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Classic “Outlet” Rectal Bleeding Does Not Require Full Colonoscopy to Exclude Significant Pathology

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Classic “Outlet” Rectal Bleeding Does Not Require Full Colonoscopy to Exclude Significant Pathology Classic “Outlet” Rectal Bleeding does not Require Full Colonoscopy to Exclude Significant Pathology ORIGINAL CONTRIBUTION Eric L. Marderstein, M.D., M.P.H. James M. Church, M.D. Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio PURPOSE: Full diagnostic colonoscopy often is performed CONCLUSIONS: In patients with classic outlet bleeding, the to exclude significant pathology in patients presenting yield of a complete diagnostic colonoscopy is low. If the with rectal bleeding. In patients with classic “outlet” history is classic for outlet bleeding and no other bleeding, defined as bright red blood after or during indication for colonoscopy exists, flexible sigmoidoscopy defecation, with no family history of colorectal neoplasia is enough to exclude significant pathology. or change in bowel habits, we hypothesize that the diagnostic yield of complete colonoscopy will be low. The purpose of this study was to determine whether complete KEY WORDS: Outlet bleeding; Gastrointestinal bleeding; colonoscopy is necessary in the evaluation of patients with Colonoscopy; Sigmoidoscopy. “outlet” rectal bleeding. METHODS: Information for all patients undergoing colo- olonoscopy is an important diagnostic tool in the noscopy by a single endoscopist was prospectively C workup of a variety of gastrointestinal symptoms. It recorded. Before each colonoscopy, a complete history, is very sensitive for the detection of pathology, resulting including indication for the examination, was obtained. in lower gastrointestinal bleeding, and can be used to 1,2 Using standard definitions, patients with outlet bleeding, provide treatment at the time of the examination. suspicious bleeding, hemorrhage, and occult bleeding Additionally, it has proven effective as a screening exa- were accessed and the findings of their colonoscopies mination for the early diagnosis of colorectal cancer. The were analyzed. Institutional permission was obtained. U.S. Preventive Services Task Force has recommended screening for colorectal cancer at aged 50 years for RESULTS: A total of 9,098 patients had colonoscopy average-risk individuals.3 As the demand for colonoscopy recorded in the database, and 703 had the indication of has increased, difficulties in access have emerged with outlet bleeding, 251 suspicious bleeding, 204 occult estimates that it would take more than ten years to screen bleeding, and 67 hemorrhage. Of the patients with outlet all who meet the criteria.4 Therefore, analysis of the bleeding, only 47 (6.7 percent) had significant lesions on indications for colonoscopy to verify the appropriateness colonoscopy (adenomas >1 cm, villous adenomas, of the examination is worthwhile as an attempt to cancer in situ, or invasive cancer). By contrast a greater prioritize patients. number of significant lesions were present in patients A detailed history of the type of gastrointestinal with all other types of bleeding (17.2 percent; P<0.001). bleeding can provide insight as to the likely source of The incidence of invasive cancer was significantly lower the pathology.5 In particular, typical outlet bleeding is in the outlet bleeding group compared with other types likely to originate from benign anal disease or from distal of bleeding (1 vs. 3.6 percent; P<0.01). Patients with colonic pathology. A “knee-jerk” reaction by referring outlet bleeding were much less likely than patients with practitioners is to send all patients with any type of rectal other bleeding to have isolated right-sided colonic bleeding for full colonoscopy, whereas flexible sigmoid- pathology. Younger patients with outlet bleeding have a oscopy will potentially identify all lesions up to the splenic particularly low yield on colonoscopy. In 182 patients flexure and may be all that is needed in patients with younger than aged 50 years with outlet bleeding, only 3 outlet bleeding that do not meet other indications for (1.6 percent) had adenomas > 1 cm and no invasive colonoscopy. Furthermore, colonoscopy, although ex- cancers were detected. tremely safe, is not an entirely benign test. The first purpose of this investigation was to compare the incidence of significant pathology demonstrated on Read at the meeting of The American Society of Colon and Rectal colonoscopy performed for the indication of lower Surgeons, St. Louis, Missouri, June 2 to 6, 2007. gastrointestinal bleeding, stratified by the pattern of Reprints are not available. bleeding history. The second purpose was to determine Address of correspondence: Eric L. Marderstein, M.D., Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, the diagnostic yield of colonoscopy in patients with outlet USA. E-mail: [email protected] bleeding stratified by age and reported according to 202 DOI: 10.1007/s10350-007-9123-1 VOLUME 51: 202–206 (2008) ©THE ASCRS. 2007 MARDERSTEIN AND CHURCH:OUTLET BLEEDING DOESN’T NEED COLONOSCOPY 203 location in the colon. It can then be determined whether Table 2 lists the incidence of significant findings by flexible sigmoidoscopy alone is enough to exclude indication for colonoscopy. Outlet bleeding had a low significant pathology in this subset of patients. (6.7 percent) incidence of significant findings compared with rates of significant findings for suspicious bleeding PATIENTS AND METHODS (19.5 percent), occult bleeding (12.7 percent), and hemorrhage (22.4 percent). When directly compared with A prospectively maintained database of patients undergo- all other types of bleeding, this lower rate of findings for ing colonoscopy by a single endoscopist at a tertiary care outlet bleeding was statistically significant (6.7 to 17.2 center from 1984 to 2006 was retrospectively queried to percent; P<0.001). Of the 47 significant findings in provide data for this study. Before the endoscopic patients with outlet bleeding, 34 had large polyps, 6 had examination, a structured history was obtained that arteriovenous malformations, and 7 had cancer. Of the 90 included the indication for the colonoscopy. Included significant findings in patients with all other bleeding, 64 among the many indications for colonoscopy was lower had large polyps, 7 had arteriovenous malformations, and gastrointestinal bleeding. This was prospectively catego- 19 had cancer. In Table 3, the incidence of cancer is rized into four types by using the standard definitions 5 compared. Patients with outlet bleeding as their indica- listed below and previously described. tion for colonoscopy had a statistically significantly lower Outlet Bleeding: Patients with bright red blood seen during or after rate of cancer compared with patients with all other defecation, on the toilet paper or in the toilet bowl, and with no family bleeding (1–3.6 percent; P<0.001). or past history of colorectal neoplasia, and no change in bowel habit. Table 4 summarizes the effect of age on colonoscopy Suspicious Bleeding: Patients with dark red blood, and/or blood mixed findings in patients with outlet bleeding. When patients with or streaked on stool. Patients with any bleeding and a family or past with outlet bleeding were stratified by age, it was seen that history of colorectal neoplasia. Patients with bleeding associated with a older patients had a much higher rate of significant change in bowel habit or the passage of mucus. findings on their colonoscopy. In patients younger than Hemorrhage: Large-volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood. aged 50 years, only 1.6 percent had significant findings Occult Bleeding: Patients with rectal bleeding and anemia, or a positive compared with 8.4 percent of those older than aged stool occult blood test. 50 years. No patients younger than aged 50 years had cancer. Although this rate was certainly less than the rate Patients with outlet bleeding, suspicious bleeding, for those older than aged 50 years with outlet bleeding hemorrhage, or occult bleeding formed the study cohort. (1.3 percent), the sample sizes were only enough to detect The following data were extracted from the database: age, a trend and the difference was not statistically significant. gender, colonoscopic examination findings, pathology, The proximal lesions found in the three young patients and location of lesions. Significant findings were defined were adenomatous polyps > 1 cm in size but completely as adenomas > 1 cm, villous adenomas of any size, cancer endoscopically resected with no elements of invasive in situ, invasive cancer, or arteriovenous malformations. cancer or cancer in situ. Location of lesions was further subdivided by their Table 5 shows the location of lesions detected by relationship (proximal or distal) to the splenic flexure. indication for colonoscopy. Importantly, only three lesions All examinations were performed by a single endoscopist. were proximal to the splenic flexure in patients with outlet Patients involved in a previous study of colonoscopic bleeding and would not have been detected had only a findings in patients with rectal bleeding were excluded 5 flexible sigmoidoscopy been performed. Both in aggregate from this analysis. and individually for each indication, the percentage of Statistical analysis was performed by using the chi- isolated proximal lesions compared with total patients with squared test in most cases, except when the expected ’ significant findings was statistically significantly less for value of a column was < 5 in which case the Fisher s exact patients with outlet bleeding compared with
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