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Grading Evidence Grading Evidence Analysis of the colonoscopic findings in patients with rectal bleeding according to the pattern of their presenting symptoms Journal Diseases of the Colon & Rectum Publisher Springer New York ISSN 0012-3706 (Print) 1530-0358 (Online) Issue Volume 34, Number 5 / May, 1991 Abstract Patients presenting with rectal bleeding were prospectively categorized according to the pattern of their presentation into those with outlet bleeding (n=115), suspicious bleeding (n=59), hemorrhage (n=27), and occult bleeding (n=68). All patients underwent colonoscopy and this was complete in 94 percent. There were 34 patients with carcinoma and 69 with adenomas >1 cm diameter. The percentage of neoplasms proximal to the splenic flexure was 1 percent in outlet bleeding, 24 percent with suspicious bleeding, 75 percent with hemorrhage, and 73 percent with occult bleeding. Barium enema was available in 78 patients and was falsely positive for neoplasms in 21 percent and falsely negative in 45 percent. Colonoscopy is the investigation of choice in patients with suspicious, occult, or severe rectal bleeding. Bleeding of a typical outlet pattern may be investigated by flexible sigmoidoscopy. J Surg Res. 1993 Feb;54(2):136-9. Colonoscopy for intermittent rectal bleeding: impact on patient management. Graham DJ, Pritchard TJ, Bloom AD. Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106. Abstract Rectal bleeding is a frequent presenting symptom of a number of benign anorectal disorders. However, it may also be a warning sign of more significant gastrointestinal pathology. For this reason, full colonic evaluation has been recommended in patients with intermittent bright red rectal bleeding. The purpose of this study is to evaluate the utility of colonoscopy in this setting. Data were prospectively collected on 125 colonoscopies performed on the surgical service at the Cleveland Wade Park Veterans Administration Medical Center during a two year period. During this period 33 patients underwent colonoscopy for the evaluation of intermittent bright red rectal bleeding. Fourteen patients had abnormal rectal exams, including hemorrhoids in 9, mass lesions in 3, prolapse in 1, and fistula in ano in 1. Colonoscopy was normal in only 7 (21%) of the 33 patients examined. Findings in the remaining 26 included 31 polyps in 14 patients, cancer in 3, AVM in 1, diverticula in 9, hemorrhoids in 4, and other benign lesions in 5. Positive findings on rectal examination had no relationship to findings at endoscopy, with abnormal findings in 52% of patients with normal rectal exams and in 27% of patients with abnormal rectal exams (P = 0.187, NS). Findings at colonoscopy resulted in a change in management in 16 (48%) of patients examined. In patients with intermittent rectal bleeding, the entire colon should be evaluated regardless of findings on rectal examination, as a significant number of patients will have concomitant findings. Colonoscopy is an excellent method for colonic evaluation in this setting. (ABSTRACT TRUNCATED AT 250 WORDS) Education improves colonoscopy appropriateness Gastrointestinal Endoscopy - Volume 67, Issue 1 (January 2008) - Table 2 -- Nine hundred twenty-one indications in 866 appropriate colonoscopies ASGE/SIED guidelines No % Hematochezia 218 23.7 Occult fecal blood 154 16.7 Surveillance after endoscopic polypectomy (3- to 5-y intervals after adequate clearance 136 14.7 of neoplastic polyps) Persistent change in bowel habits 105 11.4 Surveillance after resection of cancer (colonoscopy to remove synchronous neoplastic 100 10.8 lesion at or around time of curative resection of cancer followed by colonoscopy at 3 y and 3 to 5 y thereafter to detect metachronous cancer) Chronic abdominal pain 57 6.2 Unexplained iron-deficiency anemia 54 5.9 Family history of sporadic colorectal cancer before age 60 y: colonoscopy every 5 y 42 4.6 beginning 10 y earlier than affected relative or every 3 y if adenoma is found Abnormality on imaging 28 3.0 Unexplained weight loss 18 1.9 Chronic inflammatory bowel disease of colon, if more precise diagnosis or 9 1.0 determination of textent of activity of disease will influence immediate management In patients with ulcerative or Crohn's pancolitis for 8 y or more or left-sided colitis for 15 y or more every 1-2 y with systematic biopsies to detect dysplasia Table 3 -- Indications in 151 inappropriate colonoscopies Indication No. % Surveillance of colonic polyps out of recommended intervals (3- to 5-y intervals after 49 32.4 adequate clearance of neoplastic polyps) Transitory or already endoscopically investigated unmodified chronic abdominal pain 30 19.9 Transitory change in bowel habit 21 13.9 Colorectal carcinoma surveillance out of guidelines (colonoscopy to remove 20 13.2 synchronous neoplastic lesion at or around time of curative resection of cancer followed by colonoscopy at 3 y and 3 to 5 y thereafter to detect metachronous cancer) Melena with upper GI source already identified 9 6.0 Screening in patients with family history of sporadic colorectal cancer before age 60 y 6 4.0 out of guidelines (colonoscopy every 5 y beginning 10 y earlier than affected relative or every 3 y if adenoma is found) Hematochezia in patients <40 y without previous rectal evaluation 4 2.6 Follow-up for inflammatory bowel diseases out of recommended intervals 3 2.0 Chronic inflammatory bowel disease of colon, if more precise diagnosis or determination of extent of activity of disease will influence immediate management In patients with ulcerative or Crohn's pancolitis for 8 y or more or left-sided colitis for 15 y or more every 1-2 y with systematic biopsies to detect dysplasia Anal symptoms 3 2.0 Rectal incontinence 2 1.3 Abnormal serologic markers (carcinoembryonic antigen, cancer antigen 19-9) 2 1.3 Metastatic adenocarcinoma of unknown origin without colonic symptoms when it will not 1 0.7 influence management Inguinal hernia 1 0.7 Table 4 -- Pathologic findings Appropriate procedures Inappropriate procedures (n = 866) (n = 151) No. % No. % Low-grade dysplasia adenoma 92 41.8 9 6.0 Colorectal cancer 71 32.3 — — Undetermined polyps (unretrieved 25 11.4 5 3.3 polyps <5 mm) High-grade dysplasia adenoma 25 11.4 2 1.3 Inflammatory bowel disease 17 7.7 — — In situ adenocarcinoma 3 1.4 — — Total 233 26.9 16 10.6 Overuse and underuse of colonoscopy in a European primary care setting Gastrointestinal Endoscopy - Volume 52, Issue 5 (November 2000) Table 1. Major categories of clinical conditions for which colonoscopy might be considered Unexplained hemoccult positive stools or iron deficiency anemia Hematochezia Uncomplicated lower abdominal pain or change in bowel habits Diarrhea of 3 weeks' or more duration Evaluation of known inflammatory bowel disease Surveillance following polypectomy Surveillance or screening for colorectal cancer Miscellaneous conditions Use of this content is subject to the Terms and Conditions Colonoscopy: A Review of Its Yield for Cancers and Adenomas by Indication American Journal of Gastroenterology - Volume 90, Issue 3 (March 1995) - Copyright © 1995 Elsevier 353 Clinical reviews Colonoscopy: A Review of Its Yield for Cancers and Adenomas by Indication Douglas K. Rex M.D., F.A.C.G. Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana Colonoscopy for bleeding indications (positive fecal occult blood test, emergent or nonemergent rectal bleeding, melena with a negative upper endoscopy and iron deficiency anemia) has a substantial yield for cancers (1 per 9 to 13 colonoscopies), although slide rehydration of fecal occult blood tests decreases the yield (1 per 45 colonoscopies). Prospective studies indicate that nonbleeding colonic symptoms have a substantially lower yield for cancer than bleeding symptoms (1 per 109 colonoscopies). Patients with indications for screening colonoscopy with a relatively high yield of cancer are those with Lynch syndrome (1 per 39 colonoscopies) and males more than 60 yr old (1 per 64 colonoscopies). Perioperative colonoscopy in persons undergoing colorectal cancer resection has a high yield for synchronous cancer (2-3%). An initial examination in persons with long-standing ulcerative colitis has a high yield for cancer (12%). Surveillance colonoscopy after cancer resection has an intermediate yield for anastomotic cancer (1 per 74 procedures) and metachronous cancers (1 per 82 colonoscopies), although this number may overestimate the yield of metachronous cancer. Postpolypectomy surveillance and ulcerative colitis surveillance colonoscopy have relatively low yields for cancer (1 per 317 and 360 colonoscopies, respectively). However, postpolypectomy surveillance colonoscopy, in combination with initial clearing colonoscopy, has been proven to be almost entirely effective in preventing colorectal cancer death. Further, cancer yields for postpolypectomy surveillance should improve with implementation of new surveillance guidelines, with little or no impact on mortality. The effectiveness of ulcerative colitis surveillance is less certain. Referral of patients with low-grade dysplasia for colectomy would improve the value and effectiveness of surveillance colonoscopy in ulcerative colitis. Adenoma yields at colonoscopy are relatively independent of indication, as evidenced by the high yield of adenomas in screening colonoscopy studies. Demographic factors, including increasing age and male gender, are important predictors of adenomas at initial colonoscopy.
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