Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis

The efficacy and safety of colonoscopy in nonagenarians: A multicenter study

INTRODUCTION

The number of colonoscopy (CS) for the elderly is increasing. There are only a few reports focusing on CS among the very elderly aged ≥ 90-y. We aimed to analyze the efficacy of CS and of colorectal cancer (CRC) for patients aged ≥ 90-y.

METHODS

We retrospectively analyzed consecutive patients aged ≥ 90-y receiving CS at eight institutions from October 2016 to September 2017. Bowel preparation, complications, and endoscopic diagnosis were analyzed. The non-elderly group aged between 50-y and 64-y and elderly group aged between 65-y and 79-y were compared to very-elderly group aged ≥ 90-y. Through propensity score matching of sex and CS indications (symptomatic or asymptomatic), the number of CRC and the treatment in each group were analyzed.

RESULTS

We analyzed 125 patients receiving 154 colonoscopies (0.9%) in the very-elderly group from among 16,968 cases. Among 92 cases who received bowel-cleansing solution, good preparations were achieved in 94.5%. The rate of CS-related complications was 1.3% (2/154). The rate of CRC in the very-elderly group was 27.2% (34/125), higher than the non-elderly group (7.2%, 9/125, p < 0.01) and elderly group (8.8%, 11/125, p < 0.01). Therapeutic interventions for CRC in the very-elderly group were performed in 73.5% (24/34) patients. The mean survival of 12 patients with CRC resection was 788 days.

CONCLUSIONS

CS could be performed safely for the very elderly aged ≥ 90-y with careful considerations. CRC was confirmed to be more frequent in this group with over 70% of patients receiving appropriate therapeutic intervention.

Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies

Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.

Adverse Events After Inpatient Colonoscopy in Octogenarians: Results From the National Inpatient Sample (1998-2013)

BACKGROUND AND AIM

Colonoscopy is commonly performed in the elderly who have a higher proportion of lower gastrointestinal (GI) tract disorders. However, few studies have evaluated the safety of colonoscopy specifically in the octogenarian population. The goal of this study is to examine the safety of colonoscopy among octogenarians over a 16-year period. We also examine risk factors associated with morbidity and mortality in octogenarians after inpatient colonoscopy.

MATERIALS AND METHODS

We queried the National Inpatient Sample to identify octogenarians who had a colonoscopy during hospitalization from 1998 to 2013. We examined inpatient GI-related adverse events including colonic perforation, postcolonoscopy bleeding, and splenic injury. We also examined all-cause mortality rates after colonoscopy.

RESULTS

About a quarter of inpatient colonoscopies performed annually were in octogenarians. Of 296,385 colonoscopies included in our study, colon perforation, postcolonoscopy bleeding, and splenic injury occurred in 11, 9, and 0.22 per 1000 colonoscopies, respectively. Overall mortality rate was 2.8%, most (2.5%) dying within 30 days of colonoscopy. After controlling for covariates, those who had colon perforation, postcolonoscopy bleeding, or splenic injury were at a much higher risk of inpatient mortality.

CONCLUSIONS

There seems to be a higher risk of adverse GI-related events after colonoscopy in octogenarians as compared with the general population. Furthermore, occurrence of adverse GI-related events increased the risk of mortality among octogenarians regardless of comorbid status.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

Cancer Prevention and Screening for Older Adults: Part 1. Lung, Colorectal, Bladder, and Kidney Cancer

The incidence of most cancers increases with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. The prevention and identification of cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This first of a two-part review addresses special considerations regarding cancer prevention for adults aged 65 and older. Screening decisions and the impact of limited life expectancy and an older adult's ability to tolerate cancer treatment are also addressed. Guidance is provided regarding the prevention and early identification of lung, colorectal, bladder, and kidney cancer in older adults. The prevention of breast, prostate, and female urogenital cancers are addressed in Part 2. J Am Geriatr Soc 68:2399-2406, 2020.

Feasibility of balloon endoscope-assisted endoscopic retrograde cholangiopancreatography for the elderly

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy is challenging. Recently, balloon endoscopy has been shown to facilitate ERCP for this population with a high technical success rate, but adverse events (AEs) are not uncommon. Compared to non-elderly patients, elderly patients may be at higher risk of AEs due to underlying comorbidities. The current study aimed to evaluate the feasibility of balloon endoscope-assisted ERCP (BE-ERCP) for the elderly. Patients and methods  We retrospectively identified patients who underwent BE-ERCP between January 2010 and September 2019. For patients who underwent multiple procedures during the study period, the first session was analyzed. Early AEs associated with BE-ERCP were compared between elderly (≥ 75 years) and non-elderly patients. Results  A total of 1,363 BE-ERCP procedures were performed, and 568 patients (211 elderly and 357 non-elderly) were included for the analyses. Technical success rates were high in both the elderly and non-elderly groups (80 % vs. 80 %, respectively). The rates of early AEs were similar between the groups (12 % vs. 9.0 % in the elderly and non-elderly group, respectively; P  = 0.31). The mltivariable-adjusted odds ratio for early AEs comparing elderly to non-elderly patients was 1.36 (95 % confidence interval, 0.74-2.51; P  = 0.32). Specifically, we did not observe between-group differences in rates of gastrointestinal perforation (2.4 % vs. 2.8 % in elderly and non-elderly groups, respectively; P  = 0.99) and aspiration pneumonia (1.9 % vs. 0.6 %, P  = 0.20). Conclusions  BE-ERCP is a feasible procedure for elderly individuals with surgically altered anatomy.

Impacts of age and sedation on cardiocerebrovascular adverse events after diagnostic GI endoscopy: a nationwide population-based study

BACKGROUND AND AIMS

Data are limited regarding the impact of age and sedation on cardiocerebrovascular disease (CCD) adverse events after GI endoscopy. We investigated the incidence of and risk factors for CCD adverse events after diagnostic GI endoscopy and the impact of age and sedation on these unfavorable outcomes.

METHODS

In this nationwide population-based study, the incidence of and risk factors for newly diagnosed CCD within 14 days after diagnostic endoscopy were analyzed using Health Insurance Review and Assessment Service data from January to December 2015.

RESULTS

Among 1,943,150 subjects, CCD adverse events occurred in approximately 2.23% within 14 days after endoscopy. According to the performance of sedation during endoscopy (60.1% nonsedation vs 39.9% sedation, midazolam alone [96.4%]), the incidence rates of CCD adverse events (per 10,000 persons) were 275.8 versus 302.8 for EGD, 116.9 versus 143.8 for colonoscopy, and 230.4 versus 243.2 for EGD + colonoscopy, respectively. On multivariate analysis, older age (70-99 years) and sedation were independent risk factors for CCD adverse events. Regarding CCD risk stratified by age and sedation, older age had a significant impact on CCD adverse events in individuals who underwent EGD only or EGD + colonoscopy, but sedation did not. However, both older age and sedation had considerable influence on CCD adverse events in individuals who underwent colonoscopy only. Sedation during endoscopy was significantly associated with minor but not major CCD adverse events. CCD adverse events were significantly higher for inpatients.

CONCLUSION

CCD adverse events after diagnostic endoscopy were significantly frequent in individuals with older age (70-99 years) and/or sedation during endoscopy. Stratification by age and sedation shows that the impact of these 2 factors on CCD adverse events differs according to endoscopy type.

Cancer Screening Among Older Adults: a Geriatrician's Perspective on Breast, Cervical, Colon, Prostate, and Lung Cancer Screening

PURPOSE OF REVIEW

We summarize the evidence of benefits, harms, and tools to assist in individualized decisions among older adults in screening for breast, prostate, colon, lung, and cervical cancer.

RECENT FINDINGS

The benefits of cancer screening in older adults remain unclear due to minimal inclusion of adults > 75 years old in most randomized controlled trials. Indirect evidence suggests that the benefits of screening seen in younger adults (< 70 years old) can be extrapolated to older adults when they have an estimated life expectancy of at least 10 years. However, older adults, especially those with limited life expectancy, may be at increased risk for experiencing harms of screening, including overdiagnosis of clinically unimportant diseases, complications from diagnostic procedures, and distress after false positive test results. We provide a framework to integrate key factors such as health status, risks and benefits of specific tests, and patient preferences to guide clinicians in cancer screening decisions in older adults.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.

AIM

To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.

METHODS

A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events.

RESULTS

There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis.

CONCLUSION

Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.

Acceptance on colorectal cancer screening upper age limit in South Korea

BACKGROUND

The Korea National Cancer Screening Program currently provides screening for colorectal cancer (CRC) for adults older than 50 years with no upper age limit. In general, people are likely to only pay attention to the benefits of cancer screening and to neglect its risks. Most consider the benefits of cancer screening as being far greater than the risks and are unaware that any potential benefits and harms can vary with age.

AIM

To report acceptance of an upper age limit for CRC screening and factors associated therewith among cancer-free individuals in Korea.

METHODS

The present study analyzed data from the Korea National Cancer Screening Survey 2017, a nationally representative random sample of 4500 Korean individuals targeted for screening for the five most common types of cancer. A total of 1922 participants were included in the final analysis. The baseline characteristics of the study population are presented as unweighted numbers and weighted proportions. Both univariate and multivariate logistic regression models were developed to examine factors related with acceptance of an upper age limit for CRC screening; subgroup analysis was also applied.

RESULTS

About 80% (1554/1922) of the respondents agreed that CRC screening should not be offered for individuals older than 80 years. Specifically, those who had never been screened for CRC had the highest acceptance rate (91%). Overall, screening history for CRC [screened by both fecal occult blood test and colonoscopy, adjusted odds ratio (aOR) = 0.33, 95%CI: 0.22-0.50] and other cancers (aOR = 0.55, 95%CI: 0.34-0.87), as well as a family history of cancer (aOR = 0.66, 95%CI: 0.50-0.87), were negatively associated with acceptance of an upper age limit for CRC screening. In contrast, metropolitan residents (aOR = 1.86, 95%CI: 1.29-2.68) and people who exercised regularly (aOR = 1.42, 95%CI: 1.07-1.89) were more likely to accept an upper age limit. After subgrouping, we found gender, marital status, and lifetime smoking history among never-screened individuals and residential region, family history of cancer, and physical activity among never-screened individuals to be associated with acceptance of an upper age limit.

CONCLUSION

This study describes acceptance of an upper age limit for CRC screening and factors associated with it, and provides perspectives that should be considered, in addition to scientific evidence, when developing population-based cancer screening policies and programs.

Patients over Age 75 Are at Increased Risk of Emergency Department Visit and Hospitalization Following Colonoscopy

BACKGROUND

The age to stop screening or surveillance colonoscopy is not well established, and unplanned hospital use after colonoscopy in the elderly is not well understood.

AIMS

To evaluate unplanned emergency department (ED) visits and hospitalization in patients over 75 within 7 days of outpatient colonoscopy.

METHODS

In this retrospective, single-center, cohort study, we reviewed outpatient screening or surveillance colonoscopies in patients ≥ 50 in a tertiary care academic medical center or affiliated facility between January 2008 and September 2013. Colonoscopies were divided by age based on USPSTF recommendations. The rate of ED visits and hospitalizations per colonoscopy for each age-group was determined. Predictors of ED visit and hospitalization were assessed through univariate and multivariate logistic regressions, and mortality following colonoscopy was evaluated using Kaplan-Meier analysis.

RESULTS

A total of 30,409 colonoscopies were performed in 27,173 patients (51% male) by 40 endoscopists. ED visits occurred after 188 colonoscopies (0.62%). Age over 75 years was independently associated with ED visit (OR 1.58, 95% CI 1.05-2.37, p = 0.027) and hospitalization (OR 3.7, 95% CI 2.03-6.73, p < 0.001) within 7 days of colonoscopy. Higher number of medication classes, recent ED visit, polypectomy, and endoscopic mucosal resection were also independent variables associated with ED utilization after procedure. The mortality rate at the end of the follow-up (median 4.4; IQR 2.7-6 years) was 1.9, 8.6, and 15.8% for the age-groups 50-75, 76-85, and > 85 years, respectively.

CONCLUSION

Patients over age 75 are 1.6 times as likely to use the ED and 3.7 times as likely to be hospitalized after colonoscopy. Further prospective studies are needed to assess the risk/benefit of nondiagnostic colonoscopy in geriatric patients.

Association Between Age and Complications After Outpatient Colonoscopy

Importance

There are insufficient data describing the incidence and risk factors of postcolonoscopy complications in older individuals.

Objective

To assess the association between older age (≥75 years) and the risk of postcolonoscopy complications.

Design, Setting, and Participants

This population-based retrospective cohort study included adults (≥50 years) undergoing outpatient colonoscopy between April 2008 and September 2017, identified from Ontario administrative databases. Individuals with inflammatory bowel disease and hereditary colorectal cancer syndromes were excluded. The study population was subdivided into a colorectal cancer screening-eligible cohort (patients aged 50-74 years) and an older cohort (patients aged ≥75 years). The statistical analysis was conducted from December 2018 to September 2019.

Exposures

Older age (≥75 years).

Main Outcomes and Measures

The primary outcome was postcolonoscopy complications, defined as the composite of hospitalization or emergency department visits in the 30-day period after the outpatient colonoscopy. Secondary outcomes included incidence of surgically treated colorectal cancer and all-cause mortality at 30 days. Independent variables associated with postcolonoscopy complications were also assessed.

Results

The study sample included 38 069 patients; the mean (SD) age was 65.2 (10.1) years, there were 19 037 women (50.0%), and 27 831 patients (73.1%) underwent a first colonoscopy. The cumulative incidence of complications was 3.4% (1310 patients) in the overall population, and it was higher in individuals aged 75 years or older (515 of 7627 patients [6.8%]) than in screening-eligible cohort (795 of 30 443 patients [2.6%]) (P < .001). Independent risk factors for postcolonoscopy complications were age 75 years or older (odds ratio [OR], 2.3; 95% CI, 2.0-2.6), anemia (OR, 1.4; 95% CI, 1.2-1.7), cardiac arrhythmia (OR, 1.7; 95% CI, 1.2-2.2), congestive heart failure (OR, 3.4; 95% CI, 2.5-4.6), hypertension (OR, 1.2; 95% CI, 1.0-1.5), chronic kidney disease (OR, 1.8; 95% CI, 1.1-3.0), liver disease (OR, 4.7; 95% CI, 3.5-6.5), smoking history (OR, 3.2; 95% CI, 2.4-4.3), and obesity (OR, 2.3; 95% CI, 1.2-4.2). The number of previous colonoscopies was associated with a lower risk of complications (OR, 0.9; 95% CI, 0.7-1.0). The incidence of surgically treated colorectal cancer was higher in the older cohort than the screening-eligible cohort (119 patients [1.6%] vs 144 patients [0.5%]; P < .001). All-cause mortality rates were 0.1% overall (39 patients) and 0.1% (19 patients) for individuals aged 50 to 74 years and 0.2% (20 patients) for those aged 75 years and older (P < .001).

Conclusions and Relevance

In this population-based cohort study of individuals living in southern Ontario, age of 75 years and older was associated with a higher risk of 30-day postprocedure complications after outpatient colonoscopy. These findings suggest that the decision to perform a colonoscopy should be carefully considered in patients older than 75 years, especially in the presence of comorbidities. Further studies are needed to better understand the benefits of invasive procedures as opposed to less invasive approaches for colorectal cancer screening and surveillance among older patients.

Mortality and Rate of Hospitalization in a Colonoscopy Screening Program From a Randomized Health Services Study

BACKGROUND & AIMS

It is difficult to quantify adverse events related to screening colonoscopy due to lack of valid and adequately powered comparison groups. We compared mortality and rate of unplanned hospitalizations among subjects who underwent screening colonoscopies within the Polish Colonoscopy Screening Program (PCSP) vs unscreened matched controls in Poland.

METHODS

Persons 55-64 years old living in the area covered by the PCSP from 2012 through 2015 were assigned in a (1:1) to a group invited for screening colonoscopy (n = 338,477) or a matched group that would be invited 5 years later (controls, n = 338,557). All subjects in the screening group were assigned proposed screening colonoscopy dates (actual dates when invitees confirmed or rescheduled colonoscopy) and those in the control group were assigned virtual dates corresponding to the matched individuals from the screening group. In the screening group, 55,390 subjects (16.4%) underwent screening colonoscopy. Mortality and hospitalization data were obtained from National Registries. We compared mortality and rate of hospitalization between the groups for defined intervals before and after colonoscopy date. Hospitalizations were divided into related and unrelated to colonoscopy based on ICD codes by 3 specialists. Our primary aim was to compare mortality and hospitalization 6 weeks before and 30 days following the actual or virtual date of colonoscopy in the screening or control group.

RESULTS

In the intent to treat analysis, overall there were no significant differences in mortality between the colonoscopy group and control group (0.22% vs 0.22%; risk difference less than .01%; 95% CI, decrease of 0.02% to 0.02%; P = .913). The overall rate of unplanned hospitalization was significantly higher for the colonoscopy group (2.39% vs 2.31% for the control group; risk difference, 0.08%; 95% CI, 0.01%-0.15%; P=.026) for the entire observation period. This was due to the higher rate of hospitalizations after screening (1.10% vs 1.01% for the control group; risk difference, 0.09%; 95% CI, 0.04%-0.14%; P < .001) including higher proportion of hospitalizations that were assessed as related to colonoscopy (0.24% vs 0.22% for the control group; risk difference, 0.02%; 95% CI, 0.00%-0.05%; P = .046). In the per-protocol analysis, the overall rate of hospitalizations did not differ significantly between control and screening colonoscopy groups (1.87% vs 1.90%; P=.709). However, screening colonoscopy did increase rates of related hospitalizations after the date of screening (from 0.14% to 0.31%; P < .001).

CONCLUSIONS

In an analysis of data from the PCSP, we found high-quality evidence that colonoscopy as a screening intervention does not increase mortality before or after colonoscopy. However, it may be associated with a small but significant increase in unplanned hospitalizations, especially after the colonoscopy is completed.

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.

New horizons in iron deficiency anaemia in older adults

Iron deficiency anaemia (IDA) is common in older adults and associated with a range of adverse outcomes. Differentiating iron deficiency from other causes of anaemia is important to ensure appropriate investigations and treatment. It is possible to make the diagnosis reliably using simple blood tests. Clinical evaluation and assessment are required to help determine the underlying cause and to initiate appropriate investigations. IDA in men and post-menopausal females is most commonly due to occult gastrointestinal blood loss until proven otherwise, although there is a spectrum of underlying causative pathologies. Investigation decisions should take account of the wishes of the patient and their competing comorbidities, individualising the approach. Management involves supplementation using oral or intravenous (IV) iron then consideration of treatment of the underlying cause of deficiency. Future research areas are outlined including the role of Hepcidin and serum soluble transferrin receptor measurement, quantitative faecal immunochemical testing, alternative dosing regimens and the potential role of IV iron preparations.

Factors affecting bowel preparation adequacy and procedural time

Background and Aim

Poor bowel preparation results in difficult colonoscopies, missed lesions, and repeat procedures. Identifying patient risk factors for poor bowel preparation, such as prolonged runway time and prolonged cecal intubation, will aid in interventions prior to a procedure.

Methods

This was a retrospective, single‐center analysis of 3 295 colonoscopies performed between May 2012 and November 2014. Indications for colonoscopy included gastrointestinal bleed and anemia, change in bowel habits, for screening, and others (including planning re‐anastomoses, abdominal distension, family history and angioectasias). Data were collected from medical charts and endoscopy reports. Comparisons between patient factors and runway time were made with adequacy of bowel preparation as the primary outcomes.

Results

Male and diabetic patients had statistically higher rates of inadequate bowel preparation and prolonged cecal intubation times. A previous history of abdominal surgery also demonstrated prolonged cecal intubation. A runway time of ≤7.63 h was associated with higher rates of adequate bowel preparation by multivariate analysis. The optimal time frame is 3–6 h for the highest success rates.

Conclusion

Patient risk factors for inadequate bowel preparation or prolonged cecal intubation should signal clinicians to intervene prior to colonoscopy. A runway time between 3 and 6 h is optimal for adequate bowel preparation. This may involve further patient education, along with work flow optimization, to facilitate ideal runway times. Future studies should explore how to avoid repeat endoscopies using protocols enforcing this timeframe.

Risk of metachronous neoplasia on surveillance colonoscopy among young and older patients after polypectomy

BACKGROUND AND AIMS

Few reports address the appropriate colonoscopy surveillance interval for individuals <50-years-old. We compared the risk of metachronous neoplasia among young (<50 years), adult (50-74 years) and older (≥75 y) age groups.

METHODS

This was a single center retrospective cohort study. Eligible subjects underwent their first colonoscopy with polypectomy between 2005 and 2014 and had at least one surveillance colonoscopy 3-5 years later. Patients (N = 495) were stratified at baseline into low-risk adenoma (LRA) and advanced adenoma groups. Study outcomes were overall and high-risk neoplasia at surveillance colonoscopy.

RESULTS

In the baseline LRA-group (N = 201), the 5-year risk of metachronous high-risk neoplasia was 12.5%, 15.2% and 22.5% (P = 0.426) in the young, adult and older age groups, respectively. In the baseline advanced adenoma group (N = 294), the 3-year risk of metachronous high-risk neoplasia was 13.3%, 14.8% and 25.3% (P = 0.041), respectively. In multivariate analysis, the only risk factor for metachronous high-risk neoplasia was older age (OR 1.876, CI 1.087-3.238; P = 0.024).

CONCLUSIONS

Considering the comparable risk of metachronous high-risk neoplasia in young and adult patients, surveillance recommendations after polypectomy should not differ. Since this risk is higher among older people, more frequent surveillance schedule can be considered for this age group but should be individualized.

The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study

Background

Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions.

Method

This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage.

Results

A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893.

Conclusion

Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.

Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Stage at Diagnosis

INTRODUCTION

In Western Washington (WA), colorectal cancer (CRC) mortality between 2012 and 2016 was highest in American Indian/Alaska Natives (AI/AN) and African-Americans (AA) at 20.7 and 18.7, respectively, compared with non-Hispanic Whites at 14.1/100,000 people. We hypothesized that time from billed encounters for CRC-associated symptoms to endoscopy completion or CRC stage at diagnosis contributed to observed differences.

METHODS

Using administrative insurance claims linked to WA cancer registry data, we performed a retrospective cohort study of patients diagnosed with CRC between 2011 and 2017, with continuous insurance for 15 months prior to diagnosis and a billed encounter for CRC-associated symptoms. We determined the wait-time (days) and stage at diagnosis and conducted logistic regression analysis to identify the factors associated with endoscopy completion.

RESULTS

Of the 3461 CRC patients identified, 57% had stage 2 or 3 disease with no differences in stage by race, and 84% completed an endoscopy after a billed encounter for CRC-associated symptoms. The median wait-time to endoscopy was 52 days (IQR 14-218) without differences by race. Compared with patients diagnosed with stage 1 CRC, patients with stage 4 CRC were more likely to complete an endoscopy within the first quartile of time (22.2% vs. 17.4%, p < 0.01). Living arrangement, insurance type, and comorbidity, but not race, were significant factors associated with endoscopy completion.

CONCLUSIONS

We found no statistically significant differences in time from billed CRC-associated symptoms to endoscopy completion or in CRC stage among AA and AI/AN compared to Whites. This suggests that other factors are more likely to contribute to observed mortality disparities.

Efficacy of mosapride citrate with a split dose of polyethylene glycol plus ascorbic acid for bowel preparation in elderly patients: A randomized controlled trial

BACKGROUND/AIMS

Old age is a risk factor of suboptimal bowel preparation. This study aimed to evaluate the efficacy of mosapride citrate with a split dose of polyethylene glycol (PEG) plus ascorbic acid for bowel preparation in elderly patients (aged ≥65 years) before they underwent a colonoscopy.

MATERIALS AND METHODS

This prospective investigator-blinded randomized study was conducted from November 2017 to October 2018. The patients were randomly divided into 2 groups, a mosapride group (mosapride citrate with a split-dose of PEG plus ascorbic acid) or a non-mosapride group (a split-dose of PEG plus ascorbic acid alone). Mosapride citrate 15 mg (Gastin CR) was administered once with each split-dose of the bowel preparation. The bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS).

RESULTS

A total of 257 patients were finally included and analyzed in our study. The total BBPS score was significantly higher in the mosapride group than in the non-mosapride group (8.53 vs 8.24, P = .033). The BBPS scores of the right colon and mid-colon were 2.75 vs 2.61 (P = .044) and 2.89 vs 2.79 (P = .030), respectively. The rate of adequate bowel preparation (BBPS ≥ 6) was similar in both groups (98.4% vs 98.5%, P = .968), while the rate of excellent bowel preparation (BBPS = 9) was higher in the mosapride group than in the non-mosapride group (73.8% vs 61.1%, P = .029). The total incidence of adverse events during the administration of the bowel cleansing agent, particularly abdominal fullness, was lower in the mosapride group (11.9% vs 30.5%, P < .001).

CONCLUSION

The administration of mosapride citrate with a split-dose of PEG plus ascorbic acid in elderly patients showed an increase in bowel preparation efficacy and reduced adverse events, particularly abdominal fullness, during the administration of a bowel cleansing agent.

Screening for Colon Cancer in Older Adults: Risks, Benefits, and When to Stop

Colorectal cancer (CRC) is the fourth leading cause of cancer and second leading cause of mortality from cancer in the United States. As the population ages, decisions regarding the initiation and cessation of screening and surveillance for CRC are of increasing importance. In elderly patients, the risks of CRC and the presenting signs and symptoms are similar to those in younger patients. Screening and ongoing surveillance should be considered in patients who have a life expectancy of 10 years or more. Life expectancy estimates can be calculated using online calculators. If screening is deemed appropriate, the choice of which test to use first is unclear. Currently, there are a number of modalities available to screen for CRC, including both invasive modalities (eg, colonoscopy, sigmoidoscopy, capsule colonoscopy, and computed tomographic colonography) and noninvasive modalities (fecal immunochemical test, stool DNA testing, and blood testing). Colonoscopy and other invasive testing options are considered safe, but the risks of complications of the bowel preparation, the procedure, and sedation medications are all increased in older patients. In contrast, noninvasive testing provides a safe initial test; however, it is important to consider the increased false-positive rates in the elderly, and a positive test result will usually necessitate colonoscopy to establish the diagnosis. Ongoing screening and surveillance should be a shared decision-making process with the patient based on multiple factors including the patient's morbidity and mortality risk from CRC and his or her underlying comorbidities, the patient's functional status, and the patient's preferences for screening. Ultimately, the decision to initiate or discontinue screening for CRC in older patients should be done based on a case-by-case individualized discussion.

The yield and patient factors associated with CT colonography C-RADS results in a non-screening patient population

OBJECTIVES

To determine the proportion of diagnostic computed tomography colonography (CTC) Reporting and Data System (C-RADS) categories in a non-screening population, and which patient factors are associated with a positive CTC (C2-4), a non-diagnostic CTC (C0), and potentially relevant extracolonic findings (ECF, E3-4).

METHODS

Diagnostic CTCs performed at a single academic center from 2017 to 2018 were retrospectively reviewed. For each examination, the indications, age, sex, admission status, and C-RADS categories were recorded. Multivariate logistic regression was performed of patient demographic factors and clinical indications, with adjusted odds ratios (OR) and 95% confidence intervals.

RESULTS

1373 CTCs were included. The mean age was 66.4 ± 13 years (range 24-97). There were 782 women and 75 inpatients. The number of CTCs reported as C0-C4 were 194/1373 (14.1%), 970/1373 (70.6%), 77/1373 (5.6%), 86/1373 (6.3%), and 46/1373 (3.4%), respectively, and 134/1373 (9.8%), 960/1373 (69.9%), 173/1373 (12.6%), and 106/1373 (7.7%) CTCs were reported as E1-4, respectively. Factors that demonstrated the strongest associations were as follows: with C2-4, age groups 50-79 (OR 2.8, 95% confidence interval 1.4-6.1), 80-89 (6.2, 2.9-14.5) and ≥ 90 (7.6, 2.0-29.1), and inpatients (3.4, 1.8-6.4); with C0, age groups 50-79 (5.9, 2.2-24.4), 80-89 (9.8, 3.4-41.8), and ≥ 90 (22.5, 5.8-113.0), incomplete colonoscopy (3.2, 2.0-5.1) and melena or gastrointestinal bleeding (4.1, 1.8-9.4); and with E3-4, age groups 50-79 (1.6, 1.0-2.9), 80-89 (2.0, 1.1-3.9), and ≥ 90 (3.2, 1.2-8.8), and inpatients (2.3, 1.3-3.9).

CONCLUSION

Older age is increasingly associated with a positive test, a non-diagnostic test and potentially relevant ECF. Inpatients are also associated with positive tests and E3-4 findings. Symptoms are not strongly associated with a positive CTC.

Safety and Efficacy of Low-Volume Preparation in the Elderly: Oral Sulfate Solution on the Day before and Split-Dose Regimens (SEE SAFE) Study

Background/Aims

The use of a low-volume bowel cleansing agent is associated with a greater willingness to undergo repeat colonoscopy. Oral sulfate solution (OSS) is a recently approved low-volume agent; however, its efficacy and safety in the elderly population remain unclear. We aimed to evaluate the efficacy, safety, and acceptability of the OSS preparation, in comparison to those of a standard polyethylene glycol (PEG; 4 L) preparation, in elderly patients.

Methods

A multicenter, randomized, investigator-blinded study was conducted. Participants were randomized to receive OSS or 4-L PEG with a split-dose regimen. Bowel cleansing efficacy was assessed using the Boston Bowel Preparation Scale (BBPS). Acceptance, satisfaction, and preparation-related symptoms were recorded. Additionally, blood parameters were analyzed for electrolyte abnormalities and nephrotoxicity.

Results

A total of 193 patients were analyzed. No group differences in overall bowel cleansing efficacy were observed, with “adequate” preparations achieved in 95.9% (93/97) and 94.8% (91/96) of patients in the OSS and 4L PEG groups, respectively (p=0.747). However, mean BBPS scores for the entire (p=0.010) and right colon (p=0.001) were significantly higher in the OSS group than in the 4-L PEG group. The severity of clinical adverse events and frequency of acute kidney injury were similarly low, and no clinically meaningful electrolyte changes were identified. Self-reported scores regarding amount (p<0.001) and feeling (p=0.007), as well as overall satisfaction (p=0.001) and willingness to repeat the preparation (92.8% vs 67.7%, p<0.001), were significantly better in the OSS group than in the 4-L PEG group.

Conclusions

In elderly individuals, OSS with a split-dose regimen has greater acceptability and comparable efficacy in bowel cleansing compared to 4-L PEG. (Clinical trials registration number: NCT03112967)

Can surveillance colonoscopy be discontinued in an elderly population with diminutive polyps?

OBJECTIVES

Surveillance colonoscopy after endoscopic resection (ER) for adenomatous polyps reduces the incidence and mortality of colorectal cancer (CRC). However, its significance in the elderly population is uncertain. The study aimed to determine whether surveillance colonoscopy should be discontinued in the elderly population.

METHODS

We enrolled 105 patients who underwent baseline colonoscopy between January 2004 and December 2009 and were subsequently followed-up over 5 years in our institution. All had diminutive colorectal polyps and were aged <80 years at baseline colonoscopy and ≥80 years at follow-up in May 2018. Patients who had undergone colectomy or who had inflammatory bowel disease, familial adenomatous polyposis, Lynch syndrome, and no diminutive polyps were excluded. The cumulative incidence of the target lesion was evaluated. Histopathological diagnoses included low-grade dysplasia (LGD), high-grade dysplasia (HGD), and carcinoma.

RESULTS

The target lesion was detected in 15% (16/105) of the patients. There was no invasive carcinoma; however, two HGDs were detected. There were three lesions that had increased from previously detected diminutive lesions, all of which were LGDs. There were no target lesions detected after 84 years of age, and the cumulative incidence was 0.20. The cumulative incidence was significantly higher in the group with HGD than in the group with no target lesions at baseline colonoscopy. There was no HGD after age 79 years, and the cumulative incidence was 0.019.

CONCLUSION

Surveillance colonoscopy for patients with diminutive polyps may be discontinued after age 79 years.

Splenic rupture as a rare and unpredicted complication in a patient with systemic lupus erythematosus after colonoscopy

Colonoscopy is a common procedure that gastroenterologists perform on a daily basis. It is considered a low-risk outpatient procedure and patients can be discharged on the same day after the procedure. Colonoscopy has become more feasible with the increasing application of standard screening for colon cancer and diagnostic procedures for large intestinal disease. There are reported possible risk factors of splenic rupture during the procedure. However, splenic injury after colonoscopy is considered a rare complication and less than 100 cases have been reported in international literature. Interestingly, this is the first case report demonstrating systemic lupus erythematosus (SLE) as a possible risk factor leading to splenic rupture post-colonoscopy. Failure to recognise this possibility even in its rarity can lead to life-threatening complications. We present a case of an acute splenic rupture with massive intraperitoneal bleeding after colonoscopy in a patient with SLE.

The role of colonoscopy and endotherapy in the management of lower gastrointestinal bleeding

Colonoscopy is an integral diagnostic and therapeutic tool in the management of patients with lower gastrointestinal bleeding (LGIB). After resuscitation, reversal of coagulopathy, and exclusion of a proximal source of bleeding, colonoscopy should be performed in most patients with LGIB. Bowel preparation, typically with polyethylene glycol based solutions, is needed to closely inspect the colonic mucosa for bleeding sources. Colonoscopy within 24 h is recommended for high-risk patients with ongoing bleeding, although there is limited evidence that this strategy improves clinical outcomes. When active or stigmata of bleeding is detected, endoscopic intervention is indicated and can reduce future rebleeding. The most common options for endoscopic intervention include clipping, endoscopic band ligation, and coagulation, however rigorous head-to-head comparisons of different endoscopic tools are unavailable. Future research is needed to determine the optimal timing of colonoscopy, appropriate reversal strategies for patients on antithrombotics, and the most effective endoscopic hemostatic therapy.

Adverse events related to colonoscopy: Global trends and future challenges

Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.

Iatrogenic Colonic Perforations: Changing the Paradigm

PURPOSE

The purpose of our study was to investigate the clinical outcomes of colonoscopic perforations in patients.

MATERIALS AND METHODS

We retrospectively studied patients with perforations secondary to diagnostic/therapeutic colonoscopy between 2009 and 2015 at the Pontevedra Hospital Complex. We analyzed age, closure method, length of hospitalization, and long-term progress.

RESULTS

Of the 34 perforations detected, 67.6% occurred in patients aged below 75 years. Most perforations occurred in the descending colon (55%). Perforations occurred in 55.9% of outpatients and 45% of inpatients. Diagnostic and therapeutic colonoscopies caused perforations in 20.6% and 79.4% of patients, respectively. Conservative treatment alone was performed in 5.9%, complete or partial endoscopic closure in 14.7%, and surgery in 79.4% of patients. Patients treated only conservatively or with concomitant endoscopic closure showed no mortality. The mortality rate was 14.8% in those treated surgically, and 55% of these patients required a subsequent ostomy.

CONCLUSIONS

Conservative management with antibiotics and parenteral nutrition concomitant with complete/partial endoscopic closure effectively treats perforations, provided intraprocedural diagnosis is possible with immediate administration of antibiotics after the procedure. Nevertheless, studies with larger number of patients and statistical analysis are necessary in the near future.

Influence of Age, Health, and Function on Cancer Screening in Older Adults with Limited Life Expectancy

BACKGROUND/OBJECTIVES

We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy.

DESIGN

Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims.

PARTICIPANTS

Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759).

MEASUREMENTS

We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups.

RESULTS

For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p = 0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002).

CONCLUSION

Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.

Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

IMPORTANCE

Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations.

OBJECTIVE

To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators).

DESIGN, SETTING, AND PARTICIPANTS

This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017.

MAIN OUTCOMES AND MEASURES

Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?"

RESULTS

Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89).

CONCLUSIONS AND RELEVANCE

The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Frailty Assessment Predicts Acute Outcomes in Patients Undergoing Screening Colonoscopy

BACKGROUND

Colonoscopy is associated with multiple adverse outcomes. With an aging population undergoing colorectal cancer screening, few modalities exist to assess the patient risk prior to colonoscopy. Frailty, the age-related decline in reserve and function across multiple organ systems, predicts poor surgical outcomes, but its role in endoscopy is unclear.

AIMS

This prospective cohort study assesses the efficacy of frailty in predicting acute colonoscopy outcomes.

METHODS

Participants aged ≥ 50 years undergoing screening colonoscopy at a tertiary care center were recruited over 2 months ending in July 2017. Frailty was assessed using a validated 20-s upper-extremity frailty test, which measures the capacity of muscle performance. Demographic data, American Society of Anesthesiologists (ASA) status, and Charlson comorbidity index (CCI) were evaluated. Procedure-related adverse events and cardiopulmonary changes during and in the immediate post-procedure period were recorded. Adverse events were stratified into minor and major events. Chi-square and ANCOVA models were used in the analysis.

RESULTS

Ninety-nine adults (mean age 62.8 years) were enrolled, among which 49 were non-frail and 50 were pre-frail/frail; 50 were female. Overall, 55 participants experienced a total of 87 adverse events. Frailty and ASA status were significantly associated with colonoscopy adverse events (p = 0.01 and p = 0.02, respectively). Age and CCI did not predict colonoscopy outcomes.

CONCLUSIONS

Compared to age and CCI, frailty status better predicts colonoscopy outcomes in older adults. Among adults undergoing colonoscopy, routine frailty screening should be considered for risk stratification. Additional prospective studies evaluating frailty measurements in endoscopy will further clarify its role in forecasting adverse events.

Which Patient-Related Factors Determine Optimal Bowel Preparation?

PURPOSE OF REVIEW

Adequate bowel cleansing before colonoscopy is a simple concept but the high rate of inadequate or incomplete bowel cleanliness and its consequences have been the subject of many studies, guidelines, and meta-analysis. The complexity resides in all the factors surrounding preparation intake such as type and regimen of bowel preparation, diets, compliance, and also patient-related factors that all influence quality of the bowel preparation. The purpose of this review is to focus specifically on patient-related factors and their challenges. Patients with lower GI bleeding are excluded from this review.

RECENT FINDINGS

Patient factors that may be associated with a poor bowel preparation were searched for in the literature. With regard to patient's characteristics, higher age, male gender, and socio-economic status (lower income, Medicaid, and lower education) were all associated with higher rates of inadequate bowel preparation. Comorbidities such as inflammatory bowel disease (IBD), in-patients, body mass index (BMI), cirrhosis, constipation, and neurological condition as well as some pharmacotherapy were also associated with inadequate bowel preparation. Studies identifying predictive patient factors as well as those studying these patients in particular showed variability in the strength of the patient factor associations. Patients taking tricyclic antidepressant, narcotics, and those with neurological conditions were identified to have a stronger association with worse bowel cleanliness. Those can be implemented with the current recommendations of split-dosing. Identifying individual factors that can impact the quality of bowel cleanliness can be challenging. Some have been well-studied in the literature such as age, in-patient status, or constipation and others such as male gender or higher BMI have required more studies to clearly conclude on any possible association. In many studies, simple recommendations like walking 30 min during the preparation, and additional instructions or support have also been added to instructions to improve motility and compliance.

Colonoscopy in Patients Aged 85 Years or Older: An Observational Study

OBJECTIVES

Colonoscopy is the first-line modality to examine the colon even in the very elderly but may have an increased risk of complications. This study aimed to evaluate the efficacy and safety of colonoscopy in the very elderly.

METHODS

Patients ≥85y old, who underwent colonoscopy between September 2010 and August 2012 in two tertiary-care hospitals in Japan were enrolled. Main outcome measures were cecal intubation rate, detection rate of adenomas and cancers, treatment, adverse events, and long-term outcomes.

RESULTS

A total of 207 colonoscopies were performed in 177 patients (females 72, males 105; maximum age 95 years). Of these, 202 attempted to reach the cecum, with success in 92%. Excluding patients with known colorectal neoplasms, invasive cancers were detected in 12%, including T1 lesions in 2% and T2 or deeper in 9%. No cancers were detected in patients referred for surveillance or mild abdominal symptoms. Cancers were found in 25% of patients with positive fecal immunochemical tests, 22% with altered bowel habits, 21% with anemia, and 18% with hematochezia. Treatment of 29 patients with cancer included surgery in 22, endoscopic resection in two and no treatment (due to comorbidities) in five. There were no complications. During 730 days (mean) of follow up, 27 patients died but only three died from recurrent colorectal cancer.

CONCLUSIONS

Colonoscopy for patients aged ≥85 years is safe. A relatively high detection rate of cancers was found, and most were treatable and even curable. (UMIN000018575).

Kidney injury and other complications related to colonoscopy in inpatients at a tertiary teaching hospital

OBJECTIVES

To describe clinical complications related to colonoscopy in inpatients with multiple diseases. Among the known complications, acute kidney injury was the primary focus.

METHODS

This was an observational retrospective study of 97 inpatients. Data relating to age; gender; comorbidities; current medication; blood tests (renal function, blood glucose and LDL cholesterol levels); length of hospital stay; indication, results, and complications of colonoscopies; and time to the development of kidney injury were collected between June 2011 to February 2012.

RESULTS

A total of 108 colonoscopies (9 screening and 88 diagnostic) were conducted in 97 patients. Renal injury occurred in 41.2% of the patients. The univariate analysis revealed that kidney injury was related to the use of diuretics, statins, calcium channel blockers, and angiotensin converting enzyme inhibitor; however, the multivariate analysis showed that only the use of diuretics was associated with kidney injury. The occurrence of kidney injury and the time to its development were independent of the previous glomerular filtration rate as calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

CONCLUSIONS

The use of diuretics was the only independent variable associated with the development of kidney injury in inpatients with multiple comorbidities who underwent colonoscopy. The occurrence of kidney injury and the time to its development were independent of previous CKD-EPI-based assessments of renal function. These results highlight the increased risk of colonoscopy in such patients, and its indication should be balanced strictly and perhaps avoided as a screening test.

Benefits, Harms, and Cost-Effectiveness of Potential Age Extensions to the National Bowel Cancer Screening Program in Australia

BACKGROUND

The Australian National Bowel Cancer Screening Program (NBCSP) is rolling out 2-yearly immunochemical fecal occult blood test screening in people aged 50 to 74 years. This study aimed to evaluate the benefits, harms, and cost-effectiveness of extending the NBCSP to younger and/or older ages.

METHODS

A comprehensive validated microsimulation model, Policy1-Bowel, was used to simulate the fully rolled-out NBCSP and alternative strategies assuming screening starts at 40 or 45 years and/or ceases at 79 or 84 years given three scenarios: (i) perfect adherence (100%), (ii) high adherence (60%), and (ii) low adherence (40%, as currently achieved).

RESULTS

The current NBCSP will reduce colorectal cancer incidence (mortality) by 23% to 51% (36% to 74%) compared with no screening (range reflects participation); extending screening to younger or older ages would result in additional reductions of 2 to 6 (2 to 9) or 1 to 3 (3 to 7) percentage points, respectively. With an indicative willingness-to-pay threshold of A$50,000/life-year saved (LYS), only screening from 50 to 74 years [incremental cost-effective ratio (ICER): A$2,984-5,981/LYS) or from 45 to 74 years (ICER: A$17,053-29,512/LYS) remained cost-effective in all participation scenarios. The number-needed-to-colonoscope to prevent a death over the lifetime of a cohort in the current NBCSP is 35 to 49. Starting screening at 45 years would increase colonoscopy demand for program-related colonoscopies by 3% to 14% and be associated with 55 to 170 additional colonoscopies per additional death prevented.

CONCLUSIONS

Starting screening at 45 years could be cost-effective, but it would increase colonoscopy demand and would be associated with a less favorable incremental benefits-to-harms trade-off than screening from 50 to 74 years.

IMPACT

The study underpins recently updated Australian colorectal cancer management guidelines that recommend that the NBCSP continues to offer bowel screening from 50 to 74 years.

Colonoscopy in the very elderly

INTRODUCTION

Colonoscopy is the gold standard test for investigating lower gastrointestinal symptoms and is an important therapeutic tool for colonic polypectomy. This paper is aimed at the general physician and examines the role of colonoscopy in very elderly patients by exploring the particular risks in this population, the yield of colonoscopy and potential alternative investigations.

SOURCES OF DATA

Original research and review articles were identified through selective PubMed searches. Guidelines were identified through interrogation of national and international society websites in addition to PubMed searches.

AREAS OF AGREEMENT

Advanced age alone is not a reason to avoid investigation. The decision to perform colonoscopy in this population must take into account indication and yield, risks of the procedure and bowel preparation, physical fitness of the patient, potential alternative and the ability to consent. As a general rule, the principle of 'first doing no harm' should be applied and requires balancing of the risks of the procedure and preparation with the benefits of doing the test.

AREAS OF CONTROVERSY

There is no defined upper age limit at which colonoscopy is contraindicated, however; the National Health Service Bowel Cancer Screening Programme stops inviting patients for screening and surveillance colonoscopy at age 75.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

The concepts of 'first do no harm' and shared decision-making are not new but are increasingly important, particularly in this patient group. It is crucial to provide patients with information about risks, benefits and alternative investigations to empower their decision-making.

Usefulness of Mean Corpuscular Volume for Detection of Advanced Colorectal Cancer in Patients Older than 85 Years

BACKGROUND/AIMS

The aim of this study was to elucidate clinical indicators for the detection of advanced colorectal cancer (ACRC).

METHODS

This was a retrospective study conducted at a tertiary hospital. This study included 333 patients older than 85 years who underwent colonoscopy from April 2006 to May 2010. The detection rate of ACRC was assessed. Then, we analyzed the association between the detection of ACRC and various background factors including mean corpuscular volume (MCV). We also analyzed the cumulative overall survival of patients with detected ACRC.

RESULTS

ACRC was found in 37 patients, resulting in a detection rate of 15%. Multivariate logistic regression analysis revealed that a decreased MCV was an independent predictor for the detection of ACRC (OR 0.88, 95% CI 0.84-0.94), whereas symptoms such as abdominal pain, hematochezia, or anemia were not independent predictors. MCV was an independent predictor irrespective of the location of the tumor. The cumulative survival rates at 3 and 5 years after diagnosis were 78 and 58%, respectively, during a median observational period of 30.3 months.

CONCLUSION

This study demonstrated the usefulness of MCV as an indicator of the necessity of colonoscopy for older patients.

Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation

Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.

Second look at Streptococcus sanguinis and the colon

Although the link between Streptococcus bovis bacteraemia and colon cancer is well established, bacteraemia from other viridans group streptococci that commonly colonise colonic mucosa may also herald occult malignancy. We present a case of Streptococcus sanguinis bacteraemia in an elderly man with new anaemia that led to the detection and removal of a high-grade colon neoplasm. This case contributes to a growing body of literature contending that unexplained streptococcal bacteraemia merits a thorough workup that may include relatively invasive procedures such as endoscopy. Diagnostic colonoscopy provides an opportunity to prevent invasive malignancy that may outweigh bleeding and perforation risks in elderly patients.

[Gastrointestinal endoscopy in patients of advanced age]

The dramatic increase in life expectancy is leading to a significant increase in the use of gastrointestinal endoscopy in the elderly. Taking into account these demographic changes, the use of gastrointestinal endoscopy in this age group is of great importance. Although these procedures are generally safe and well tolerated even in very elderly patients, the onset of physiological changes associated with aging and the increased prevalence of cardiovascular and pulmonary comorbidities raise the risk of sedation related complications in these patients. Age alone is not a contraindication for performing any endoscopic procedure. However, elderly patients have their own peculiarities that require a detailed review of the characteristics, risks and benefits of endoscopic procedures in this specific context.