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Colles T, Ziegelmann PK, Damin DC. The role of colonoscopy in young patients with rectal bleeding: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:230. [PMID: 37712988 DOI: 10.1007/s00384-023-04524-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE Anal bleeding is a frequent complaint in the coloproctological practice. Although usually associated with common anorectal disorders, it may represent a sign of an occult colorectal carcinoma. Our purpose was to evaluate the accuracy of the colonoscopy for detection of neoplastic lesions in patients under 50 years of age with rectal bleeding. METHODS This systematic review and meta-analysis searched publications in PubMed, Web of Science, and Cochrane Library databases up to August, 2023. Cross-sectional and case-control studies including patients under 50 years with rectal bleeding evaluated by colonoscopy were included. Primary outcome was prevalence of neoplastic lesions (adenomas and adenocarcinomas). Secondary outcomes were prevalence of those lesions according to age and anatomic location. The study was registered on PROSPERO (CRD42021257859) on July 5, 2021. RESULTS Nine studies comprising 4162 patients were analyzed. A total of 398 patients with adenomas and 40 patients with adenocarcinoma were identified. Prevalence of neoplastic lesions (adenomas and carcinomas) was 10%. In patients under 40 years, the prevalence of neoplastic lesions was 7% (6% of adenomas, 1% of carcinomas). Among patients aged 40-50 years the prevalence was 15%, 14%, and 1%, respectively. Most lesions (71%) were located distally to splenic flexure. CONCLUSION About 10% of patients under 50 years with anal bleeding will have a neoplastic lesion detected through colonoscopy. The greatest benefit of the procedure is observed between 40 and 50 years. Almost 30% of the neoplastic lesions were found in the proximal colon and could not be detected without the performance of a complete colonoscopy.
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Affiliation(s)
- Tuane Colles
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Patrícia K Ziegelmann
- Postgraduate Program in Epidemiology, Department of Statistics, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel C Damin
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Division of Coloproctology, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, RS, Brazil.
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
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Szpakowski JL, Tucker LY. Iron deficiency and symptoms in women aged 20-49 years and relation to upper gastrointestinal and colon cancers. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000947. [PMID: 35896276 PMCID: PMC9335060 DOI: 10.1136/bmjgast-2022-000947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Iron deficiency anaemia (IDA) in women aged 20–49 years may be caused by menses or gastrointestinal cancer. Data are sparse on the yield of endoscopy/colonoscopy in this population. Our aim was to determine the association of IDA and symptoms with cancers. Design Retrospective cohort study within Kaiser Permanente Northern California. Participants were women aged 20–49 years tested for iron stores and anaemia during 1998, 2004 and 2010 and followed for 5 years for outcomes of oesophageal, gastric and colon cancers. Symptoms from the three prior years were grouped into dysphagia, upper gastrointestinal (UGI), lower gastrointestinal (LGI), rectal bleeding and weight loss. Results Among 9783 anaemic women aged 20–49 years, there were no oesophageal, 6 gastric and 26 colon cancers. Incidences per 1000 for gastric cancer with and without iron deficiency (ID) were 0.60 (95% CI 0.23 to 1.55) and 0.63 (95% CI 0.17 to 2.31), and for colon cancer, 2.72 (95% CI 1.72 to 4.29) and 2.53 (95% CI 1.29 to 4.99). Endoscopies for UGI or dysphagia symptoms rather than bidirectional endoscopy for ID yielded more gastric cancers (n=5 and n=4, respectively) with fewer procedures (3793 instead of 6627). Colonoscopies for LGI or rectal bleed instead of for ID would detect more colon cancers (n=19 and n=18) with about 40% of the procedures (=2793/6627). Conclusions UGI and colon cancers were rare in women of menstruating age and when controlled for anaemia were as common without as with ID. Using symptoms rather than IDA as an indication for endoscopy found equal numbers of cancers with fewer procedures.
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Affiliation(s)
- Jean-Luc Szpakowski
- Department of Gastroenterology, Kaiser Permanente Northern California, Fremont, California, USA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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3
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Högberg C, Karling P, Rutegård J, Lilja M. Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study. BMC FAMILY PRACTICE 2020; 21:129. [PMID: 32611307 PMCID: PMC7331274 DOI: 10.1186/s12875-020-01194-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/15/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested. OBJECTIVE Firstly, to determine patients' symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease. METHODS AND MATERIALS This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors. RESULTS Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2-14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2-33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7-100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4-9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1-30.9) and the NPV 100% (95% CI 90.3-100). CONCLUSIONS Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.
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Affiliation(s)
- Cecilia Högberg
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development – Östersund, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Pontus Karling
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development – Östersund, Östersund Hospital, Umeå University, Umeå, Sweden
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4
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Tang MH, Foo FJ, Ng CY. Endoscopic Findings in Patients Under the Age of 40 Years with Hematochezia in Singapore. Clin Endosc 2020; 53:466-470. [PMID: 32549525 PMCID: PMC7403014 DOI: 10.5946/ce.2019.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/11/2020] [Indexed: 01/27/2023] Open
Abstract
Background/Aims Sigmoidoscopy is performed in most medical centers to evaluate the distal colons of young adults presenting with hematochezia who are at risk of developing proximal lesions. Colonoscopies offer more complete evaluations but are associated with a higher incidence of complications and possible low yield.
Methods An analysis was conducted on colonoscopies performed in our center on patients 40 years of age or younger. The study population was sub-divided into 2 age groups for analysis: <30 years of age and 30–39 years of age.
Results We recruited 453 patients for the study. Patients were 115 and 338 individuals that were <30 and 30–39 years of age, respectively. Hemorrhoids was identified as the cause of bleeding in the majority of cases. The overall incidence of polyps was 6.5%; this was significantly higher in the 30–39 age group (7.4% vs. 1.7%, p=0.026). There were two cases of advanced/malignant polyps. While the majority of the polyps were in the distal colon, 28% of the polyps in the older age group were found in the proximal colon. There was one case of colonic perforation.
Conclusions Colonic polyps are more prevalent in patients aged 30–39. Colonoscopies should be considered for patients over the age of 30 with rectal bleeding.
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Affiliation(s)
- Man Hon Tang
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Fung Joon Foo
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Chee Yung Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Kamiński M, Borger M, Prymas P, Muth A, Stachowski A, Łoniewski I, Marlicz W. Analysis of Answers to Queries among Anonymous Users with Gastroenterological Problems on an Internet Forum. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17031042. [PMID: 32041356 PMCID: PMC7037061 DOI: 10.3390/ijerph17031042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 12/24/2022]
Abstract
Internet forums are an attractive source of health-related information. We aimed to investigate threads in the gastroenterological section of a popular Polish medical forum for anonymous users. We characterised the following aspects in threads: the main problem of the original poster, declared ailments and rationale of the responses (rational, neutral, harmful or not related to the problem of the original poster). We analysed over 2717 forum threads initiated in the years 2010–2018. Users mostly asked for diagnosis of the problem [1814 (66.8%)], treatment [1056 (38.9%)] and diagnostic interpretation [308 (11.3%)]. The most commonly declared symptoms were abdominal pain [1046 (38.5%)], diarrhea [454 (16.7%)] and bloating [354 (13.0%)]. Alarm symptoms were mentioned in 309 (11.4%) threads. From the total 3550 responses, 1257 (35.4%) were assessed as rational, 693 (19.5%) as neutral, 157 (4.4%) as harmful and 1440 (40.6%) as not related to the user’s problem. The original poster’s declaration of blood in stool, dyspepsia, pain in the abdominal right lower quadrant, weight loss or inflammatory bowel disease was positively related to obtaining at least one potentially harmful response. Advice from anonymous users on Internet forums may be irrational and disregards alarm symptoms, which can delay the diagnosis of life-threatening diseases.
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Affiliation(s)
- Mikołaj Kamiński
- Sanprobi Sp.z o.o. Sp. k., 70-535 Szczecin, Poland
- Correspondence: ; Tel.: +48-516268563
| | - Michał Borger
- Faculty of Medicine I, Poznan University of Medical Sciences, 60-780 Poznań, Poland; (M.B.); (P.P.); (A.M.); (A.S.)
| | - Piotr Prymas
- Faculty of Medicine I, Poznan University of Medical Sciences, 60-780 Poznań, Poland; (M.B.); (P.P.); (A.M.); (A.S.)
| | - Agnieszka Muth
- Faculty of Medicine I, Poznan University of Medical Sciences, 60-780 Poznań, Poland; (M.B.); (P.P.); (A.M.); (A.S.)
| | - Adam Stachowski
- Faculty of Medicine I, Poznan University of Medical Sciences, 60-780 Poznań, Poland; (M.B.); (P.P.); (A.M.); (A.S.)
| | - Igor Łoniewski
- Department of Biochemistry and Human Nutrition, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, 70-204 Szczecin, Poland;
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Pace LE, Percac-Lima S, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:1146-1153. [PMID: 31011969 PMCID: PMC6614558 DOI: 10.1007/s11606-019-05003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 11/06/2018] [Accepted: 03/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions. OBJECTIVES To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion. DESIGN A retrospective cohort study using explicit chart abstraction methods. PARTICIPANTS Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016. MAIN MEASURES Rates and timing of test ordering and completion and patterns of visits and communications. KEY RESULTS At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS The study relied on documented care, and findings may be most generalizable to academically affiliated institutions. CONCLUSIONS Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.
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Affiliation(s)
- Lydia E Pace
- Harvard Medical School, Boston, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, OBC 3-34, 75 Francis Street, Boston, MA, 02115-9950, USA.
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanford University School of Medicine and Graduate School of Business, Stanford, CA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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7
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Park SK. Clinical assessment and treatment algorithm for lower gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Soo-Kyung Park
- Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Nguyen HH, Bechara R, Paterson WG, Hookey LC. Two-year retrospective analysis of patients undergoing direct to procedure flexible sigmoidoscopy investigation with rectal bleeding as a primary complaint. Endosc Int Open 2018; 6:E1059-E1064. [PMID: 30105294 PMCID: PMC6086679 DOI: 10.1055/a-0600-2157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 09/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS Rectal bleeding affects ~15 % of the general population and is a common reason for referral to gastroenterologists by primary care physicians. Direct to procedure flexible sigmoidoscopy is an appealing modality to investigate rectal bleeding due its diagnostic yield, safety profile, and accessibility. Patients referred on a routine basis for direct to procedure clinic by primary care physicians with the sole complaint of rectal bleeding have not previously been studied. Our study aims to explore the spectrum of diagnoses and evaluate for potential clinical predictors of underlying pathology in this specific patient population. METHODS In total, 528 charts of patients referred to the Kingston General Hospital and Hotel Dieu Hospital endoscopy units (Kingston, Canada) with the sole complaint of rectal bleeding were reviewed. All of these patients were referred on a routine basis to direct to procedure clinic from primary care physicians. The performance of various clinical variables in predicting significant pathology was assessed by univariate analysis. RESULTS The diagnostic spectrum of the cohort studied included hemorrhoids (75.5 %), anal fissures (4 %), ulcerative colitis (3.2 %), Crohn's disease (1.1 %), indeterminate proctitis/colitis (1.7 %), and colorectal malignancy (2.7 %). Of the various clinical variables assessed, only male sex predicted significant pathology (25.2 % of males vs 17.6 % of females, P < 0.05). CONCLUSION Our study highlights the need for a thorough investigation of rectal bleeding given the lack of clinical predictors. Future prospective studies with more patients are needed to fully assess the utility of various clinical variables in predicting pathology in this patient population. This would allow for more effective triaging of a routine rectal bleeding, a very common reason for patient referral to gastroenterologists by primary care physicians. Flexible sigmoidoscopy was not associated with complications or missed diagnosis in our study. As such, the technique appears to be a suitable initial investigative modality for patients with rectal bleeding.
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Affiliation(s)
- Henry H. Nguyen
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary AB, Canada
| | - Robert Bechara
- Gastrointestinal Diseases Research Unit (GIDRU), Department of Medicine, Queen’s University, Kingston ON, Canada
| | - William G. Paterson
- Gastrointestinal Diseases Research Unit (GIDRU), Department of Medicine, Queen’s University, Kingston ON, Canada
| | - Lawrence C. Hookey
- Gastrointestinal Diseases Research Unit (GIDRU), Department of Medicine, Queen’s University, Kingston ON, Canada,Corresponding author Dr Lawrence Hookey Division of GastroenterologyHotel Dieu Hospital166 Brock StreetKingstonOntarioCanada+1-403-592-5090
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9
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Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding. J Gen Intern Med 2018; 33:415-422. [PMID: 29302885 PMCID: PMC5880768 DOI: 10.1007/s11606-017-4273-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
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Affiliation(s)
- Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.
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Affiliation(s)
| | - Vikram Jala
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
| | | | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
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11
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Thompson MR, O'Leary DP, Flashman K, Asiimwe A, Ellis BG, Senapati A. Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI). Br J Surg 2017. [PMID: 28634990 DOI: 10.1002/bjs.10573] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics. METHODS This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR). RESULTS Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them. CONCLUSION A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.
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Affiliation(s)
- M R Thompson
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - D P O'Leary
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - K Flashman
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - B G Ellis
- Swan Surgery General Practice, Petersfield, UK
| | - A Senapati
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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12
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Oberoi DV, Jiwa M, McManus A, Parsons R. Do Men Know Which Lower Bowel Symptoms Warrant Medical Attention? A Web-Based Video Vignette Survey of Men in Western Australia. Am J Mens Health 2016; 10:474-486. [DOI: 10.1177/1557988315574739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The current study aims to explor how men would advise other men about seeking help for lower bowel symptoms and also to determine the factors that may influence help seeking. A purposive sample of Western Australian men aged 18 years and older was recruited for the study. Participants completed 8 of the 28 randomly assigned video vignettes (video clips) displaying men (older or younger) with various combinations of one or more lower bowel symptoms. Participants were asked if the person in the vignette should seek health advice. Subsequently, the participants answered a set of questions based on the Health Belief Model. A total of 408 participants (response rate = 51%) answered 3,264 vignettes. Participants younger than 50 years, participants who were not tertiary educated and those who had lower incomes, or those living in regional or remote areas were less likely to advise help seeking from general practitioner (GP). Participants who visited their general practitioner less frequently were also less likely to advisehelp seeking. There was a trend to consider unintentional weight loss and diarrhea as minor symptoms not necessitating medical attention compared with rectal bleeding. The findings suggest for a need to improve public awareness among men about the need to seek timely medical advice for lower bowel symptoms in primary care. The importance of early presentation of persistent lower bowel symptoms must be specifically targeted at men younger than 50 years, those with lower incomes, or residing in regional or remote areas.
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Affiliation(s)
| | - Moyez Jiwa
- Curtin University, Bentley, Western Australia, Australia
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Tessler R, Gupta S, Pathak J, Ghimire P, Kingham TP, Kushner AL, Amatya KS, Nwomeh BC. Rectal bleeding and implications for surgical care in Nepal. J Surg Res 2015; 197:12-7.e1. [PMID: 25899148 DOI: 10.1016/j.jss.2015.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/18/2015] [Accepted: 02/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. METHODS A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis. RESULTS A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%). CONCLUSIONS The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.
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Affiliation(s)
- Robert Tessler
- Department of Surgery, University of California San Francisco East Bay, Oakland, California.
| | - Shailvi Gupta
- Department of Surgery, University of California San Francisco East Bay, Surgeons OverSeas, Oakland, California
| | | | - Pranita Ghimire
- Department of Critical Care and Emergency Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal
| | - Thomas P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Surgeons OverSeas, New York, New York
| | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Surgeons OverSeas, Baltimore, Maryland
| | | | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Surgeons OverSeas, Columbus, Ohio
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Oberoi DV, Jiwa M, McManus A, Hodder R, de Nooijer J. Help-seeking experiences of men diagnosed with colorectal cancer: a qualitative study. Eur J Cancer Care (Engl) 2014; 25:27-37. [PMID: 25521505 DOI: 10.1111/ecc.12271] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 01/12/2023]
Abstract
Advanced-stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi-structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient-related delays were more common than delays attributable to the health-care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system-delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.
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Affiliation(s)
- D V Oberoi
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - M Jiwa
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - A McManus
- Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - R Hodder
- Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - J de Nooijer
- Faculty of Health Sciences, Maastricht University, Maastricht, the Netherlands
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15
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Abstract
This article examines causes of occult, moderate and severe lower gastrointestinal (GI) bleeding. The difference in the workup of stable vs unstable patients is stressed. Treatment options ranging from minimally invasive techniques to open surgery are explored.
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Abstract
INTRODUCTION Colorectal cancer (CRC) is a common type of malignancy encountered in the United States. A significant proportion of patients with CRC will seek emergency medical care during the course of their illness and treatment. BACKGROUND Emergent presentations can be the result of either local tumor invasion, regional progression, or therapeutic techniques. Specific complications of CRC which present emergently include rectal bleeding, abdominal pain, and bowel obstruction. Less common issues encountered include malignant ascites, neutropenic enterocolitis, and radiation enteropathy. CONCLUSION The care of CRC patients in the setting of an acute severe illness typically requires the joint efforts of the emergency medical team in consultation with surgical, medical, and radiation oncology. A high degree of suspicion for the typical and atypical complications of CRC is important for all clinicians who are responsible for the care of these patients.
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Coelho-Prabhu N, Shah ND, Van Houten H, Kamath PS, Baron TH. Endoscopic retrograde cholangiopancreatography: utilisation and outcomes in a 10-year population-based cohort. BMJ Open 2013; 3:bmjopen-2013-002689. [PMID: 23793659 PMCID: PMC4387279 DOI: 10.1136/bmjopen-2013-002689] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To determine utilisation of endoscopic retrograde cholangiopancreatography (ERCP); incidence of inpatient admissions for complications occurring within 30 days of ERCP and risk factors for procedural-related complications, in a population-based study. DESIGN Retrospective cohort study. SETTING Olmsted County, Minnesota. PARTICIPANTS All adult residents of Olmsted County, Minnesota, who underwent ERCP from 1997 to 2006. INTERVENTIONS Diagnostic and therapeutic ERCPs were assessed. PRIMARY AND SECONDARY OUTCOME MEASURES Patient and procedural characteristics and complications within 30 days; and rates of ERCP utilisation and unplanned admissions and risk factors for admissions. RESULTS In 10 years, 1072 ERCPs were performed on 827 individual patients. Average utilisation of ERCP was 83.1 ERCPs/100 000 persons/year, with an increase from 58 to 104.8 ERCPs/100 000 persons/year over time, driven by increases in therapeutic procedures. Within 30 days after 236 procedures, 62 admissions were definitely related to the index ERCP. The complication rate was 5.3%, including pancreatitis (26, 2.4%), infection/cholangitis (16, 1.5%), bleeding (15, 1.4%) and perforation (4, 0.37%). 30-day mortality was 2.4%, none of which was directly related to the ERCP or complications thereof. Risk factors identified through multivariate analysis to be associated with adverse events included: age <45 years (p=0.0498); body mass index ≥35 (p=0.0024); pancreatic duct cannulation (p=0.0026); outpatient procedure (p<0.0001); intraprocedure sphincterotomy bleeding (p<0.0001); difficulty grade (p=0.115) and patient's first ERCP (p=0.0394). LIMITATIONS Retrospective study. CONCLUSIONS Population utilisation of ERCP rose during the study period, specifically in therapeutic procedures. Admissions within 30 days of ERCP are common but often unrelated. Complications of ERCP remain infrequent and deaths quite unusual.
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Affiliation(s)
| | - Nilay D Shah
- Division of Health Care Policy and
Research, Mayo Clinic, Rochester,
Minnesota, USA
| | - Holly Van Houten
- Division of Health Care Policy and
Research, Mayo Clinic, Rochester,
Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and
Hepatology, Mayo Clinic, Rochester,
Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and
Hepatology, Mayo Clinic, Rochester,
Minnesota, USA
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19
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Courtney RJ, Paul CL, Sanson-Fisher RW, Macrae FA, Attia J, McEvoy M. Factors associated with consultation behaviour for primary symptoms potentially indicating colorectal cancer: a cross-sectional study on response to symptoms. BMC Gastroenterol 2012; 12:100. [PMID: 22862960 PMCID: PMC3503829 DOI: 10.1186/1471-230x-12-100] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 07/26/2012] [Indexed: 12/30/2022] Open
Abstract
Background Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC). Methods 1592 persons aged 56–88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire. Results Males and those who had received screening advice from a doctor were at significantly higher odds of ever seeking medical advice for rectal bleeding. Persons who had private health coverage, consulted a doctor because the ‘symptom was serious’, or who did not wait to consult a doctor for another reason were at significantly higher odds of seeking early medical advice (< 2 weeks). For change in bowel habit, persons with lower income, within the healthy weight range, or who had discussed their family history of CRC irrespective of whether informed of ‘increased risk’ were at significantly higher odds of ever seeking medical advice. Persons frequenting their GP less often and seeing their doctor because the symptom persisted were at significantly higher odds of seeking early medical advice (< 2 weeks). Conclusions The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.
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Affiliation(s)
- Ryan J Courtney
- The Priority Research Centre for Health Behaviour, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
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20
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Daram SR, Lahr C, Tang SJ. Anorectal bleeding: etiology, evaluation, and management (with videos). Gastrointest Endosc 2012; 76:406-17. [PMID: 22817792 DOI: 10.1016/j.gie.2012.03.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/13/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sumanth R Daram
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
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Newman J, Fitzgerald JEF, Gupta S, von Roon AC, Sigurdsson HH, Allen-Mersh TG. Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding. Colorectal Dis 2012; 14:1020-6. [PMID: 21910819 DOI: 10.1111/j.1463-1318.2011.02824.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM The BLEED criterion is a triaging model for lower gastrointestinal bleeding (LGIB), which was developed and validated in the USA. We assessed the BLEED criteria in a UK population and aimed to elucidate factors that can be implemented for early risk stratification. METHOD Patients were identified from a prospectively maintained surgical admission database at a central London teaching hospital. Data were collected on 26 clinical factors available on initial presentation. The primary-outcome end-points included severe bleeding (persistent bleeding within the first 24 h, blood transfusion, a decrease in haematocrit of ≥ 20% or recurrent bleeding after ≥ 24 hours of stability) and adverse outcome (emergency surgery to control bleeding, intensive care unit [ITU] admission or death). RESULTS One hundred and eighty-four clinical episodes were identified, representing 3% of all surgical referrals. Twelve patients with upper gastrointestinal bleeding were excluded. Severe bleeding occurred in 110 (64%) patients. An adverse outcome was recorded in 20 (11.6%) patients, and 10 (5.4%) patients died during admission. The commonest aetiologies were diverticular disease, haemorrhoids and malignancy. Four prognosticators of adverse outcome were identified, these being: creatinine > 150 μm (P = 0.002); age > 60 years (P = 0.001); abnormal haemodynamic parameters on presentation (P = 0.05); persistent bleeding within the first 24 h (P = 0.05); and area under the receiver-operating characteristics curve (AUC) = 0.79. The BLEED criteria were shown to be nonpredictive (AUC = 0.60). CONCLUSION The BLEED criterion was not shown to have any predictive value in this patient cohort. Our study has determined an independent set of prognostic factors that could be incorporated into initial triaging of patients presenting with LGIB. This may facilitate the early identification of patients requiring more aggressive resuscitation, admission to a monitored bed and consideration for early radiological or surgical intervention.
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Affiliation(s)
- J Newman
- Department of General Surgery, Chelsea & Westminster NHS Hospital Trust, London, UK
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22
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Courtney RJ, Paul CL, Sanson-Fisher RW, Macrae F, Attia J, McEvoy M. Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation. Colorectal Dis 2012; 14:e222-9. [PMID: 22381146 DOI: 10.1111/j.1463-1318.2012.02881.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit. METHOD In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire. RESULTS In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study. CONCLUSION The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.
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Affiliation(s)
- R J Courtney
- Priority Research Centre for Health Behaviour, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, New South Wales, Australia.
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23
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Gad YZ, Zeid AA. Portal hypertensive colopathy and haematochezia in cirrhotic patients: an endoscopic study. Arab J Gastroenterol 2011; 12:184-8. [PMID: 22305498 DOI: 10.1016/j.ajg.2011.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 09/25/2011] [Accepted: 11/14/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS In patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia. PATIENTS AND METHODS The current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions. RESULTS There was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients' age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child-Pugh class (p<0.05), history of splenectomy (p<0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p<0.05), prior history of upper gut bleeding (p<0.05), the presence of gastric varices (GVs) (p<0.05), presence of portal hypertensive gastropathy (PHG) (p<0.05), presence of haemorrhoids (p<0.05) and rectal varices (<0.05) and therapy with β-blockers (p<0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation. Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation. CONCLUSION Our data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.
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Affiliation(s)
- Yahia Z Gad
- Internal Medicine, Hepatogastroenterology Unit, Mansoura Specialized Medical Hospital, Mansoura University, Mansoura, Egypt.
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Abstract
The symptoms and signs of colorectal cancer vary from the general population to primary care and in the referred population to secondary care. This review aims to address the diverse symptoms, signs and combinations with relevance to colorectal cancer at various points in the diagnostic pathway and tries to shed light on this complex and confusing area. A move towards a lower threshold for referral and increased use of diagnostics might be a more reliable option for early diagnosis.
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Affiliation(s)
- S K P John
- General Surgery, Northern Deanery, Newcastle upon Tyne UK.
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25
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Koning MV, Loffeld RJLF. Rectal bleeding in patients with haemorrhoids. Coincidental findings in colon and rectum. Fam Pract 2010; 27:260-2. [PMID: 20207693 DOI: 10.1093/fampra/cmq008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Rectal bleeding is a very common clinical sign. It is often caused by haemorrhoids. However, it can be a symptom of other pathology in the rectum or colon. There are little data coincidental pathology in patients with haemorrhoids and rectal bleeding. OBJECTIVE To examine coincidental pathology in patients with rectal bleeding and haemorrhoids, especially with respect to age. METHODS Prospectively, 290 consecutive patients presenting with bleeding and haemorrhoids were analysed. All patients had an endoscopic examination. All significant endoscopic findings (diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded. RESULTS The patients were divided into two groups. Group 1 consisted of patients with only haemorrhoids (n = 129, % male: 41.1, mean age: 53.6 +/- 12.7 years). Group 2 consisted of patients with haemorrhoids and coincidental pathology (n = 161, % male: 46.6, mean age: 67.3 +/- 13.7 years). There was no difference in gender or in the type of endoscopy. However, patients in Group 2 were significantly older. CONCLUSION It can be concluded that in cases of rectal bleeding and haemorrhoids, coincidental pathology occurs in a large proportion of patients, especially the elderly. Omitting endoscopy in these patients can lead to major doctors delay.
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Affiliation(s)
- M V Koning
- Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, The Netherlands
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Hematochezia in the young patient: a review of health-seeking behavior, physician attitudes, and controversies in management. Dig Dis Sci 2010; 55:233-9. [PMID: 19238544 DOI: 10.1007/s10620-009-0750-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Accepted: 01/27/2009] [Indexed: 12/09/2022]
Abstract
Hematochezia, defined as the passage of blood or clots from the rectum, is common and can be quite alarming. Few patients in general consult their physicians for this symptom. Various reasons have been explored for this behavior. Physician attitudes also shed some light onto why some patients are referred and others are not. Hematochezia may be associated with an anal cause in most healthy young adults (<50 years of age), but some may end up being diagnosed with colorectal cancer (CRC). Many studies have looked at the usefulness of clinical presentation in helping to decide which patients need further evaluation and what the optimal mode of investigation should be. Of note, studies on patients less than 50 years of age presenting with rectal bleeding have been few and far between. The results of these studies have been contradictory to the point where, today, there is no single set of consensus guidelines on the approach to hematochezia in young patients. In this review, the value of clinical symptoms and the underlying risk of CRC in guiding this clinical decision will be discussed.
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Salzman BE, Lamb K, Olszewski RF, Tully A, Studdiford J. Diagnosing cancer in the symptomatic patient. Prim Care 2010; 36:651-70; table of contents. [PMID: 19913180 DOI: 10.1016/j.pop.2009.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.
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Affiliation(s)
- Brooke E Salzman
- Division of Geriatric Medicine, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Eslick GD, Kalantar JS, Talley NJ. Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study. Colorectal Dis 2009; 11:921-6. [PMID: 19175652 DOI: 10.1111/j.1463-1318.2008.01721.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Rectal bleeding is considered an important sign of colonic disease, particularly colorectal cancer. The epidemiology of rectal bleeding in the community is poorly understood. Moreover, there is little information as to whether individuals seek health care for this problem. This study aimed to determine the prevalence of rectal bleeding and levels of healthcare seeking amongst an Australian population. METHOD A community sample of adults aged above 18 years of Penrith (a Sydney suburb representative of the Australian population) selected randomly from the electoral roll. The survey consisted of a self-administered questionnaire sent out to 440 residents stratified for equal numbers of men and women. RESULTS The response rate was 77% (n = 338; mean age 46 years; SD: 16; range: 18-90; 55% women). Blood in the stools in the previous 12 months was reported by 18% (95% CI: 14-23). Colour of the blood in bowel movements was reported as bright (72%), dark (7%), bright and dark (10%), 11% did not know. Only 31% (n = 21/68) of respondents with rectal bleeding had visited a physician primarily about the presence of blood in the bowel movement within the previous 12 months. The majority (90%) who consulted about the presence of blood were aged between 30 and 60 years. Blood in the stools was independently associated with younger age (OR = 0.97, 95% CI: 0.95-0.99, P = 0.01), feelings of incomplete rectal evacuation (OR = 3.42, 95% CI: 1.66-7.08, P = 0.001), self-reported injury or tear (OR = 3.45, 95% CI: 1.53-7.69, P = 0.002), and surgery (OR = 2.70, 95% CI: 1.03-7.14, P = 0.04) to the perianal region. CONCLUSIONS Rectal bleeding is common in the general population. Only one-third of those with rectal bleeding consults a physician about their condition. Rectal bleeding occurs in younger individuals, those who suffer from incomplete evacuation and among individuals who have had an injury, tear or surgery to the anus.
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Affiliation(s)
- G D Eslick
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.
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Fiorino C, Valdagni R, Rancati T, Sanguineti G. Dose–volume effects for normal tissues in external radiotherapy: Pelvis. Radiother Oncol 2009; 93:153-67. [DOI: 10.1016/j.radonc.2009.08.004] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 08/11/2009] [Accepted: 08/11/2009] [Indexed: 02/07/2023]
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Alonso-Coello P, Marzo-Castillejo M, Mascort JJ, Hervás AJ, Viña LM, Ferrús JA, Ferrándiz J, López-Rivas L, Rigau D, Solà I, Bonfill X, Piqué JM. [Clinical practice guideline on the management of rectal bleeding (update 2007)]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:652-67. [PMID: 19174083 DOI: 10.1016/s0210-5705(08)75814-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública (Universidad Autónoma de Barcelona), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Nikpour S, Asgari AA. Colonoscopic evaluation of minimal rectal bleeding in average-risk patients for colorectal cancer. World J Gastroenterol 2008; 14:6536-40. [PMID: 19030208 PMCID: PMC2773342 DOI: 10.3748/wjg.14.6536] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the prevalence of clinically significant lesions in patients with minimal bright red bleeding per rectum (BRBPR).
METHODS: Consecutive outpatients prospectively underwent colonoscopy at Loghman Hakim Hospital, Tehran. Minimal BRBPR was defined as small amounts of red blood after wiping or in the toilet bowl. Patients with the following alarm signs were excluded: Positive personal history of colorectal neoplasms or inflammatory bowel disease (IBD), positive first degree family history of colorectal neoplasms, history of altered bowel habits, recent significant weight loss, and presence of iron deficiency anemia. Neoplastic polyps, colorectal carcinoma, and IBD were defined as significant lesions.
RESULTS: A total of 402 patients (183 female and 219 male, aged 43.6 ± 15.7 years) were studied. Hemorrhoids (54.2%), anal fissures (14.2%) and ulcerative colitis (14.2%) were the most common lesions and colonoscopy was normal in 8.0%. Significant lesions were found in 121 (30.1%) patients, including 26 patients (6.5%) with adenocarcinoma and 30 (7.5%) with adenomatous polyps. Almost all patients with significant lesions had at least one lesion in the distal colon; an adenocarcinoma and an adenomatous polyp in the proximal colon were found in 2 patients with hemorrhoids.
CONCLUSION: Flexible sigmoidoscopy appears to be sufficient for the evaluation of average risk patients with minimal BRBPR. Rigid sigmoidoscopy may be used as an alternative in patients less than 40 years of age in settings where the former is not available. The choice of colonoscopy over flexible sigmoidoscopy in patients aged over 50 years should be individualized.
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Adelstein BA, Irwig L, Macaskill P, Katelaris PH, Jones DB, Bokey L. A self administered reliable questionnaire to assess lower bowel symptoms. BMC Gastroenterol 2008; 8:8. [PMID: 18312680 PMCID: PMC2311315 DOI: 10.1186/1471-230x-8-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 03/01/2008] [Indexed: 11/10/2022] Open
Abstract
Background Bowel symptoms are considered indicators of the presence of colorectal cancer and other bowel diseases. Self administered questionnaires that elicit information about lower bowel symptoms have not been assessed for reliability, although this has been done for upper bowel symptoms. Our aim was to develop a self administered questionnaire for eliciting the presence, nature and severity of lower bowel symptoms potentially related to colorectal cancer, and assess its reliability. Methods Immediately before consulting a gastroenterologist or colorectal surgeon, 263 patients likely to have a colonoscopy completed the questionnaire. Reliability was assessed in two ways: by assessing agreement between patient responses and (a) responses given by the doctor at the consultation; and (b) responses given by patients two weeks later. Results There was more than 75% agreement for 78% of the questions for the patient-doctor comparison and for 92% of the questions for the patient-patient comparison. Agreement for the length of time a symptom was present, its severity, duration, frequency of occurrence and whether or not medical consultation had been sought, all had agreement of greater than 70%. Over all questions, the chance corrected agreement for the patient-doctor comparison had a median kappa of 65% (which represents substantial agreement), interquartile range 57–72%. The patient-patient comparison also showed substantial agreement with a median kappa of 75%, interquartile range 68–81%. Conclusion This self administered questionnaire about lower bowel symptoms is a useful way of eliciting details of bowel symptoms. It is a reliable instrument that is acceptable to patients and easily completed. Its use could guide the clinical consultation, allowing a more efficient, comprehensive and useful interaction, ensuring that all symptoms are assessed. It will also be a useful tool in research studies on bowel symptoms and their predictive value for colorectal cancer and other diseases. Studies assessing whether bowel symptoms predict the presence of colorectal cancer should provide estimates of the reliability of the symptom elicitation.
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Affiliation(s)
- Barbara-Ann Adelstein
- Screening and Test Evaluation Program (STEP), School of Public Health, University of Sydney, Australia.
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John SKP, George S, Howell RD, Primrose JN, Fozard JBJ. Validation of the Lower Gastrointestinal Electronic Referral Protocol. Br J Surg 2008; 95:506-14. [PMID: 18196552 DOI: 10.1002/bjs.5908] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Recognition of people presenting to the general practitioner with symptoms suggestive of colorectal cancer varies considerably, as do the subsequent patterns of referral and treatment. The Lower Gastrointestinal Electronic Referral Protocol (e-RP) was developed to be used alongside the national Choose and Book programme. This paper addresses the validation of the e-RP.
Methods
The e-RP was validated using three datasets: 100 consecutive patients with colorectal cancer, 100 2-week wait (TWW) suspected cancer referrals and 100 routine referrals. The actual destination of referred patients, their clinical diagnosis and referral urgency were compared with destination and referral urgency assigned by the e-RP.
Results
Some 43·0 per cent of patients with colorectal cancer were actually referred through the TWW system and the e-RP successfully upgraded 85·0 per cent of these patients as TWW referrals (Pearson χ2 = 9·76, 1 d.f., P = 0·002). The e-RP also redirected three of four patients with colorectal cancer in routine referrals to TWW clinics. Right-sided cancers were appropriately directed to colonoscopy as the first contact in secondary care or to outpatients for investigation of a palpable mass. Most patients with left-sided cancers were directed to flexible sigmoidoscopy clinics.
Conclusion
A dedicated referral protocol addressing all colorectal symptoms would significantly improve the overall yield of colorectal cancers through the TWW route and reduce delays in patient pathways with ‘straight to test’ in secondary care.
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Affiliation(s)
- S K P John
- Specialty Registrar, General Surgery, Northern Deanery, Southampton, UK
| | - S George
- Southampton Clinical Research Institute, Southampton General Hospital, Southampton, UK
| | - R D Howell
- Department of Colorectal Surgery, Royal Bournemouth Hospital, Bournemouth, UK
| | - J N Primrose
- Department of University Surgery, Southampton General Hospital, Southampton, UK
| | - J B J Fozard
- Department of Colorectal Surgery, Royal Bournemouth Hospital, Bournemouth, UK
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Sotoudehmanesh R, Ainechi S, Asgari AA, Kolahdoozan S. Endoscopic lesions in low-to average-risk patients with minimal bright red bleeding from midline anal fissures. How much should we go in? Tech Coloproctol 2007; 11:340-2. [PMID: 18060528 DOI: 10.1007/s10151-007-0377-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Accepted: 08/11/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anal fissure is a common condition in young patients, and the main symptoms include anal pain and bleeding. Our aim was to determine the need to perform lower gastrointestinal endoscopy on patients with midline anal fissure who present with minimal bright red rectal bleeding and who are at low risk for colorectal neoplasia. METHODS Patients with midline anal fissure who reported small amounts of red blood on toilet paper, toilet bowl or stool after defecation were evaluated. Patients with alarm signs (recently altered bowel habit, weight loss, anemia and family or personal history of colorectal neoplasms) were excluded. A total of 134 patients (80 female and 54 male, aged 35.8+/-11.4 years) were studied. Patients younger than 40 years underwent flexible sigmoidoscopy and colonoscopy was used for older ones. RESULTS Fissures were posterior in 106 cases (79.1%) and anterior in 27 cases (20.1%); one patient (0.7%) had both anterior and posterior fissures. The lower gastrointestinal endoscopy was normal in 120 patients (89.6%), and 36 patients (26.9%) had associated internal hemorrhoids. Adenomatous polyps were found in 4 cases (3.0%), ulcerative colitis in 8 (6.0%) and Crohn's disease in one patient (0.7%). There was no case of adenocarcinoma. CONCLUSIONS Clinical evaluation plus rectoscopy might be the appropriate evaluation in this selected group of patients, if our results are confirmed by further studies.
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Affiliation(s)
- R Sotoudehmanesh
- Digestive Disease Research Center, Medical Sciences University of Tehran Shariati Hospital, Tehran, Iran
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Liou JM, Lin JT, Wang HP, Huang SP, Lin JW, Wu MS. Age and distal colonic findings determine the yield of advanced proximal neoplasia in Chinese patients with rectal bleeding. J Gastroenterol Hepatol 2007; 22:1780-5. [PMID: 17914950 DOI: 10.1111/j.1440-1746.2006.04607.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Few data were available on the optimal diagnostic strategy for Chinese patients with hematochezia. We aimed to evaluate the impact of age and distal colonic findings on the yield of diagnostic strategies in young Chinese patients with hematochezia. METHODS Consecutive outpatients aged less than 50 years were analyzed using a hypothesized mixed diagnostic strategy to determine the optimal cut-off age for the use of sigmoidoscopy and colonoscopy. The efficacy and cost of the diagnostic strategy and the number of colonoscopies needed to detect one advanced proximal neoplasm (APN) using different cut-off ages were assessed. RESULTS In the hypothesized mixed diagnostic strategy for young patients, the sensitivities for the detection of APN were 100%, 92% and 75% if the cut-off ages were 30, 35 and 40 years, respectively. The cost needed to detect one APN would be $US 3155, $US 3179 and $US 3497 if the cut-off ages were 30, 35 and 40 years, respectively. Colonoscopy would be performed in 84%, 69% and 51% of patients if the cut-off ages were 30, 35 and 40 years, respectively. CONCLUSION Colonoscopy should be considered for Chinese patients with rectal bleeding who are aged > or =35 years or those aged <35 years who have adenoma in the distal colon.
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Affiliation(s)
- Jyh-Ming Liou
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Spinzi G, Fante MD, Masci E, Buffoli F, Colombo E, Fiori G, Ravelli P, Ceretti E, Minoli G. Lack of colonic neoplastic lesions in patients under 50 yr of age with hematochezia: a multicenter prospective study. Am J Gastroenterol 2007; 102:2011-5. [PMID: 17521401 DOI: 10.1111/j.1572-0241.2007.01332.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES It is still not clear what is the best way of evaluating rectal bleeding in young people. Our aim was to examine the prevalence of neoplastic colonic lesions in these patients. METHODS This prospective, multicenter study enrolled 622 patients aged 30-50 yr (F 232/M 390) consecutively seen in 14 open-access endoscopy departments for hematochezia, defined as bright red blood from the rectum, red blood noted either in the feces, on toilet paper, or in the toilet bowl. At colonoscopy, pathology was stratified as either proximal or distal to the splenic flexure. Exclusion criteria were a history of colitis, colorectal cancer, polyps, anemia, significant weight loss, severe bleeding, or strong family history of colorectal cancer. RESULTS Malignant polyps were found in two patients (0.6%), aged 30-40 yr, one in the rectum and one in the sigmoid. A malignant polyp of the cecum was found in a 41-yr-old patient. Another, aged 47, had a malignant granular-cell tumor of the rectum. A total of 35 advanced adenomas were identified in 18 patients. In 7 patients (2.2 %) within the 30-40 yr age bracket we found 8 advanced adenomas (all in the rectum/sigmoid). The other 27 advanced adenomas were in 11 patients (3.5%) in the 41-50 yr age bracket. In this age group we observed 3 patients with 10 isolated proximal advanced adenomas. CONCLUSIONS In patients younger than 40 yr with hematochezia, advanced neoplastic lesions are rare and usually located in the rectum and sigmoid colon. Sigmoidoscopy appears to be sufficient for evaluation in these patients.
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Thompson MR, Perera R, Senapati A, Dodds S. Predictive value of common symptom combinations in diagnosing colorectal cancer. Br J Surg 2007; 94:1260-5. [PMID: 17701937 DOI: 10.1002/bjs.5826] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
This study compared the diagnostic values of age and single symptoms of colorectal cancer with those of age and symptom combinations.
Methods
Consecutive patients with lower gastrointestinal symptoms referred to a surgical clinic over a 12-year period were studied prospectively. The diagnostic value of age and common symptoms of bowel cancer, individually and in combination, was determined by measuring positive predictive value, sensitivity and specificity.
Results
In total, 467 (5·5 per cent) of 8529 patients had colorectal cancer. Symptom combination analyses showed that patients presenting with rectal bleeding and change in bowel habit without anal symptoms had the highest risk of cancer. Those with rectal bleeding and perianal symptoms without change in bowel habit were at the lowest risk of having cancer. Symptom subgroups defined by age had positive predictive values for cancer that varied from less than 1 to 35 per cent.
Conclusion
Symptom combinations defined by age have greater diagnostic value than single symptoms alone.
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Affiliation(s)
- M R Thompson
- Department of Surgery, Queen Alexandra Hospital, Portsmouth, UK
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Kirshtein B, Ariad S, Mizrahi S, Man S, Walfisch S. Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome. Tech Coloproctol 2007; 11:121-6; discussion 126-7. [PMID: 17510744 DOI: 10.1007/s10151-007-0341-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 03/02/2007] [Indexed: 01/22/2023]
Abstract
BACKGROUND The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment. METHODS This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival. RESULTS A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment. CONCLUSIONS Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.
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Affiliation(s)
- B Kirshtein
- Department of Surgery A, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel.
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Raje D, Scott M, Irvine T, Walshe M, Mukhtar H, Oshowo A, Ingham Clark C. Telephonic management of rectal bleeding in young adults: a prospective randomized controlled trial. Colorectal Dis 2007; 9:86-9. [PMID: 17181851 DOI: 10.1111/j.1463-1318.2006.01049.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The majority of young adults referred with rectal bleeding to a colorectal specialist clinic have a very low risk of serious disease such as cancer, and a high chance of gaining symptom relief by simple dietary changes. To determine whether young low-risk patients with rectal bleeding can be managed with a structured telephonic interview and dietary advice, rather than an outpatient visit. METHOD A single-blinded, prospective, randomized controlled trial was performed in two stages. Patients under 40 years with rectal bleeding only were offered inclusion. Part-I trial: Patients were interviewed on telephone by the colorectal nurse specialist (CNS) and randomized to receive dietary advice (Advice Group) or not (Control Group). All patients were seen in clinic 6 weeks later by a doctor 'blinded' to their trial status. Part-II trial: Patients were interviewed on telephone by the CNS and again randomized to an Advice Group or a Control Group. The Control Group were seen in clinic 6 weeks later. The Advice Group were telephoned again 6 weeks later, and if their bleeding had stopped, were not brought to clinic. All patients were tracked for a year after the study to ensure no adverse diagnoses came to light. RESULTS Part-I trial: 63 of 89 eligible patients were contactable and none refused the study. Seventy per cent of the Advice Group compared with 33% (P = 0.001) of the Control Group had symptomatic improvement when seen in clinic. Approximately 30% of each group required further treatment. Part-II trial: 54 of 94 eligible patients were contactable. However a further nine declined to enter the trial; 90% of patients in the Advice Group had improved at 6 weeks as judged by telephone interview compared with 56% of patients in the Control Group (P = 0.024) who were seen in clinic. The 90% of patients who improved in the Advice Group did not need to come to clinic to be seen. In both parts of the trial, the CNS identified a small number of patients with urgent symptoms at interview and brought them to clinic. The majority had anal fissures or haemorrhoids although in Part-II, one patient had ulcerative colitis and one had colorectal cancer. CONCLUSION Telephonic consultation is an effective way of identifying those patients with urgent symptoms among a cohort of young adults referred to the hospital with rectal bleeding. Telephonic dietary advice leads to resolution of rectal bleeding in the majority of patients without urgent symptoms.
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Affiliation(s)
- D Raje
- Department of Colorectal Surgery, Whittington Hospital, London, UK
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Abstract
BACKGROUND The number of long-term survivors after a cancer diagnosis is increasing, yet relatively few studies have addressed survivors' reported symptoms beyond the initial year after diagnosis. METHODS The symptom reports of 474 survivors of colon and rectal cancer from 5 US metropolitan areas were collected during 2002-2003 as part a larger study of the quality of care for patients with cancer diagnosed in 1998. The relation between the prevalence of reported symptoms and prior treatments received was analyzed, adjusting statistically for other patient characteristics. RESULTS Sixty-nine percent of the survivors had colon cancer and 31% had rectal cancer. The most commonly reported symptoms were "fatigue" (23%), "negative feelings about body appearance" (14%), "diarrhea" (13%), and "constipation" (7%). Higher percentages of respondents attributed health effects to cancer or its treatment including "worry about health" (24%), "physical discomfort" (19%), and "activity limitations" (15%). In general, prior treatment was not associated with symptom prevalence. However, radiation therapy recipients and patients that received a diverting ostomy were more likely than others to report some of the symptoms we studied. Attribution of health effects to disease or treatment did not vary by prior treatment except that recipients of radiation therapy were more likely than others to report limitations in their activities (30% vs 10%; P = .003). CONCLUSIONS Among colorectal cancer survivors the prevalence of symptoms at 4 years was low and relatively comparable to published estimates for the general population, but some survivors continue to attribute health effects to cancer or its treatment.
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Affiliation(s)
- Eric C Schneider
- Department of Health Policy and Management, Harvard School of Public Health, Section on Health Policy, Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Paterson WG, Depew WT, Paré P, Petrunia D, Switzer C, van Zanten SJV, Daniels S. Canadian consensus on medically acceptable wait times for digestive health care. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:411-23. [PMID: 16779459 PMCID: PMC2659924 DOI: 10.1155/2006/343686] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Delays in access to health care in Canada have been reported, but standardized systems to manage and monitor wait lists and wait times, and benchmarks for appropriate wait times, are lacking. The objective of the present consensus was to develop evidence- and expertise-based recommendations for medically appropriate maximal wait times for consultation and procedures by a digestive disease specialist. METHODS A steering committee drafted statements defining maximal wait times for specialist consultation and procedures based on the most common reasons for referral of adult patients to a digestive disease specialist. Statements were circulated in advance to a multidisciplinary group of 25 participants for comments and voting. At the consensus meeting, relevant data and the results of voting were presented and discussed; these formed the basis of the final wording and voting of statements. RESULTS Twenty-four statements were produced regarding maximal medically appropriate wait times for specialist consultation and procedures based on presenting signs and symptoms of referred patients. Statements covered the areas of gastrointestinal bleeding; cancer confirmation and screening and surveillance of colon cancer and colonic polyps; liver, biliary and pancreatic disorders; dysphagia and dyspepsia; abdominal pain and bowel dysfunction; and suspected inflammatory bowel disease. Maximal wait times could be stratified into four possible acuity categories of 24 h, two weeks, two months and six months. FUTURE DIRECTIONS Comparison of these benchmarks with actual wait times will identify limitations in access to digestive heath care in Canada. These recommendations should be considered targets for future health care improvements and are not clinical practice guidelines.
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Affiliation(s)
- William G Paterson
- Queen’s University, Hotel Dieu Hospital, Kingston, Ontario
- Correspondence: Dr William G Paterson, Queen’s University, 166 Brock Street, Kingston, Ontario K7L 5G2. Telephone 613-544-3400 ext 3376, fax 613-544-3114, e-mail
| | | | - Pierre Paré
- Université Laval, Hôpital du St-Sacrement, Québec City, Québec
| | | | - Connie Switzer
- University of Alberta, Grey Nuns Community Hospital, Edmonton, Alberta
| | | | - Sandra Daniels
- Canadian Association of Gastroenterology, Oakville, Ontario
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Andersson G, Johansson JE, Sahlberg-Blom E, Pettersson N, Nilsson K. Urinary incontinence--why refraining from treatment? A population based study. ACTA ACUST UNITED AC 2006; 39:301-7. [PMID: 16118105 DOI: 10.1080/00365590510031129] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate why persons with urinary incontinence (UI) refrain from seeking care and treatment. MATERIAL AND METHODS A population-based study was undertaken in which a public health survey and a specific UI questionnaire were sent to 15 360 randomly selected residents (age 18-79 years) of Orebro County, Sweden. For all persons reporting UI, the expressed wish for treatment or no treatment was analyzed in relation to relevant variables from both inquiry forms using binary logistic regression analysis. RESULTS The response rate was 64.5%. UI was reported by 2194 persons, 1724 of whom comprised the study population. A statistically significant association was found between the degree of UI and a desire for treatment. Persons who did not experience daily leakage and those who did not perceive the leakage as troublesome or having an affect on their daily life mostly stated that they did not desire treatment. Socioeconomic or other health-related factors were not associated with desiring or not desiring treatment for UI. CONCLUSIONS Our results show that it is the perceived severity of UI that determines whether afflicted persons desire treatment or not. Other factors, relating to seeking healthcare in general, were not found to be of importance. Interventions to identify those in need of treatment for UI should primarily be directed towards those with severe symptoms.
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Affiliation(s)
- Gunnel Andersson
- Department of Clinical Medicine, Orebro University, Orebro, Sweden.
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Lieberman DA, Holub J, Eisen G, Kraemer D, Morris CD. Utilization of colonoscopy in the United States: results from a national consortium. Gastrointest Endosc 2005; 62:875-83. [PMID: 16301030 DOI: 10.1016/j.gie.2005.06.037] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 06/07/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND To assess capacity for colonoscopy, we need to understand current utilization of colonoscopy in diverse clinical practice settings. The objective of this study was to determine the utilization of colonoscopy in diverse clinical practice settings. METHODS The Clinical Outcomes Research Initiative (CORI) data repository, which receives endoscopy reports from 73 diverse adult practice sites in the United States was used. Colonoscopy reports from January 2000 to August 2002 were analyzed to determine the demographic characteristics of adult patients who received a colonoscopy and the procedure indication. The relationship of age, race, gender, and procedure indication was analyzed. RESULTS Results of colonoscopies in 146,457 unique patients were analyzed. Of the reports, 68% came from nonacademic settings. Patients less than 50 years of age accounted for 20% of colonoscopies. The most common indications were rectal bleeding (33.6%), irritable bowel symptoms (23.8%), or screening because of a positive family history of colorectal cancer (22.4%) and screening with a primary colonoscopy or a fecal occult blood test (FOBT) (12.8%). In patients 50 years and older, asymptomatic screening (average-risk screening colonoscopy, positive family history, or FOBT positivity) accounted for 38.1% of all colonoscopies. Surveillance colonoscopy in patients with previous cancer or polyps accounted for 21.9% of colonoscopies performed in this age group. Differences in utilization were noted, based on gender and race. CONCLUSIONS Colonoscopy utilization varies based on age, gender, and race. Colonoscopy often is performed in patients less than 50 years old for irritable bowel symptoms; rectal bleeding; or average-risk screening, for which benefits are uncertain. In patients older than 50 years, surveillance after polyp removal is a common indication and may be overused. Understanding utilization can lead to further study to determine outcomes, to optimize utilization, and to provide a basis for shifting limited resources.
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Affiliation(s)
- David A Lieberman
- Division of Gastroenterology; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon 97239, USA
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Payne S. Sex, gender, and irritable bowel syndrome: making the connections. ACTA ACUST UNITED AC 2005; 1:18-28. [PMID: 16115580 DOI: 10.1016/s1550-8579(04)80007-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2004] [Indexed: 02/05/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a widespread chronic health condition experienced more often by women than by men. The extent to which women outnumber men varies, however, with a narrower sex ratio found in population surveys and the widest in gastroenterology clinics. This suggests that explanations of women's excess risk of this condition likely involve both sex, or biological, differences between men and women as well as gender, or social, differences. OBJECTIVE This article reviews research on sex and gender factors in IBS and, in particular, the ways in which these factors affect the risk of IBS, either independently or in synergy. METHODS A multidisciplinary literature review of English-language IBS research published between 1966 and 2002 was conducted using a number of electronic databases (ASSIA, MEDLINE, PsycLIT, and SSCI/Web of Knowledge), augmented by manual search of issues not yet entered onto the databases. The key terms sex, gender, women, men, and irritable bowel disease were used to identify articles with potential relevance; titles and abstracts were reviewed and downloaded to a bibliographic referencing system. This approach yielded approximately 450 articles of interest in the subject area. RESULTS The literature review highlighted a range of sex- and gender-linked factors in IBS, including hormonal factors, genetic differences, psychosocial factors related to stress, mental well-being, gender roles, and the experience of sexual abuse. In addition, the literature suggests that gender-related factors overlap each other in explanations of IBS among women, and the interactions between these factors and sex-linked biology are not yet fully understood. CONCLUSION A complex model is needed-reflecting sex- and gender-linked factors and their interactions-to fully understand how these factors affect variations in risk and outcome between men and women with IBS.
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Affiliation(s)
- Sarah Payne
- School for Policy Studies, University of Bristol, UK.
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Allen E, Nicolaidis C, Helfand M. The evaluation of rectal bleeding in adults. A cost-effectiveness analysis comparing four diagnostic strategies. J Gen Intern Med 2005; 20:81-90. [PMID: 15693933 PMCID: PMC1490043 DOI: 10.1111/j.1525-1497.2005.40077.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown. OBJECTIVE To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding. DESIGN Cost-effectiveness analysis using a Markov decision model. DATA SOURCES Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. TARGET POPULATION Patients over age 40 with otherwise asymptomatic rectal bleeding. TIME HORIZON The patient's lifetime. PERSPECTIVE Modified societal perspective. INTERVENTIONS Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy. OUTCOME MEASURES Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was 5,480 dollars per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy. RESULTS OF SENSITIVITY ANALYSES The cost of colonoscopy was reduced to 1,686 dollars per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above 34,000 dollars. CONCLUSIONS Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.
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Affiliation(s)
- Elizabeth Allen
- Portland Veterans Affairs Medical Center, Portland, OR 97207, USA.
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Mathew J, Shankar P, Aldean IM. Audit on flexible sigmoidoscopy for rectal bleeding in a district general hospital: are we over-loading the resources? Postgrad Med J 2004; 80:38-40. [PMID: 14760179 PMCID: PMC1757955 DOI: 10.1136/pmj.2003.008284] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Patients with rectal bleeding are being over investigated because of the fear of missing colorectal cancers. This study aimed to identify the percentage of patients <45 years of age who undergo flexible sigmoidoscopy for rectal bleeding, and to assess and compare the incidence of colorectal cancers and polyps above and below this age. METHODS Patients who underwent flexible sigmoidoscopy for rectal bleeding between 1 January 2000 and 31 December 2002 were reviewed. Patients were divided into two groups: group 1 consisted of patients aged >or=45 years and group 2 patients <45 years. The histopathology of biopsy specimens taken was also studied. RESULTS Altogether 18.9% of the patients who had flexible sigmoidoscopy for rectal bleeding were <45 years. The incidence of colorectal cancers in group 1 was 3.5%; all these cases were confirmed on histopathology. Only one patient in group 2 was diagnosed with colorectal cancer on flexible sigmoidoscopy, but the histopathology disproved it. The incidence of polyps was 16.6% in group 1 and 7.9% in group 2. Following histopathology, the incidence of adenomatous polyps was 6.8% in group 1 and 2.1% in group 2. There was a significant difference between the two groups, with a p value of <0.0001. CONCLUSION The incidence of colorectal cancers and adenomatous polyps in patients aged <45 years with rectal bleeding is very low. A flexible sigmoidoscopy costs approximately pound 330. If new guidelines are implemented considering the age of the patient, considerable cost savings could be made, and the available resources could be appropriately used in groups with high incidences of colorectal cancers.
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Affiliation(s)
- J Mathew
- Department of Surgery, Trafford General Hospital, Manchester, UK.
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Ferraris R, Senore C, Fracchia M, Sciallero S, Bonelli L, Atkin WS, Segnan N. Predictive value of rectal bleeding for distal colonic neoplastic lesions in a screened population. Eur J Cancer 2004; 40:245-52. [PMID: 14728939 DOI: 10.1016/j.ejca.2003.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The aim of this study was to determine the diagnostic value of rectal bleeding for distal colorectal cancer (CRC), or large (> or =10 mm) adenomas among an average-risk population. A cross-sectional survey was conducted among individuals aged 55-64 years, who attended sigmoidoscopy (FS) screening in the context of a multicentre randomised trial of FS screening for CRC. Sensitivity, specificity and positive predictive value (PPV) of rectal bleeding for large distal adenomas or CRC were calculated. Rectal bleeding was reported by 8.8% of 8507 patients examined (15% of those with large adenomas and 29% of those with CRC). The risk of CRC was increased when bleeding was associated with an altered bowel habit: odds ratio (OR)=10.42; 95% Confidence Interval (CI): 4.08-26.59; the corresponding OR for isolated bleeding was 5.29 (95% CI: 2.28-12.30). Rectal bleeding carries an increased risk of distal neoplastic lesions. However, most lesions are detected among asymptomatic subjects. This finding suggests that screening represents the optimal strategy to detect CRC or large adenomas in the distal colon in the targeted age range.
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Affiliation(s)
- R Ferraris
- Unit of Gastroenterology, Mauriziano Umberto I Hospital, Turin, Italy
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Alonso P, Marzo M, Mascort JJ, Hervás A, Viñas L, Ferrús J, Ferrándiz J, López-Rivas L, Bonfill X, Piqué JM. [Clinical practice guidelines for the management of patients with rectal bleeding]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:605-32. [PMID: 12459124 DOI: 10.1016/s0210-5705(02)70325-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- P Alonso
- Centro Cochrane Iberoamericano, Barcelona, España
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Abstract
BACKGROUND Chronic, bright red, rectal bleeding is a common symptom in our community and the aetiology is frequently benign anal disease. The aim of the present study was to determine the efficacy of performing a flexible sigmoidoscopy on patients with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who, on rigid sigmoidoscopy, are found to have an identifiable anal cause (e.g. haemorrhoids, fissure) for their bleeding. METHODS A prospective study was conducted on patients presenting with chronic, bright red, rectal bleeding. Patients were considered at low risk for colorectal neoplasia if they fulfilled the following criteria: (i) less than 55 years of age; (ii) no past or family history of colorectal neoplasia or inflammatory bowel disease; (iii) no symptoms of altered bowel habit or abdominal pain; and (iv) a source of bleeding identified (e.g. haemorrhoids, fissure) on rigid sigmoidoscopy. All patients underwent a flexible sigmoidoscopy. RESULTS Eighty-two patients were entered into the trial, mean age 39 +/- 9 years (range: 22-55 years), and the ratio of men:women was 1.8:1. The anal cause of bleeding was haemorrhoids in 96%, and anal fissure in 4%. At flexible sigmoidoscopy, five patients were found to have adenomatous polyps. Rigid sigmoidoscopy missed diminutive neoplastic lesions in 6% of patients. CONCLUSIONS Flexible sigmoidoscopy results in a low yield of colorectal neoplasia in patients presenting with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who have an identifiable anal cause for their bleeding.
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Affiliation(s)
- D Mehanna
- Department of Surgery, University of Western Australia, Fremantle Hospital, Fremantle, Australia
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Abstract
There are few randomized, prospective trials evaluating the optimal diagnostic and therapeutic strategies in the management of lower gastrointestinal bleeding. However, recent data suggest that urgent colonoscopy represents a safe and effective initial diagnostic approach. The role of tagged erythrocyte scintigraphy is yet to be defined, but it may be of utility as a screening test for visceral angiography. Colonoscopy and angiography both offer substantial therapeutic options but remain of unproved benefit from a treatment standpoint; surgery continues to play an important role in the management of lower gastrointestinal bleeding. Obscure gastrointestinal bleeding, which often presents as lower gastrointestinal bleeding, continues to be one of the most challenging diagnostic and therapeutic problems in gastroenterology. Occult gastrointestinal bleeding, often arising from the lower gastrointestinal tract, usually mandates gastrointestinal evaluation.
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Affiliation(s)
- R S Bloomfeld
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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