonoscopy was the initial test in 39; age, sex, and race distributions were similar to those who did not have colonoscopy. A definite source of bleeding was seen at colonoscopy in only three patients, a probable source in 26, and no source in 10. Therapeutic intervention in four patients with a definite or probable source was successful in three. The commonest reasons for not performing urgent colonoscopy were bleeding from presumed hemorrhoids or bleeding that was clinically insignificant. Spontaneous resolution of bleeding and length of hospital stay were not affected by urgent colonoscopy. Five patients had surgery for unrelated reasons. In-hospital mortality was 2% and was unrelated to bleeding. CONCLUSION: Urgent colonoscopy as the initial investigation in acute lower GI tract bleeding probably does not alter the outcome in most cases. Identification of a definite bleeding source leading to successful therapeutic intervention is rare. Spontaneous resolution is frequent, length of hospital stay is similar, and clinical outcome is excellent regardless of whether or not urgent colonoscopy is performed.

Acute Disease↗

PubMed2003

Is early colonoscopy after admission for acute diverticular bleeding needed?

OBJECTIVES: Urgent colonoscopy has been proposed for the diagnosis and management of acute colonic diverticular bleeding. Identification of active bleeding and nonbleeding stigmata facilitates diagnosis and endoscopic therapy, but it is unclear whether urgent colonoscopy after presentation increases the diagnostic yield. This study evaluated the association between timing of colonoscopy and diagnostic yield in patients admitted with acute colonic diverticular bleeding. METHODS: Patients admitted for hematochezia and receiving a diagnosis of diverticular hemorrhage were identified using the Mayo Clinic GI Bleeding Team and Emergency Room Admissions Databases for the years 1998-2000. Timing of colonoscopy was determined from the time of admission. Logistic regression analysis was used to assess whether the timing of colonoscopy was associated with an endoscopic finding of active bleeding or nonbleeding stigmata (or both). RESULTS: A diagnosis of definitive or presumptive diverticular bleeding was made in 78 patients (39 men and 39 women, mean age 78 yr, range 49-96 yr). Twelve patients (15%) had active bleeding or stigmata. Colonoscopies were performed a mean of 18 +/- 11 h after admission. The association between a definitive diagnosis of acute diverticular bleeding and the timing of colonoscopy was not significant (p > 0.46). CONCLUSIONS: No significant association is apparent between the timing of colonoscopy after admission and encountering active bleeding or nonbleeding stigmata. Based on these observations, urgent colonoscopy for these patients does not seem advantageous.

Acute Disease↗

PubMed2004

Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study.

OBJECTIVES: Computer-based colonoscopy simulation (CBCS) is being utilized in endoscopy training without supporting evidence that it improves patient-based colonoscopy performance. The goal of this pilot study was to determine if CBCS training improves gastroenterology (GI) fellows' patient-based colonoscopy skills. METHODS: Competency at colonoscopy among 4 novice GI fellows who completed a 6-h CBCS curriculum was compared with 4 novice fellows who were not CBCS-trained. Measurements of competency were rendered by supervising faculty by recording "insertion time,""depth of unassisted insertion,""independent procedure completion,""ability to identify endoscopic landmarks,""inserts in a safe manner,""adequately visualizes mucosa on withdrawal," and "responds appropriately to patient discomfort" with each colonoscopy. RESULTS: Simulator-trained fellows outperformed traditionally trained fellows during their initial 15 colonoscopies in all performance aspects except "insertion time" (pp < 0.05). Simulator-trained fellows inserted the endoscope significantly further and reached the cecum independently nearly twice as often during this early training period. Three parameters ("depth of insertion,""independent completion," and "ability to identify landmarks") demonstrated a continued advantage out to 30 colonoscopies. Beyond 30 procedures, there was no difference in the performance of the two groups. CONCLUSION: In this pilot study, a 6-h CBCS curriculum provides an early training advantage by enhancing competency at the early stages of patient-based colonoscopy. These advantages are negligible after approximately 30 patient-based procedures. CBCS-enhanced training may allow faculty to be more efficient with their colonoscopy practice.

Clinical Competence↗

PubMed2006

Maximizing detection of adenomas and cancers during colonoscopy.

Some patients who undergo colonoscopy that appeared to have cleared the colorectum of neoplasia return within a short interval (1-3 yr) with colorectal cancer. Although several a priori mechanisms could account for this occurrence, wide variation in detection rates of adenomas and cancer at colonoscopy suggests that suboptimal colonoscopic technique is a significant contributor. Optimal technique with white-light colonoscopy involves taking adequate time for inspection during withdrawal (an average of at least 6 min in normal colons), interrogating the proximal sides of folds, flexures, and valves, clearing fluid and debris, and distending adequately. Some adjunctive techniques are directed toward exposing more colonic mucosa during colonoscopy. Wide-angle colonoscopy appears to improve efficiency but does not eliminate miss rates. Colonoscopy in retroflexion was unsuccessful in reducing miss rates in one study, whereas cap-fitted colonoscopy was successful in reducing miss rates in one small study. Techniques to improve detection of flat lesions include pancolonic chromoendoscopy (CE). In two randomized controlled trials, CE improved adenoma detection, but CE does not appear to provide substantially greater yields than those obtained by the more sensitive white-light colonoscopists. Narrow band imaging and autofluorescence are being assessed for improved detection of flat lesions. Adenoma detection rates are an important measure of the quality of colonoscopy and should be reported to endoscopists in quality improvement programs in colonoscopy.

Adenoma↗

PubMed2004

A retrospective study on the use of post-operative colonoscopy following potentially curative surgery for colorectal cancer in a Canadian province.

BACKGROUND: Surveillance colonoscopy is commonly recommended following potentially curative surgery for colorectal cancer. We determined factors associated with patients undergoing a least one colonoscopy within five years of surgery. METHODS: In this historical cohort study, data on 3918 patients age 30 years or older residing in Alberta, Canada, who had undergone a potentially curative surgical resection for local or regional stage colorectal cancer between 1983 and 1995 were obtained from the provincial cancer registry, ministry of health and cancer clinic charts. Kaplan-Meier estimates of the probability of undergoing a post-operative colonoscopy were calculated for patient, tumor and treatment-related variables of interest. RESULTS: A colonoscopy was performed within five years of surgery in 1979 patients. The probability of undergoing a colonoscopy for those diagnosed in the 1990s was greater than for those diagnosed earlier (0.65 vs 0.55, P < 0.0001). The majority of the difference was seen at one-year following surgery, consistent with changes in surveillance practices. Those most likely to undergo a colonoscopy were those under age 70 (0.74 vs 0.50 for those age 70-79, P < 0.0001), who underwent a pre-operative colonoscopy (0.69 vs 0.54, P < 0.0001), and who underwent a resection with reanastomosis (0.62 vs 0.47 for abdominoperineal resection, P < 0.0001) by a surgeon who performs colonoscopies (0.68 vs 0.54, P < 0.0001). CONCLUSIONS: The majority of patients undergo colonoscopy following colorectal cancer surgery. However, there are important variations in surveillance practices across different patient and treatment characteristics.

Adult↗

PubMed2006

Benign pneumoperitoneum after colonoscopy: a prospective pilot study.

Benign pneumoperitoneum is asymptomatic free intraabdominal air and is reported to occur occasionally with colonoscopy. Management of benign pneumoperitoneum after colonoscopy is controversial and may depend on incidence or etiology. No previous studies prospectively investigated the incidence or inciting factors of benign pneumoperitoneum resulting from colonoscopy. In this study, 100 patients underwent colonoscopy and then radiography of the chest and abdomen to detect free air. The average age was 58 +/- 6.2 years, and 48 of the colonoscopies were therapeutic. No cases of benign pneumoperitoneum were detected, estimating the incidence at 0% to 3% for diagnostic and therapeutic colonoscopy. These data indicate that benign pneumoperitoneum attributable to colonoscopy is rare and possibly nonexistent. Given the paucity of data favoring the occurrence of benign pneumoperitoneum after colonoscopy, we advocate treating all cases of free intraabdominal air after colonoscopy as perforations.

Colonoscopy↗

PubMedDate not supplied

The impact of an incomplete preoperative colonoscopy in patients with colorectal cancer.

Total large bowel evaluation remains an essential step in the treatment of patients with colorectal cancer (CRC). Colonoscopy is the gold standard in the evaluation of the colon for colorectal tumors, but may be incomplete due to tumor obstruction, which is a frequent event in distal cancers. Double-contrast barium enema has a lower accuracy and is not ideal in the presence of signs of obstruction. In theory, intraoperative colonoscopy is a valid alternative, but its routine use is impeded by various practical limitations. Preoperative survey of the colon in 521 consecutive patients treated for CRC in our department was based on colonoscopy (92.5%). Our series was characterised by a high percentage of distal lesions (76.4%) and therefore by a high percentage of incomplete preoperative colonoscopies (50.4%) due to tumor obstruction. In the presence of an incomplete preoperative colonoscopy, we evaluated the entire colon with a double-contrast barium enema in selected cases (36.7%) and with a postoperative colonoscopy within 3 months of surgery in almost all patients (93.4%). The overall rate of complete endoscopic evaluation, either pre- or postoperatively, was 96.7%. The incidence of adenomas was significantly higher in the preoperative examinations as compared to early postoperative colonoscopy. This means that in distal cancer the vast majority of polyps will be located in the distal colon and therefore included in a standard resection. Four patients (0.8%), required a second operation for treatment of a missed lesion (2 benign and 2 malignant). The need for a repeat surgery apparently did not affect the therapeutic results in these four patients. On the basis of our experience, intraoperative colonoscopy would not appear to be a mandatory procedure in all cases of incomplete preoperative evaluation of the colon. However, in the absence of prospective, randomised trials comparing intraoperative vs early postoperative colonoscopy, the dilemma as to the strategy of choice remains.

Adenoma↗

PubMed2003

Colonoscopy without sedation.

BACKGROUND/AIMS: In Turkey, colonoscopy is a procedure generally performed with intravenous sedation and analgesia. Most of the complications of colonoscopy are related to sedation. The aims of this study were to determine the percentage of patients who could successfully undergo nonsedated colonoscopy without sedation and to assess patient tolerance and acceptance. METHODS: The study included 120 consecutive patients undergoing colonoscopy by two endoscopists in our endoscopy unit. The procedure routinely began without sedation, which was later given (midazolam and hyoscine butylbromide) only if significant discomfort occurred. Parameters of blood pressure, oxygen saturation and heart rate were measured before and during colonoscopy. After the procedure patients were asked to rate their pain on a four point scale 1=no pain, 2=slight, 3=moderate, 4=severe and they were also asked if they would be willing to undergo colonoscopy again without sedation. RESULTS: Eighty eight percent of all colonoscopies were completed without sedation. Mean PaO2 was 96.46 in nonsedated patients and 93.90 (significant p<0.05) in sedated patients. No difference was found between blood pressure and pulse rate of nonsedated and sedated patients. The mean pain score was 2.0 for the nonsedated patients and 3.8 (significant p<0.05) for the sedated patients. Eighty eight percent of patients stated that they would be willing to undergo colonoscopy without sedation again. CONCLUSIONS: In experienced hands, colonoscopy without sedation can be completed successfully in most patients, without any complications and use of extra instrumentation.

Adolescent↗

PubMed2003

[Electrolytic disturbances and colonoscopy: bowel lavage solutions, age and procedure].

INTRODUCTION: Colonoscopy and bowel preparation cause a number of serum electrolytes changes. AIMS: To determine the prevalence of these changes in patients who underwent colonoscopy and to identify risk factors for these effects. PATIENTS AND METHODS: Forty five patients undergoing colonoscopy were assessed prospectively. They have been previously randomized to receive either sodium phosphate (NaP) or polyethylene glycol (PEG) as preparation. Serum levels of sodium and potassium were analyzed before colonoscopy, immediately after the end of colonoscopy, and 1 hour thereafter. Serum calcium and phosphorus levels were measured just before colonoscopy. RESULTS: Twenty five patients (55.5%) received PEG and 17 (37.7%) NaP. Three patients (6.6%) did not follow the recommended bowel preparation instructions and were excluded from the study. Five patients (11%) developed hyponatremia, of whom, in 4 cases (8.8%), it occurred after the procedure. Thirteen patients (28.8%) developed hypokalemia, of whom it occurred after the end of the procedure in seven (15.5%). There was a non-significant trend to decreased serum potassium levels 1 hour after colonoscopy in patients prepared with NaP (63.6 vs 36.4%). The multivariate analysis showed that low potassium levels were independently associated with age and NaP preparation. Hypocalcemia was observed in 2 patients (4%) and hypophosphatemia in 8 (18%). Hyperphosphatemia was found in 8 cases (18%). Non-significant increases in phosphorus levels were observed in the NaP group. CONCLUSIONS: Temporal sequences of the development of serum electrolyte disturbances suggest that colonoscopy itself might play a role in the pathogenesis of these changes. Preparation for colonoscopy with NaP and the age of patients are risk factors for the development of hypokalemia.

Adolescent↗

PubMed2004

The safety, feasibility, and acceptability of patient-controlled sedation for colonoscopy: prospective study.

OBJECTIVE: To assess the safety, feasibility, and acceptability of patient-controlled sedation for elective day-case colonoscopy, and the factors predicting patients' unwillingness to use patient-controlled sedation for colonoscopy. DESIGN: Prospective, non-randomised study. SETTING: University-affiliated endoscopy centre, Hong Kong. PARTICIPANTS: Five hundred patients who underwent elective day-case colonoscopy were prospectively recruited from January 2001 to June 2002. INTERVENTION: Sedation for colonoscopy was a mixture of propofol and alfentanil, which was delivered by means of a patient-controlled syringe pump. Each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. MAIN OUTCOME MEASURES: Cardiopulmonary complications, dose of patient-controlled sedation used, recovery time, satisfaction score, delayed side-effects, and the willingness to use the same sedation protocol for future colonoscopy. A multiple stepwise logistic regression model was used to assess which factors might predict unwillingness to use patient-controlled sedation for colonoscopy. RESULTS: The mean (standard deviation) age of patients was 53.0 (13.9) years. The mean dose of propofol consumed was 0.93 (0.69) mg/kg. Forty-three (8.6%) patients developed hypotension during the procedure. The mean satisfaction score was 7.2 (2.6). Sixteen (3.2%) patients developed delayed side-effects. The median (interquartile range) recovery time was 0 (0-5) minutes. Approximately 78% of patients were willing to use patient-controlled sedation for future colonoscopy if needed. Younger age (<50 years), female sex, a higher mean dose of sedatives used, a lower satisfaction score, and the presence of delayed side-effects were independent factors that were associated with patients' unwillingness to use patient-controlled sedation for colonoscopy. CONCLUSION: . The use of patient-controlled sedation for elective colonoscopy is safe, feasible, and acceptable to most patients.

Adolescent↗

PubMed2004

The volume and capacity of colonoscopy procedures performed at New York City hospitals in 2002.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer death in New York City. In March 2003, the New York City Department of Health and Mental Hygiene recommended colonoscopy every 10 years as the preferred screening test for adults aged 50 years and older in New York City. To screen all eligible adults in New York City would require that approximately 200,000 colonoscopy exams be performed annually. As part of this recommendation, we evaluated current colonoscopy capacity in New York City hospitals. METHODS: We surveyed endoscopy suite nursing or administrative staff at all 66 adult acute care hospitals performing colonoscopy in New York City. Data on colonoscopy procedures performed in 2002 were collected between February and June 2003. RESULTS: All hospitals and two affiliated clinics responded. The number of hospital-based colonoscopy exams performed in 2002 was estimated to be 126,000. Of these, 53,600 (43%) were estimated to be for screening. Hospitals reported their maximum annual capacity to be 195,200, approximately 69,100 more than current practice. Reported barriers to performing more colonoscopy exams included inadequate suite time and space (31%), inadequate staffing (28%), and insufficient patient referrals (24%). CONCLUSION: In 2003, endoscopy suites at New York City hospitals performed approximately one quarter of the estimated citywide need of 200,000 screening colonoscopies. Procedures conducted in outpatient office settings were not assessed. Most endoscopy suites, particularly private hospitals, reported having the capacity to conduct additional procedures. Hospitals and endoscopy suites should prioritize the development of institutional measures to increase the number of persons receiving screening colonoscopy.

Colonoscopy↗

PubMed2005

Sedation during colonoscopy.

In order to perform a proper screening for colonic cancer, repeated colonoscopies are required. Comfort during colonoscopy is very important, so that the patient will accept repeated procedures. Currently, there are 3 types of sedation used during colonoscopy: general anesthesia performed by an anesthesiologist; sedo-analgesia performed by an anesthesiologist or by a gastroenterologist; sedo-analgesia performed by a trained nurse. Sedo-analgesia is the most frequently used type of sedation during colonoscopy worldwide. It is realized by combining midazolam with propofol and/or fentanyl (alfentanyl) or pethidine. According to the data obtained from 34 centers performing colonoscopy in Romania, in 2003, 22,162 colonoscopies were performed: 54.5% without anesthesia, 39.5% with sedation with midazolam and 6% with sedo-analgesia. In a study performed in our department we noticed a significant improvement in the outcome of the colonoscopy when sedo-analgesia was used on a regular basis. The percentage of total colonoscopies (excluding those that could not be continued due to stenosis) was 84.2% when sedation was seldomly performed and 92.3% when sedo-analgesia was regularly used (p=0.042). We believe that the strategy of sedation during colonoscopy in Romania should be changed so that all the patients should benefit from sedo-analgesia, proved to be safe and cost/efficient.

Colonoscopy↗

PubMed1995

[Quality of psychomotor recovery after colonoscopy under general anesthesia using propofol. Value of tests of awakening].

Achieving colonoscopy under general anaesthesia entails the problem of ambulatory-care anaesthesia, in particular because perception of patient's recovery determines to some extent the length of monitoring following colonoscopy. The aims of the study was to assess the quality of patient's recovery after a colonoscopy under general anaesthesia while using propofol, by means of psychomotor-tests. METHODS--Colonoscopy was performed in 40 patients according to the following anaesthetic protocol: induction: propofol 2 mg/kg, continuous support: propofol 10 mg/kg/h i.v. with a 50 mg bolus in case of insufficient sedation; series of 3 psychomotor-tests were performed the day before and 1 hour, 3 hours and 6 hours after colonoscopy. The 3 psychomotor-tests studied: coordination (Newman test), time-space orientation and short-term memory. RESULTS--Forty patients, 25 females and 15 males, underwent colonoscopy with general anaesthesia for an average time-period of 22 +/- 11 min. The mean dose of propofol used was 286 +/- 102 mg. Awakening was complete in all patients, according to physical criteria such as consciousness and cardiovascular status, 20 min after receiving colonoscopy. The average psychomotor-tests results over time were (as percentages of original values) (*P < 10(-3); **P < 0.05): [table: see text] At 6 hours, 35 patients (87.5%) had recovered to their original performance and at 3 hours, 30 patients (75%) retained 90% their former state as measured with 3 psychomotor-tests. Neither by age or sex nor by propofol doses used or length or anaesthesia, the study population differed significantly. CONCLUSION--Three hours after colonoscopy under general anaesthesia using propofol, 30 patients (75%) had recovered at least 90% to their initial performances. Newman test was the most disturbed but there was no predictive factor for the quality of recovery. Psychomotor-tests may be useful before authorizing early discharge after colonoscopy under general anaesthesia but other recommendations about conditions of discharge after sedation must be also implemented.

Anesthesia Recovery Period↗

PubMed1993

[Acceptance, side-effects and reactive ability after medicamentous anxiolysis with midazolam. A prospective study with 519 gastroscopy and 506 colonoscopy patients].

In a prospective study 519 patients had gastroscopy (393 with and 126 without midazolam-premedication) and 506 patients had colonoscopy (377 with and 129 without midazolam-premedication) to evaluate acceptance, adverse reactions and reactivity after midazolam-premedication in outpatients immediately and 24 hours later by standard telephone interview. Patients could choose whether they would have midazolam or not. Normally 2 mg midazolam for gastroscopy and 4 mg for colonoscopy were given intravenously directly before endoscopy. 71.5% of gastroscopy and 75.3% of colonoscopy patients who received midazolam afterwards accepted endoscopy only with premedication. 27.7% of our gastroscopy and 14.1% of the colonoscopy patients who than received midazolam were beforehand unable to decide about premedication by themselves. 27.5% of the gastroscopy and 13.8% of the colonoscopy group were persuaded to have midazolam by the doctor examining. 12.7% of our gastroscopy- and 27.1% of our colonoscopy-patients who wished to have midazolam were persuaded to withdraw from it. There were no cardio-pulmonal complications but fatigue was found in 35.4% of the gastroscopy Patients with and 11.9% of those without premedication; colonoscopy patients: 50.4% with and 34.9% without premedication. The incidence of headache was: gastroscopy patients: 6.4% vs. 4%; colonoscopy patients: 11.1% vs. 10.9%. Dizziness: gastroscopy patients: 6.4% vs. 3.2%; colonoscopy patients: 7.6% vs. 7%. Nausea and vomiting were rare (0 to 5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2006

Endoscopic findings in the upper gastrointestinal tract of faecal occult blood-positive, colonoscopy-negative patients.

BACKGROUND: Detection of faecal occult blood is recommended for colorectal cancer screening in average risk populations. However, many subjects do not have any cause found in the colon to account for the occult blood loss. AIMS: To determine the prevalence of upper gastrointestinal tract disease in faecal occult blood-positive, colonoscopy-negative patients. PATIENTS AND METHODS: Retrospective audit of 99 patients (56 females; mean age 60 years, range 18-83) who underwent same-day colonoscopy and upper gastrointestinal endoscopy over a 2-year period. RESULTS: Fifty-two of the 99 patients had a normal colonoscopy, 16 had diverticulosis and 2 had hyperplastic polyps; these 70 patients comprised the colonoscopy-negative group. Significant upper gastrointestinal tract disease was noted in 25 (36%) of the colonoscopy-negative group compared with 10 (34%) of the 29 colonoscopy-positive group (p=ns). Most of the upper gastrointestinal tract lesions identified were benign. Within the colonoscopy-negative group, patients with anaemia or upper gastrointestinal tract symptoms had a higher prevalence of positive findings in the upper gastrointestinal tract, but this association was not statistically significant. CONCLUSIONS: Endoscopic examination of the upper gastrointestinal tract in faecal occult blood-positive individuals reveals mostly benign disease, with an equal prevalence in colonoscopy-negative and colonoscopy-positive patients. Routine performance of upper gastrointestinal endoscopy in faecal occult blood-positive individuals is not indicated and should be undertaken only for appropriate symptoms.

Adolescent↗

PubMed2006

The use of screening colonoscopy for patients cared for by the Department of Veterans Affairs.

BACKGROUND: Medicare data indicate an increase in colorectal cancer (CRC) screening using colonoscopy and a decline in fecal occult blood testing, flexible sigmoidoscopy, and double-contrast barium enema. Because of differences in the delivery of health care, this trend in use of colonoscopy in fee-for-service settings might not be paralleled in the Department of Veterans Affairs (VA). METHODS: National inpatient and outpatient VA databases were searched for codes indicative of colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double-contrast barium enema during fiscal years 1998 to 2003 among VA users aged 49 to 75 years. RESULTS: The frequency of tests for CRC screening increased from 432,778 in 1998 to 1,179,764 in 2003. Of those who were screened, only the proportion of subjects screened with fecal occult blood testing increased from 81.7% to 90.4%, while screening colonoscopy declined from 5.7% to 4.7%; flexible sigmoidoscopy declined from 8.3% to 3.6%; and double-contrast barium enema declined from 4.1% to 1.3%. The total use of screening colonoscopy procedures increased from 24,955 in 1998 to 55,199 in 2003, but the proportion of colonoscopy procedures performed for CRC screening purposes increased only slightly from 34.3% to 38.4%. In regression models adjusting for age, race, and sex, there was no consistent secular trend in the likelihood of undergoing screening colonoscopy for patients cared for in the VA health care system. CONCLUSIONS: Colorectal cancer screening has dramatically increased in the VA, but unlike in other practice settings, fecal occult blood testing is the dominant mode of screening. Although screening colonoscopy more than doubled in frequency, it constitutes a small proportion of the total CRC screening procedures used in the VA health care setting.

Aged↗