The diagnostic yield of colonoscopy in hospitalized patients. An observational multicenter prospective study

Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison

BACKGROUND

There is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This "overuse" of colonoscopies has become a major burden for health care.

OBJECTIVES

to assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria.

PATIENTS AND METHODS

this cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria.

RESULTS

From 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153).

CONCLUSIONS

The updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.

2L polyethylene glycol combined with castor oil versus 4L polyethylene glycol for bowel preparation before colonoscopy among inpatients

Inpatients are more likely to have inadequate bowel preparation compared to outpatients. Although experts recommend 4L split polyethylene glycol (PEG) preparation, bowel preparation with castor oil (CaO) was recently found to reduce the volume of solution required. The aim of the study was to evaluate the cleansing effect and safety of 2L-PEG with Cao in bowel preparation among inpatients. Our study retrospectively analyzed the medical records and colonoscopy reports of inpatients (n = 1251) who underwent colonoscopy in the Affiliated Changzhou No.2 People Hospital of Nanjing Medical University, and the inpatients were divided into 2L-PEG-CaO and 4L-PEG group according to different bowel preparation protocols. Boston Bowel Preparation Scale (BBPS) is used to assess bowel preparation efficacy before colonoscopy. Furthermore, we also calculated other outcomes, such as polyp or adenoma detection rates and adverse events. A total of 1251 patients undergoing colonoscopy were included in this study, 738 were taken 4L-PEG and 513 2L-PEG-CaO. Both inpatients groups were matched for baseline characteristics. The 2L-PEG-CaO group was significantly higher than the 4L-PEG group on both BBPS (7.26 ± 1.75 vs 7.06 ± 1.58, P = .043) and adequate bowel cleansing rates (83.2% vs 77.4%, P = .011). Regarding adverse events, the 4L-PEG group was significantly higher than the 2L-PEG-CaO group on the incidence of abdominal fullness (6.4% vs 9.6%, P = .045) and adverse events (33.7% vs 28.5%, P = .048). The 2L split PEG with CaO preparation increased quality of bowel cleansing and improved tolerance in inpatients. Bowel preparation with 2L-PEG-CaO is suitable alternative to traditional 4L split PEG bowel preparation for colonoscopy of inpatients.

Clinical value of alarm features for colorectal cancer: a meta-analysis

BACKGROUND

Colorectal cancer (CRC) is a common neoplasm in Western countries. Prioritizing access to colonoscopy appears of critical relevance. Alarm features are considered to increase the likelihood of CRC. Our aim was to assess the diagnostic performance of alarm features for CRC diagnosis.

METHODS

We performed a systematic review and meta-analysis of studies reporting the diagnostic accuracy of alarm features (rectal bleeding, anemia, change in bowel habit, and weight loss) for CRC, published up to September 2021. Colonoscopy was required as the reference diagnostic test. Diagnostic accuracy measures were pooled by a bivariate mixed-effects regression model. The number needed to scope (NNS; i. e. the number of patients who need to undergo colonoscopy to diagnose one CRC) according to each alarm feature was calculated.

RESULTS

31 studies with 45 100 patients (mean age 31-88 years; men 36 %-63 %) were included. The prevalence of CRC ranged from 0.2 % to 22 %. Sensitivity was suboptimal, ranging from 12.4 % for weight loss to 49 % for rectal bleeding, whereas specificity ranged from 69.8 % for rectal bleeding to 91.9 % for weight loss. Taken individually, rectal bleeding and anemia would be the only practical alarm features mandating colonoscopy (NNS 5.3 and 6.7, respectively).

CONCLUSIONS

When considered independently, alarm features have variable accuracy for CRC, given the high heterogeneity of study populations reflected by wide variability in CRC prevalence. Rectal bleeding and anemia are the most practical to select patients for colonoscopy. Integration of alarm features in a comprehensive evaluation of patients should be considered.

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years

BACKGROUND

A relevant number of adenomas can be missed during colonoscopy.

AIMS

Assess the current status of colonoscopy procedures in Italian centers.

METHODS

A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.

RESULTS

A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.

CONCLUSION

High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.

Low-Volume Bowel Preparation Is Associated With Reduced Time to Colonoscopy in Hospitalized Patients: A Propensity-Matched Analysis

INTRODUCTION

Delays in inpatient colonoscopy are commonly caused by inadequate bowel preparation and result in increased hospital length of stay (LOS) and healthcare costs. Low-volume bowel preparation (LV-BP; sodium sulfate, potassium sulfate, and magnesium sulfate ) has been shown to improve outpatient bowel preparation quality compared with standard high-volume bowel preparations (HV-BP; polyethylene glycol ). However, its efficacy in hospitalized patients has not been well-studied. We assessed the impact of LV-BP on time to colonoscopy, hospital LOS, and bowel preparation quality among inpatients.

METHODS

We performed a propensity score-matched analysis of adult inpatients undergoing colonoscopy who received either LV-BP or HV-BP before colonoscopy at a quaternary academic medical center. Multivariate regression models with feature selection were developed to assess the association between LV-BP and study outcomes.

RESULTS

Among 1,807 inpatients included in this study, 293 and 1,514 patients received LV-BP and HV-BP, respectively. Among the propensity score-matched population, LV-BP was associated with a shorter time to colonoscopy (β: -0.43 [95% confidence interval: -0.56 to -0.30]) while having similar odds of adequate preparation (odds ratio: 1.02 [95% confidence interval: 0.71-1.46]; P = 0.92). LV-BP was also significantly associated with decreased hospital LOS among older patients (age ≥ 75 years), patients with chronic kidney disease, and patients who were hospitalized with gastrointestinal bleeding.

DISCUSSION

LV-BP is associated with decreased time to colonoscopy in hospitalized patients. Older inpatients, inpatients with chronic kidney disease, and inpatients with gastrointestinal bleeding may particularly benefit from LV-BP. Prospective studies are needed to further establish the role of LV-BP for inpatient colonoscopies.