Is whole colonic imaging necessary for symptoms of change in bowel habit and/or rectal bleeding?

Badiani, Sarit; Desai, Anant; Chapman, Mark

doi:10.1111/j.1463-1318.2011.02918.x

Cited by 5 publications

(15 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…28 It has been suggested that there is scope within the NHS to reduce the diagnostic burden for patients and endoscopy services by implementing clinical protocols which incorporate the selective use of FS, in place of WCI, for the initial investigation of patients with symptoms suggestive of distal CRC. [29][30][31][32][33] For WCI to be avoided in favour of FS, diagnostic protocols using FS for first-line investigation must be able to demonstrate INTRODUCTION NIHR Journals Library www.journalslibrary.nihr.ac.uk favourable risk-benefit profiles, in which the benefits of this less invasive procedure are balanced against the risk of a missed diagnosis of proximal cancer. [34][35][36] The use of such protocols is likely to be most relevant in clinical practice for which the clinical index of suspicion for proximal colon cancer is low, for example when patient and symptom profiles favour a diagnosis of distal CRC.…”

Section: Computerised Tomography Colonographymentioning

confidence: 99%

“…37,[53][54][55][56][57] The sensitivity of rectal bleeding for proximal lesions has been shown to be higher in elderly patients (those aged ≥ 80 years) 58 or when bleeding is severe. 54 A CIBH with rectal bleeding is also associated with distal CRC, 29 but it is less clear whether or not a CIBH without rectal bleeding can be used to distinguish distal from proximal CRC. 35 Symptoms and signs suggestive of proximal colon cancer Cancers in the proximal colon are, in general, less likely to present with overt symptoms such as rectal bleeding.…”

Section: Symptoms Suggestive Of Distal Colorectal Cancermentioning

confidence: 99%

“…For the most part, these have been retrospective analyses of patients presenting INTRODUCTION NIHR Journals Library www.journalslibrary.nihr.ac.uk through urgent 2-week wait referral pathways in England for the evaluation of symptoms suggestive of CRC. 29,32,[34][35][36] In an analysis of presenting symptoms in 2-week wait patients with proximal cancer, only 3.4% (7/206) of patients with a CIBH and/or rectal bleeding would have had their proximal cancer missed if FS had been the only investigation. 29 A lower miss rate was calculated in a separate study of patients with distal symptoms referred to a rapid access colorectal clinic.…”

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

“…29,32,[34][35][36] In an analysis of presenting symptoms in 2-week wait patients with proximal cancer, only 3.4% (7/206) of patients with a CIBH and/or rectal bleeding would have had their proximal cancer missed if FS had been the only investigation. 29 A lower miss rate was calculated in a separate study of patients with distal symptoms referred to a rapid access colorectal clinic. Two (0.24%) proximal cancers were diagnosed in patients referred with distal symptoms in isolation after a cancer-free FS; however, the authors were not explicit as to whether or not there were any other indications for WCI in these patients.…”

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

“…This has probably had an impact on the implementation of symptom-driven FS protocols at a local level leading to variations in practice. 29,32,33,35,36 A cancer service recommendation was published by NICE in 2004, 16 which stated that FS is an appropriate initial investigation for most patients with bowel symptoms, such as a CIBH and rectal bleeding, given that these symptoms are indicative of lesions in the distal colon and rectum. This publication also stated that WCI is necessary when the patient is deemed at risk of proximal disease because of risk factors/clinical features such as older age, an abdominal mass, IDA, abdominal pain and loss of appetite and weight.…”

Section: National Clinical Guidelines For Symptom-based Tailoring Of mentioning

confidence: 99%

See 4 more Smart Citations

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

Atkin

Wooldrage

Shah

et al. 2017

Health Technol Assess

View full text Add to dashboard Cite

BackgroundFor patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study.ObjectivesTo investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease.DesignA multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre.SettingParticipants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007.ParticipantsMen and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC.Main outcome measureDiagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation.ResultsThe data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62–76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%).LimitationsA limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings.ConclusionsSymptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended.Trial registrationCurrent Controlled Trials ISRCTN95152621.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.

show abstract

Section: Computerised Tomography Colonographymentioning

confidence: 99%

Section: Symptoms Suggestive Of Distal Colorectal Cancermentioning

confidence: 99%

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

Section: National Clinical Guidelines For Symptom-based Tailoring Of mentioning

confidence: 99%

See 3 more Smart Citations

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

Atkin

Wooldrage

Shah

et al. 2017

Health Technol Assess

View full text Add to dashboard Cite

show abstract

Whole-colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study

et al. 2018

View full text Add to dashboard Cite

Background Patients with suspected colorectal cancer (CRC) usually undergo colonoscopy. Flexible sigmoidoscopy (FS) may be preferred if proximal cancer risk is low. We investigated which patients could undergo FS alone. Methods Cohort study of 7375 patients (≥55 years) referred with suspected CRC to 21 English hospitals (2004–2007), followed using hospital records and cancer registries. We calculated yields and number of needed whole-colon examinations (NNE) to diagnose one cancer by symptoms/signs and subsite. We considered narrow (haemoglobin <11 g/dL men; <10 g/dL women) and broad (<13 g/dL men; <12 g/dL women) anaemia definitions and iron-deficiency anaemia (IDA). Results One hundred and twenty-seven proximal and 429 distal CRCs were diagnosed. A broad anaemia definition identified 80% of proximal cancers; a narrow definition with IDA identified 39%. In patients with broad definition anaemia and/or abdominal mass, proximal cancer yield and NNE were 4.8% (97/2022) and 21. In patients without broad definition anaemia and/or abdominal mass, with rectal bleeding or increased stool frequency (41% of cohort), proximal cancer yield and NNE were 0.4% (13/3031) and 234. Conclusion Most proximal cancers are accompanied by broad definition anaemia. In patients without broad definition anaemia and/or abdominal mass, with rectal bleeding or increased stool frequency, proximal cancer is rare and FS should suffice.

show abstract

Need For Whole Large Bowel Investigation in Sole Change in Bowel Habit: An Analysis of 719 Patients

Patel

Athisayaraj

Mishra

2019

Journal of Investigative Surgery

View full text Add to dashboard Cite

Is whole colonic imaging necessary for symptoms of change in bowel habit and/or rectal bleeding?

Cited by 5 publications

References 14 publications

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

Whole-colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study

Need For Whole Large Bowel Investigation in Sole Change in Bowel Habit: An Analysis of 719 Patients

Contact Info

Product

Resources

About