- Email: [email protected]
Neoplastic risk of the small colonic polyp
p = 0.001), Detection rates of 7% for malignancies were the same for both study modalities. Conclusion: Colonoscopy offers the same complete colonic mmging rates compared to BE with a sigmficantly higher detection rate of colonic polyps. Colonoseopy should be the firstline investigation of colonic pathology.
analysis of patients with rectal bleeding undergoing flexible slgmoidoscopy within an endoscopy unit as a day case procedure. 115 patients were identified between January 2001November 2002. The patients were atlalysed for the cause of rectal bleeding and whether subsequent full imaging of the colon was required. Results 43 of 115 patients (37.3%) required proximal imaging of the colon. 22/115 patients (19%) had colitis, 12/115 patients (10.4%) had colonic adenomatous polyps. Other diagnoses included Crohn's disease in 5 patients (4.3%), cancer in 4 patients (3.4%) and 16 (13.9%) patients for other reasons. Diverticulosis was identified in 20 patients (17.3%) and 36 patients (29%) had normal flexible sigmoidoscopy. Conclusions In this study 37.3 % of patients who undergo flexible sigmoidoscopy for rectal bleeding subsequently require colonoscopy. The reasons for this include assessment of extent of colitis and searching for proximal concurrent polyps. This study suggests that a more efficient way of investigating patients with rectal bleeding might be to perform a colonoscopy as the first investigation rather than a flexible stgmoidoscopy.
M1464
Outcome of a Nurse Practitioner (NP) Based Colorectal Cancer (CRC) Screening Flexible Sigmoidoscopy (FS) Program in a Veterans Administration Medical Center (VAMC) Margaret Jakubowicz, Gerard Isenberg, Margaret Kinnard, Shawn Lacey, Ananya Das OBJECTIVE: Current CRC screening guidelines recommend FS every 5 years in averagerisk population over the age of 50 years. However, most VAMCs have significant waiting time for scheduling screening endoscopic procedures. The LSVAMC has a population of 50,000-60,000 veterans eligible for CRC screening with an average waiting time for a screening endoscopic procedure of 5.5 months. We evaluated the effectiveness of a NP based CRC screening FS program in the Veterans Administration Heahhcare System. METHODS: Initially a NP completed a 4-month training course completing 40 supervised procedures using a 60cm flexible sigmoidoscope. An open-access consultation checklist identifying the CRC guidelines was developed and adapted to the computerized patient record system for electronic referral for screening FS from participating VAMC primary care services. RESULTS: Most electronic consultation for screening FS were appropriate and the average waiting time for scheduling was 1.2 months. Total of 210 screening FS were performed by the NP between February 2001 and September 2002. 205 of the participants were men, 5 were women with an age ranging from 50 to 89 years. Direct visualization of colonic mucosa was achieved to 40cm and beyond in 83%. Fifteen percent experienced discomfort, 10% had poor preparation. 131 (63%) of the procedures were abnormal; 25 (12%) had hemorrhoids, 51 (24%) diverticufi; 55 (27%) had polyps and were referred for colonoscopy. Of 44 completed colonoscopies 75% of polyps were within the reach of 60cm flexible sigmoidoscopy with 25% additional polyps found beyond 60cm. Forty-four percent of all polyps removed were neoplastic. CONCLUSION: A NP based CRC screening program in a VA Hospital is both feasible and effective in s~gnificantly reducing the waiting time for endoscopic screening procedures. Such a program is well accepted by both patients and primary care providers.
M1467
Should Digital Rectal Examination Still Be Part of the Physical Examination of Patients With Colonic Symptoms? Louise Langmead, D. B. Jones, Peter Katelaris Background: It is an unchallenged axiom that digital rectal examination (DRE) is an essential part of the physical examination of patients with colonic symptoms. However, there is no evidence demonstrating that routine unsedated, unprepared DRE at the initial consultation is useful in patients in whom cohinoscopy is indicated. Aims: To assess the value of DRE in patients presenting to gastroenterologists with colonic symptoms. Methods: Consecutive evaluable patients presentmg to gastroenterologists with colonic symptoms and in whom a colonoscopy was later performed were studied. Patients with perianal pain or tenesmns and those in whom DRE was done for indications other than routine were excluded. Time from consultation to cofunoscopy and the endoscopic findings were evaluated. Rectal cancers were recorded as distal (within 7cm of the anal verge and potentially palpable on unsedated DRE) or proximal (beyond 7cm). Results: Of 4834 patients undergoing colonoscopy, 166 cancers were diagnosed of which 68 (41%) were rectal cancer (23 distal, 45 proximal). Patient demographics and indications for colonoseopy were not significantly different between patients with distal and proximal rectal cancers. Anaemia was a more frequent indication in those with colonic cancers (p<0.O01). Median waiting time to colonscopy was 7 days (range 1-78). A qualitative questionnaire revealed unanimous patient and doctor preference for DRE at the time of colonoscopy rather than unsedated, unprepared DRE. In a presumptive analysis of usefulness, a 75% sensitivity of DRE for distal cancers was assumed. 280 DREs, therefore, would be required to detect one distal cancer in this cohort, with the outcome of this being a possibly reduced waiting time to colonoscopy. Conclusion: Routine DRE was not sensitive for the diagnosis of colorectal cancer. It was unpopular with patients and doctors and would not alter management in more than 0.4% of patients. In those with a positive DRE, the inaxlmum benefit would be to shorten the interval to colonoscopy. In practice, valuable time spent performing DRE may be better spent in the endoscopy suite reducing cohinoscopy waiting times.
M1465 A Population-Based Study of Risk Factors for Rectal Bleeding Ashok K. Tuteja, Sandra K. Joos, Nicholas J. Talley, David H. Hickam Background: While rectal bleeding can be an early sign of colorectal disease, especially colon cancer, it usually is a benign disorder. There have been few population-based studies of rectal bleeding and little is known about the role of physical activity in causing rectal bleeding. Non-strenuous physical activity may decrease the risk of gastrointestinal hemorrhage by protecting against splanchnic isehemia and by diminishing sympathetic stimulation. We evaluated the prevalence of various type of rectal bleeding and their association with potential risk factors, including colonic symptoms and non-strenuous physical activity. Methods: 1069 employees (age range 24 to 77) of VA Health Care System were mailed validated questionnaires (response rate 72%), inquiring about their gastrointestinal symptoms (Bowel Disease Questionnaire) and physical activity (modified Beacke Questionnaire). Those who reported rectal bleeding were subdivided as follows: blood on the toilet paper; blood coating the stools; dark blood mixed in stool. Physical activity was studied in various settings (housecare, occupational, leisqre time, sports and total physical activity). Other risk factors studied were: constipation, diarrhea, irritable bowel syndrome, straining, and urgency. Results: Rectal bleeding was reported by 113 (15.8%) respondents; 12.4% reported blood on toilet paper, 3.7% reported blood coating the stool and 2.6% reported blood mixed with stools. Prevalence of rectal bleeding increased was higher in males and older respondents, though neither of these associations was significant (p> 0.21). Education level, smoking, and aspirin use were not associated with rectal bleeding. Subjects with rectal bleeding reported more bowel dysfunction, but association was significant only for straining and urgency (table). Physical activity (housecare, occupational, leisure, sports and total activity) was no different between subjects who had or did not have rectal bleeding (p > 0.11). Twenty two percent of subjects with rectal bleeding reported having seen a physician in the last year for bowel problems. Conclusion: Self reported rectal bleeding is common in otherwLse healthy subjects. Straining and urgency are significantly associated with rectal bleeding. Non-strenuous physical activity is not associated with rectal bleeding Only a minority of subjects with rectal bleeding seek health care.
M1468 Neoplastic Risk Of The Small Colonic Polyp lan C. Lawrance, Colin A. Shemngton Background: The significance of small colonic polyps is unclear and removal is frequently decided on clinical appearance of the lesion, its location and the procedualist's assessment. In addition, with increasing demand for colonoscopy, less invasive techniques with a lower sensitivity for polyp detection such as virtual colonoscopy, are now bemg considered. Aim: The aim was to determine the rate of advanced lesions (villous component or high grade dysplasia) in polyps < = 5 m m and >5mm but < = 10mm in size and whether clinical impression can be used to determine the histological status of a polyp. Methods: We prospectively collected data on 909 lesions removed from 384 subjects out of 976 consecutive colonoscopies. Lesion size was determined at colonoscopy and compared with the histological measurements Lesion location, patient age, sex and the colonoscopist's clinical impression were recorded and correlated with the lesions' histology. Results: Clinical assessment of lesion size was consistent with histological measuremems. A total of 55.5% of lesions were neoplastic (tubular 40%, tubulovillous 10%, adenocarcinoma 4.7%) and benign in 42% (hyperplastic 36%, other benign histology 6%). In the 652 lesions < = 5 mm in size, 45% (292) were neoplastic, 3.8% (25) had a villous component and 3 were carcinoma-in-situ (CIS). In the 133 lesions 5< and < = 10 mm in size, 83% (110) were neoplastic, 24% (32) showed a villous component and 2 were malignant and 2 were CIS. Only one of the patients with an adenocarcinoma or CIS in a polyp < = 10mm had a lesion >lOmm elsewhere in the colon. Of the 124 lesions >10 mm in size 87% (108) were neoplastic, 31% (39) had a villous component and 30% (37) were malignant and 8% (10) were CIS. Factors predictive of neoplasia were age of patient, size of polyp and site outside the rectum. Clinical assessment of lesion histology had a positive predictive value of 69%, negative predictive value of 77%, sensitivity of 89 %, and specificity of 46% for detection of neoplastic polyps. Factors predictive of correct clinical impression were older patient age, female sex, larger polyp size and greater experience of the endoscopist, but not polyp location. Conclusion: Small polyps < = 10 mm have a significant risk of neoplasia and being advanced lesions, whilst clinical assessment of polyp type at colonoscopy is generally poor. Removal of all lesions, regardless of size, location or clinical impression, should therefore be considered and the use of methods such as virtual colonoscopy for the purposes of CRC screening may miss significant numbers of advanced polyps
Association of rectal bleeding with potential risk factors Straining Urgency "p
Odds RaUo 2.68 2.19
Confid~mceIntwvals 1,70- 4,22" 1.38- 3.47'
M1466 What Proportion of Patients Who Undergo Flexible Sigmoidoscopy for Rectal Bleeding Subsequently Require Colonoscopy? Mazin R. Aljabiri, Niall Vansomeren, Paul Kooner, Adrian Ramdas, Kalpesh Besberdas Background Prompted by the observation that examination of the rectum and left colon identifies a cause of rectal bleeding that requires further imaging of the proximal colon this study was undertaken. Patient deemed to require further imaging after detection of pathology within the left colon includes those patients with adenomatons polyps to identify concurrent polyps, and in patients in whom colitis is the cause of rectal bleeding and this extends beyond the splenic flexure. Aims To assess the need to perform a full cofunoseopy following flexible sigmoidoseopy in patients with rectal bleeding. Methods A single centre, retrospective
A-355
AGA
Abstracts
analysis of patients with rectal bleeding undergoing flexible slgmoidoscopy within an endoscopy unit as a day case procedure. 115 patients were identified between January 2001November 2002. The patients were atlalysed for the cause of rectal bleeding and whether subsequent full imaging of the colon was required. Results 43 of 115 patients (37.3%) required proximal imaging of the colon. 22/115 patients (19%) had colitis, 12/115 patients (10.4%) had colonic adenomatous polyps. Other diagnoses included Crohn's disease in 5 patients (4.3%), cancer in 4 patients (3.4%) and 16 (13.9%) patients for other reasons. Diverticulosis was identified in 20 patients (17.3%) and 36 patients (29%) had normal flexible sigmoidoscopy. Conclusions In this study 37.3 % of patients who undergo flexible sigmoidoscopy for rectal bleeding subsequently require colonoscopy. The reasons for this include assessment of extent of colitis and searching for proximal concurrent polyps. This study suggests that a more efficient way of investigating patients with rectal bleeding might be to perform a colonoscopy as the first investigation rather than a flexible stgmoidoscopy.
M1464
Outcome of a Nurse Practitioner (NP) Based Colorectal Cancer (CRC) Screening Flexible Sigmoidoscopy (FS) Program in a Veterans Administration Medical Center (VAMC) Margaret Jakubowicz, Gerard Isenberg, Margaret Kinnard, Shawn Lacey, Ananya Das OBJECTIVE: Current CRC screening guidelines recommend FS every 5 years in averagerisk population over the age of 50 years. However, most VAMCs have significant waiting time for scheduling screening endoscopic procedures. The LSVAMC has a population of 50,000-60,000 veterans eligible for CRC screening with an average waiting time for a screening endoscopic procedure of 5.5 months. We evaluated the effectiveness of a NP based CRC screening FS program in the Veterans Administration Heahhcare System. METHODS: Initially a NP completed a 4-month training course completing 40 supervised procedures using a 60cm flexible sigmoidoscope. An open-access consultation checklist identifying the CRC guidelines was developed and adapted to the computerized patient record system for electronic referral for screening FS from participating VAMC primary care services. RESULTS: Most electronic consultation for screening FS were appropriate and the average waiting time for scheduling was 1.2 months. Total of 210 screening FS were performed by the NP between February 2001 and September 2002. 205 of the participants were men, 5 were women with an age ranging from 50 to 89 years. Direct visualization of colonic mucosa was achieved to 40cm and beyond in 83%. Fifteen percent experienced discomfort, 10% had poor preparation. 131 (63%) of the procedures were abnormal; 25 (12%) had hemorrhoids, 51 (24%) diverticufi; 55 (27%) had polyps and were referred for colonoscopy. Of 44 completed colonoscopies 75% of polyps were within the reach of 60cm flexible sigmoidoscopy with 25% additional polyps found beyond 60cm. Forty-four percent of all polyps removed were neoplastic. CONCLUSION: A NP based CRC screening program in a VA Hospital is both feasible and effective in s~gnificantly reducing the waiting time for endoscopic screening procedures. Such a program is well accepted by both patients and primary care providers.
M1467
Should Digital Rectal Examination Still Be Part of the Physical Examination of Patients With Colonic Symptoms? Louise Langmead, D. B. Jones, Peter Katelaris Background: It is an unchallenged axiom that digital rectal examination (DRE) is an essential part of the physical examination of patients with colonic symptoms. However, there is no evidence demonstrating that routine unsedated, unprepared DRE at the initial consultation is useful in patients in whom cohinoscopy is indicated. Aims: To assess the value of DRE in patients presenting to gastroenterologists with colonic symptoms. Methods: Consecutive evaluable patients presentmg to gastroenterologists with colonic symptoms and in whom a colonoscopy was later performed were studied. Patients with perianal pain or tenesmns and those in whom DRE was done for indications other than routine were excluded. Time from consultation to cofunoscopy and the endoscopic findings were evaluated. Rectal cancers were recorded as distal (within 7cm of the anal verge and potentially palpable on unsedated DRE) or proximal (beyond 7cm). Results: Of 4834 patients undergoing colonoscopy, 166 cancers were diagnosed of which 68 (41%) were rectal cancer (23 distal, 45 proximal). Patient demographics and indications for colonoseopy were not significantly different between patients with distal and proximal rectal cancers. Anaemia was a more frequent indication in those with colonic cancers (p<0.O01). Median waiting time to colonscopy was 7 days (range 1-78). A qualitative questionnaire revealed unanimous patient and doctor preference for DRE at the time of colonoscopy rather than unsedated, unprepared DRE. In a presumptive analysis of usefulness, a 75% sensitivity of DRE for distal cancers was assumed. 280 DREs, therefore, would be required to detect one distal cancer in this cohort, with the outcome of this being a possibly reduced waiting time to colonoscopy. Conclusion: Routine DRE was not sensitive for the diagnosis of colorectal cancer. It was unpopular with patients and doctors and would not alter management in more than 0.4% of patients. In those with a positive DRE, the inaxlmum benefit would be to shorten the interval to colonoscopy. In practice, valuable time spent performing DRE may be better spent in the endoscopy suite reducing cohinoscopy waiting times.
M1465 A Population-Based Study of Risk Factors for Rectal Bleeding Ashok K. Tuteja, Sandra K. Joos, Nicholas J. Talley, David H. Hickam Background: While rectal bleeding can be an early sign of colorectal disease, especially colon cancer, it usually is a benign disorder. There have been few population-based studies of rectal bleeding and little is known about the role of physical activity in causing rectal bleeding. Non-strenuous physical activity may decrease the risk of gastrointestinal hemorrhage by protecting against splanchnic isehemia and by diminishing sympathetic stimulation. We evaluated the prevalence of various type of rectal bleeding and their association with potential risk factors, including colonic symptoms and non-strenuous physical activity. Methods: 1069 employees (age range 24 to 77) of VA Health Care System were mailed validated questionnaires (response rate 72%), inquiring about their gastrointestinal symptoms (Bowel Disease Questionnaire) and physical activity (modified Beacke Questionnaire). Those who reported rectal bleeding were subdivided as follows: blood on the toilet paper; blood coating the stools; dark blood mixed in stool. Physical activity was studied in various settings (housecare, occupational, leisqre time, sports and total physical activity). Other risk factors studied were: constipation, diarrhea, irritable bowel syndrome, straining, and urgency. Results: Rectal bleeding was reported by 113 (15.8%) respondents; 12.4% reported blood on toilet paper, 3.7% reported blood coating the stool and 2.6% reported blood mixed with stools. Prevalence of rectal bleeding increased was higher in males and older respondents, though neither of these associations was significant (p> 0.21). Education level, smoking, and aspirin use were not associated with rectal bleeding. Subjects with rectal bleeding reported more bowel dysfunction, but association was significant only for straining and urgency (table). Physical activity (housecare, occupational, leisure, sports and total activity) was no different between subjects who had or did not have rectal bleeding (p > 0.11). Twenty two percent of subjects with rectal bleeding reported having seen a physician in the last year for bowel problems. Conclusion: Self reported rectal bleeding is common in otherwLse healthy subjects. Straining and urgency are significantly associated with rectal bleeding. Non-strenuous physical activity is not associated with rectal bleeding Only a minority of subjects with rectal bleeding seek health care.
M1468 Neoplastic Risk Of The Small Colonic Polyp lan C. Lawrance, Colin A. Shemngton Background: The significance of small colonic polyps is unclear and removal is frequently decided on clinical appearance of the lesion, its location and the procedualist's assessment. In addition, with increasing demand for colonoscopy, less invasive techniques with a lower sensitivity for polyp detection such as virtual colonoscopy, are now bemg considered. Aim: The aim was to determine the rate of advanced lesions (villous component or high grade dysplasia) in polyps < = 5 m m and >5mm but < = 10mm in size and whether clinical impression can be used to determine the histological status of a polyp. Methods: We prospectively collected data on 909 lesions removed from 384 subjects out of 976 consecutive colonoscopies. Lesion size was determined at colonoscopy and compared with the histological measurements Lesion location, patient age, sex and the colonoscopist's clinical impression were recorded and correlated with the lesions' histology. Results: Clinical assessment of lesion size was consistent with histological measuremems. A total of 55.5% of lesions were neoplastic (tubular 40%, tubulovillous 10%, adenocarcinoma 4.7%) and benign in 42% (hyperplastic 36%, other benign histology 6%). In the 652 lesions < = 5 mm in size, 45% (292) were neoplastic, 3.8% (25) had a villous component and 3 were carcinoma-in-situ (CIS). In the 133 lesions 5< and < = 10 mm in size, 83% (110) were neoplastic, 24% (32) showed a villous component and 2 were malignant and 2 were CIS. Only one of the patients with an adenocarcinoma or CIS in a polyp < = 10mm had a lesion >lOmm elsewhere in the colon. Of the 124 lesions >10 mm in size 87% (108) were neoplastic, 31% (39) had a villous component and 30% (37) were malignant and 8% (10) were CIS. Factors predictive of neoplasia were age of patient, size of polyp and site outside the rectum. Clinical assessment of lesion histology had a positive predictive value of 69%, negative predictive value of 77%, sensitivity of 89 %, and specificity of 46% for detection of neoplastic polyps. Factors predictive of correct clinical impression were older patient age, female sex, larger polyp size and greater experience of the endoscopist, but not polyp location. Conclusion: Small polyps < = 10 mm have a significant risk of neoplasia and being advanced lesions, whilst clinical assessment of polyp type at colonoscopy is generally poor. Removal of all lesions, regardless of size, location or clinical impression, should therefore be considered and the use of methods such as virtual colonoscopy for the purposes of CRC screening may miss significant numbers of advanced polyps
Association of rectal bleeding with potential risk factors Straining Urgency "p
Odds RaUo 2.68 2.19
Confid~mceIntwvals 1,70- 4,22" 1.38- 3.47'
M1466 What Proportion of Patients Who Undergo Flexible Sigmoidoscopy for Rectal Bleeding Subsequently Require Colonoscopy? Mazin R. Aljabiri, Niall Vansomeren, Paul Kooner, Adrian Ramdas, Kalpesh Besberdas Background Prompted by the observation that examination of the rectum and left colon identifies a cause of rectal bleeding that requires further imaging of the proximal colon this study was undertaken. Patient deemed to require further imaging after detection of pathology within the left colon includes those patients with adenomatons polyps to identify concurrent polyps, and in patients in whom colitis is the cause of rectal bleeding and this extends beyond the splenic flexure. Aims To assess the need to perform a full cofunoseopy following flexible sigmoidoseopy in patients with rectal bleeding. Methods A single centre, retrospective
A-355
AGA
Abstracts