Journal club


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Journal club

  1. 1.
  2. 2. Introduction<br />Fresh bleeding per rectum (FBPR) may suggest possible organic pathology in the colon<br />FBPR is common<br />20% of young adults had a history of visible rectal blood<br />FBPR is underreported <br />The commonest causes of recurrent FBPR are haemorrhoids and anal fissure<br />FBPR may be one of the presentations of colorectal cancer (CRC)<br />Presence of benign anorectal lesions in patients with FBPR does not exclude serious colonic lesions<br />
  3. 3. Introduction<br />Up to 16% of patients have been found to have colorectal neoplasms concurrent with an ano-rectal source <br />CRC is uncommon in the younger age<br />Well accepted that full colonoscopicexamination should be performed in patients with FBPR in >50 years<br />To weigh the risks and costs of an extensive approach of colonoscopy with a low expected yield against missing a cancer<br />
  4. 4. Introduction<br />Colonoscopy <br />offers complete visualization<br />more discomfort<br />increased financial cost<br />more risk of complications<br />Sigmoidoscopy<br />convenient <br />cost-effective <br />May miss a potentially treatable sinister pathology in the proximal colon<br />
  5. 5. Introduction<br />Most data on FBPR in young is from west<br />In west, the incidence of CRC is very low < 50 years <br />In South Asia, CRC is diagnosed at a younger age <br />Imperative that for the South Asian population the utility of full colonoscopic examination is defined for young patients with FBPR<br />Aim: to determine the frequency and location of endoscopic lesions in young patients with FBPR and to ascertain whether full colonoscopicexamination is necessary in these patients<br />
  6. 6. Patients and methods <br />Cross-sectional study , on consecutive patients, <br />Conducted between May 2007 and October 2009 at Aga Khan University Hospital<br />Inclusion<br />Scheduled to undergo colonoscopy following complaint of FBPR, referred from the outpatient clinic <br />Informed consent had been obtained<br />Aged between 18 and 50 years <br />FBPR in the previous 6 months<br />
  7. 7. Patients and methods <br />Excluded<br />History of known IBD<br />History of colorectal surgery<br />Family history of CRC<br />Bleeding diathesis<br />Iron deficiency anaemia <br />Anticoagulant therapy<br />Significant bleeding per rectum requiring blood transfusions and/or emergency room visit<br />
  8. 8. Patients and methods <br />FBPR<br />Passing of fresh blood per rectum<br />Noticing red blood in faeces, on toilet paper, or in toilet bowl <br />Colonoscopy <br />Under conscious sedation using combination of midazolam and pethidine or fentanyl<br />Left lateral position to prevent aspiration<br />Blood pressure, heart rate, and oxygen saturation were monitored every 5 minutes during procedure & then every 15 minutes for 2 hours post-procedure <br />Details of bowel-cleansing preparation, completion of procedure, and intubation of terminal ileum were also recorded<br />
  9. 9. Patients and Methods<br />Lesions found on colonoscopy were recorded on the basis of location and type<br />Location of the lesion was defined as distal if it was present in the rectum, sigmoid colon or descending colon (and hence likely within reach of a flexible sigmoidoscope), and proximal if it was located between the cecum and splenic flexure<br />All lesions were biopsied for histopathological diagnosis except for hemorrhoids, anal fissure, diverticulosis, and arteriovenous malformation<br />Polyps found during colonoscopy were removed and sent for histopathological analysis.<br />
  10. 10. Statistical Analysis<br />Data entry and analysis using the SPSS 15 <br />Descriptive statistics were calculated for continuous variables such as age and haemoglobin. Mean ± SD were computed<br />For categorical variables such as sex and type of lesion, the frequencies and percentages were calculated<br />The chi-squared test, odds ratio (OR), and 95% confidence interval (CI) were calculated to evaluate the association of adenomatous polyps and CRC with respect to age and sex. <br />
  11. 11. Results<br />
  12. 12. Results<br />No polyp/malignant lesion in those who had incomplete colonoscopy<br />379 patients were analyzed<br />257 men (67.8 %) and 122 women (32.2 %)<br />131 patients (34.6 %) in the 40–50 yrs& 248 (65.4 %) < 40 years <br />Mean age at presentation was 36 ± 9 years<br />Mean hemoglobin was 12.93 ± 1.78 g/dL<br />No perforation and hemorrhage were noted in any patient<br />Three patients became drowsy under the effect of sedatives drugs, were treated with intravenous flumazenil and recovered<br />12 patients experienced moderate pain post-procedure<br />
  13. 13. Results<br />73 patients (19.3 %) had no lesion<br />306 patients (80.7 %) endoscopic lesions were found<br />Hemorrhoids in 219 patients (57.8 %), hemorrhoids alone in 198 patients, in 21 patients hemorrhoids coexisted with other lesions<br />Malignant lesions in nine patients with mean age of 41 years (range 33–48 years)<br />Polyps in 30 patients<br />Solitary rectal ulcers in 16 patients<br />Ulcerative colitis in 29 patients (7.7 %), 20 left-sided colitis & 9 had pancolitis<br />
  14. 14. Results<br />11 patients mild patchy erythema, non-specific changes in biopsy<br />Anal fissure in 6<br />Diverticulosis in 4; 3 in rectosigmoid, and one in both distal and proximal colon <br />Arteriovenousmalformations in 3, all in recto-sigmoid<br />
  15. 15. Results<br />
  16. 16. Malignant lesions<br />All were in distal colon<br />All were adenocarcinomas<br />All patients with CRC underwent surgery, except for one patient who had advanced metastatic disease.<br />
  17. 17. Malignant Lesions<br />
  18. 18. Polyps<br />Present in 30 patients<br />Eight had adenomatous polyps (3 in < 40 years group and five in the 40–50 years age group)<br />All were found in the distal colon, except for a 5-mm polyp in the transverse colon<br />Four polyps were less than 1 cm and the rest were 1 cm or more in diameter<br />None revealed a villous morphology or high grade dysplasia on histopathology<br />
  19. 19. Polyps<br />Juvenile polyps were also found in 13 patients<br />Hyperplastic polyps in nine<br />These lesions were predominantly in the 30–40 years age group<br />Located in the rectosigmoid region <br />Juvenile polyposis was found in one patient who underwent total colectomy<br />
  20. 20. Results<br />On univariate analysis, malignant and adenomatous lesions were significant in the 40–50 years age group (P = 0.031; OR 2.84; 95% CI 1.05–7.65)<br />
  21. 21. Results<br />
  22. 22. Discussion<br />FBPR is common in the general population<br />The incidence of CRC among patients with BPR varies from 4% to 19% <br />Serious colonic pathology is rare in the young <br />Approach to FBPR in young patients is not very clear and is still evolving. <br />It is generally accepted that patients > 50 years with FBPR should undergo full colonoscopicexamination<br />The cut-off of 50 years is chosen because the incidence of CRC begins to rise in the sixth decade of life in the Western population<br />
  23. 23. Discussion<br />In South Asia the exact incidence of CRC in patients with bleeding per rectum is not known<br />CRC is diagnosed at a younger age in South Asian individuals than in their Caucasian counterparts<br />In the present study<br />CRC was found in nine patients (2.4 %) <br />adenomatous polyps in eight (2.1 %)<br />
  24. 24. Discussion<br />These figures are greater than in the West<br />In an Italian study of young patients with rectal bleeding without other alarm features, only 0.6% had CRC and all of them were in the distal colon<br />A US study found only 1 and 11 patients out of 570 to have CRC and advanced adenoma, and all of in the distal colon<br />Another American study of 223 young patients with rectal bleeding found CRC in 1.8% and all lesionswere distal<br />
  25. 25. Discussion (Present study)<br />Nine cases of CRC in the 33–49 years age group, a much younger age compared with the Western population; <br />South Asian ethnicity may be a risk factor for early development of CRC<br />All CRC patients had left-sided lesions<br />No gender difference was found in the detection of adenomatous polyps and CRC<br />
  26. 26. Discussion (Present study)<br />Isolated proximal lesions are rare in patients with FBPR<br />One patient with an adenomatous polyp in the transverse colon but he also had congested hemorrhoids<br />If only proctoscopy is performed, potentially sinister pathology may be missed in the sigmoid and descending colon<br />Authors recommend that young patients undergo sigmoidoscopyfor their evaluation<br />A significantly increased number of CRC and adenomatous polyps in patients over 40 years old compared with patients younger than 40 year<br />Flexible sigmoidoscopy seems to be a reasonable evaluation tool in young patients with no other alarm symptoms or no family history of CRC<br />
  27. 27. Comments<br />Provides data from South Asia where CRC occurs at an earlier age but no screening programmes exist<br />Single-center study<br />Setting: tertiary-care hospital; referral<br />