Early Colonoscopy Research Articles

Is Early Colonoscopy Required in Acute Lower Gastrointestinal Bleeding?

Is Early Colonoscopy Required in Acute Lower Gastrointestinal Bleeding?

Long-term Risk of Colorectal Cancer and Related Death After Adenoma Removal in a Large, Community-based Population

The long-term risks of colorectal cancer (CRC) and CRC-related death following adenoma removal are uncertain. Data are needed to inform evidence-based surveillance guidelines, which vary in follow-up recommendations for some polyp types. Using data from a large, community-based integrated health care setting, we examined the risks of CRC and related death by baseline colonoscopy adenoma findings. Participants at 21 medical centers underwent baseline colonoscopies from 2004 through 2010; findings were categorized as no-adenoma, low-risk adenoma, or high-risk adenoma. Participants were followed until the earliest of CRC diagnosis, death, health plan disenrollment, or December 31, 2017. Risks of CRC and related deaths among the high- and low-risk adenoma groups were compared with the no-adenoma group using Cox regression adjusting for confounders. Among 186,046 patients, 64,422 met eligibility criteria (54.3% female; mean age, 61.6 ± 7.1 years; median follow-up time, 8.1 years from the baseline colonoscopy). Compared with the no-adenoma group (45,881 patients), the high-risk adenoma group (7563 patients) had a higher risk of CRC (hazard ratio [HR] 2.61; 95% confidence interval [CI] 1.87-3.63) and related death (HR 3.94; 95% CI 1.90-6.56), whereas the low-risk adenoma group (10,978 patients) did not have a significant increase in risk of CRC (HR 1.29; 95% CI 0.89-1.88) or related death (HR 0.65; 95% CI 0.19-2.18). With up to 14 years of follow-up, high-risk adenomas were associated with an increased risk of CRC and related death, supporting early colonoscopy surveillance. Low-risk adenomas were not associated with a significantly increased risk of CRC or related deaths. These results can inform current surveillance guidelines for high- and low-risk adenomas.

2095 Hemolytic Uremic Syndrome in a Young Female, Later Diagnosed With Crohn's Disease

INTRODUCTION: Hemolytic uremic syndrome (HUS) is defined by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. HUS has mostly been associated with Escherichia Coli infection but also seen with systemic infections, pregnancy, rheumatic disease and malignancies. Although, HUS has been described in previously diagnosed case of crohn’s, concomitant occurrence of both is a rarity. We describe a case of 37-year-old female, with acute onset of HUS, who was subsequently diagnosed with crohn's. CASE DESCRIPTION/METHODS: 32-year-old female presented with complaints of abdominal pain, and bloody diarrhea for 5 days, which persisted despite antibiotic therapy. In ED, laboratory tests showed anemia, thrombocytopenia, AKI and Lactic acidosis. Her hemoglobin dropped to 6.7 g/dl and platelets went down to 48k. LDH was elevated and haptoglobin was low. Peripheral smear showed moderate schistocytes. However, shiga toxin was negative. Patient was managed symptomatically for HUS but her symptoms persisted. Imaging revealed thick-walled transverse and left colon. Colonoscopy showed mucosal ulceration and severe colitis with shallow and deep ulcers in ascending, transverse, and descending colon but rectum was normal. Push enteroscopy revealed a small esophageal ulcer. Biopsy showed granulomatous inflammation suggestive of Crohn's. Hence the patient was started on sulfasalazine. Patient had significant clinical recovery within a month and repeat colonoscopy showed healing congested mucosa. DISCUSSION: Although HUS is predominantly described in the pediatric population, its incidence is rising in adult population. It has been found to involve the transverse and ascending colon, much like Crohn's disease. A few reported cases has showed interchanging clinical features between HUS and IBD. Cumulative occurrence of the both was considered rare, however, cases of HUS in patient who were already diagnosed with Crohn's has been seen. In this case, the patient presented with the clinical features of HUS as her first and only manifestation of her Crohn's. Rapid recovery and resolution of symptoms within four weeks of starting the appropriate treatment presents the importance of the appropriate management on the clinical recovery. Hence, with the growing incidence of concurrent occurrence of both entities, early colonoscopy with biopsy can be beneficial in cases of HUS not responding to treatment, even if the patient has no history of IBD, as this could be their first presentation.

289 What Differences Are There Between Early and Delayed Colonoscopy Following a Positive Stool DNA Test?

INTRODUCTION: Previous stool DNA studies excluded patients who had their colonoscopy done more than 3 months after a positive stool DNA test. In this study, we compare patients who had early colonoscopy with patients who had delayed colonoscopy following a positive stool DNA test. METHODS: Review of 1413 patients who had a positive stool DNA followed by documented colonoscopy was done. Two patients were excluded because of finding of “other carcinoma” aside from adenocarcinoma. Attention was given to the date of the colonoscopy in regards to the date of the positive stool DNA result. Patients were divided in 2 groups. Group 1 included patients who had their colonoscopy within 3 months of the positive stool DNA test while group 2 included patients who had their colonoscopy at least 3 months after the positive stool DNA test. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square and Fisher exact was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant. RESULTS: Out of the 1411 patients included in the study, 1144 (81.08%) patients had their colonoscopy done within 3 months of the positive stool DNA results, while 267 (18.92%) had it done at least 3 months after the positive stool DNA test. Between group 1 and group 2, “adenocarcinoma” was found in 1.75% vs. 1.5% respectively (P = 1.00). “Advanced adenoma” was found in 23.25% vs. 25.47% respectively (P = 0.44). “10 mm adenoma” was found in 6.91% vs. 8.24% respectively (P = 0.45). Non advanced adenoma was found in 29.11% vs. 31.09% respectively (P = 0.52). Finally, no adenomas were found in 38.99% vs. 33.71% respectively (P = 0.11). CONCLUSION: This study shows similar colonoscopy outcome in patients who have positive stool DNA test whether the colonoscopy was done within 3 months or longer than 3 months after a positive stool DNA test. In future studies, it is not necessary to exclude patients who had their colonoscopy done more than 3 months after a positive DNA test.

1658 Colonic Metastatic Disease Masquerading as Immune Checkpoint Inhibitor-Mediated Colitis

INTRODUCTION: The use of immune-checkpoint inhibitors (ICIs) in the treatment of advanced cancer has increased exceptionally since ipilimumab was first approved for melanoma in 2011. As the prevalence of patients being treated with ICIs rises so too have their immune related adverse events (irAEs). Clinicians are now faced with the challenge of accurately and promptly recognizing irAEs. With immune-mediated diarrhea and colitis being two of the most common irAEs, an algorithm for their treatment has already been established; however, it is important for clinicians to maintain a broad differential diagnosis when caring for a patient on an ICI with colitis symptoms. CASE DESCRIPTION/METHODS: A 48-year-old woman with a history of metastatic, refractory, triple negative, BRCA positive breast cancer was started on pembrolizumab four years after being diagnosed with breast cancer. 18 months after initiating treatment with pembrolizumab, she developed loose, watery stools. Cross sectional imaging revealed mild, circumferential wall thickening of the proximal ascending colon. A gastrointestinal pathogen nucleic acid detection test was negative, and she was started on a two-week course of budesonide for presumed immune checkpoint inhibitor-mediated colitis (IMC). Her symptoms progressed with bright red blood per rectum and abdominal cramping. Treatment for IMC was escalated with a prednisone taper followed by infliximab infusion. 6 weeks after being treated for IMC, her hemoglobin was 7.6 and ferritin 4. She was referred to gastroenterology for iron deficiency anemia. Repeat abdominal CT revealed increased colonic wall thickening. Colonoscopy revealed an obstructing, ulcerated mass in the ascending colon. Pathology identified poorly differentiated adenocarcinoma consistent with a breast cancer metastasis. She underwent right hemicolectomy 6 months after the initial CT showed colonic thickening. DISCUSSION: Pembrolizumab is one of many ICIs that have been developed for the treatment of advanced-stage malignancies. The gastrointestinal side effects of this class of medications pose a challenge for physicians as IMC is nearly indistinguishable from many other etiologies of diarrhea clinically, and the onset of gastrointestinal symptoms ranges widely from 1 to 32 weeks after starting the medication. As the use of ICIs becomes more widespread, quick and accurate differentiation of an irAE from other life threatening pathology is of vital importance, and early colonoscopy should be considered to rule out metastatic disease.

593 Impact of Computed Tomography Angiography-First Approach on Length of Stay and Time to Definitive Therapy in Patients Presenting for Lower GI Bleed

INTRODUCTION: The initial study of choice in patients who present to the emergency department (ED) for lower gastrointestinal bleeding (LGIB) is a topic of debate. It is unclear how patient outcomes are affected if computed tomography angiography (CTA) of the abdomen and pelvis is a preliminary study. A major teaching hospital implemented a CTA-first protocol in patients presenting for LGIB in December of 2014. Our goal was to determine how this policy impacted outcomes like hospital length of stay (LOS), time to definitive intervention, number of colonoscopies or embolizations performed, and yield or impression of colonoscopy. METHODS: Electronic medical records were queried for patients presenting for acute LGIB from January 2011 to December 2016. We gathered healthcare and demographic information in patients older than 18. SAS© software was used to perform student's t-tests, chi-square and multivariable linear regression analysis of the data. RESULTS: Five-hundred seventy-four encounters were analyzed, 297 before CTA-first policy (B-CTA) and 277 after CTA-first (A-CTA) policy implementation. The groups were without significant differences in sex, race, age, admission day of the week, hemoglobin or creatinine on presentation (Table 1). There were significant differences in heart rate and systolic blood pressure on presentation (Table 1). LOS in the B-CTA group was 5.8 days compared to 5.1 days in the A-CTA group (P > 0.05; Table 2). In those hospitalized for more than two weeks, interestingly, LOS did seem shorter overall A-CTA (P < 0.01; Figure 2). More CTAs were performed after policy implementation (Table 2). Multivariate analyses showed a 77% reduction in the number of colonoscopies (P < 0.0001) and a 47% decrease in early (those within 24h of admission) colonoscopies (P = 0.0082) (Table 3). Time to colonoscopy was not significantly reduced B-CTA versus A-CTA (Table 2). Colonoscopy impressions detailing the source of bleeding pre- and post-policy implementation were similar (Figure 1). There was no significant change in the number of or time to embolizations (Table 2). CONCLUSION: The CTA-first protocol was intended to facilitate effective triage of patients, targeted definitive therapy, and decreased overall LOS. Our findings suggest that for patients presenting for LGIB, this approach did not significantly improve LOS unless admitted for more than 2 weeks. Moreover, it is questionable that it facilitated more targeted intervention with embolization or colonoscopy.

Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding

We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P= .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.

Early Versus Standard Colonoscopy: A Randomized Controlled Trial in Patients With Acute Lower Gastrointestinal Bleeding: Results of the BLEED Study.

The aim of our study was to examine differences in length of hospital stay (LOHS) between patients with lower gastrointestinal bleeding who received either an early colonoscopy (within 24 h of presentation) or a standard colonoscopy (within 1 to 3 d). Diagnostic management of lower gastrointestinal bleeding has been extensively debated in recent literature, especially whether colonoscopy within 24 hours of presentation is feasible and safe. In this single center, nonblinded, randomized controlled trial, patients presenting at the emergency department with acute hematochezia were eligible if they required hospital admission. A total of 132 patients were included. Primary outcome was LOHS. Secondary outcomes included yield of colonoscopy, blood transfusion requirements, recurrent bleedings, complications, interventions related to complications, and 30-day mortality. The follow-up period was 1 month. In total, 63 patients were randomized for <24 hours colonoscopy and 69 for standard colonoscopy. In the intention to treat analysis, LOHS was significantly lower in patients that underwent an early colonoscopy, compared with the standard group: median 2.0 days (inter quartile range, 2.0 to 4.0) versus median 3.0 days (inter quartile range, 2.0 to 4.0) (P=0.009). Recurrent bleedings and hospital readmissions were significantly more frequent in the <24-hour group: 13% versus 3% (P=0.04) and 11% versus 2% (P=0.02), respectively. No difference was observed regarding the number of patients diagnosed with a confirmed or presumptive bleeding source. In both groups, blood transfusion rate was similar and 30-day mortality was 0. Early colonoscopy reduces LOHS, but also results in lower clinical efficacy compared with standard colonoscopy.

Tu1134 LOCALIZATION OF LOWER GASTROINTESTINAL HEMORRHAGE WITH PRIMARY COLONOSCOPY VERSUS PRIMARY COMPUTED TOMOGRAPY ANGIOGRAPY

Lower gastrointestinal bleeding (LGIB) is both common and morbid, with a mortality rate ranging from 1.5-4%. Use of computed tomography angiography (CTA) in localizing LGIB has replaced tagged red blood cell scans in many institutions but little data exists to guide the choice of first-line testing. Current guidelines suggest colonoscopy as standard of care based on limited supporting data. We aimed to compare the utility and yield of early CTA versus colonoscopy in lower gastrointestinal hemorrhage.

Patients with Non-Hodgkin's Lymphoma Are at Risk of Adenomatous Colon Polyps.

Patients with non-Hodgkin's lymphoma (NHL) are frequently referred for colonoscopy to evaluate gastrointestinal symptoms during their treatment course. Here, we described the rate of colonic adenomas in patients with NHL. This was a retrospective study of patients with NHL who underwent colonoscopy after being diagnosed with NHL between January 2000 and December 2017. Of the 17,938 patients who had been diagnosed with NHL in the study period, 2176 met the inclusion criteria. The mean age at the time of colonoscopy was 61years. Most patients were male (61%). Overall, 1273 polyps were detected in 811 patients (37%). Sessile serrated adenomas were detected in 102 (5%) patients. The overall ADR was 12% in patients younger than 40years of age (n = 103), 26% in patients aged 40-50 (n = 251), 34% in patients aged 51-60 (n = 630), and 43% in patients older than 60 (n = 1212). Most polyps were located in the right colon (63%), and 101 (8%) were larger than 1cm. Villous adenomatous features were present in 1% of polyps, while high-grade dysplasia was detected in 22%. Invasive adenocarcinoma was identified in 4%. The median interval from lymphoma diagnosis to adenoma detection was 1.4years (interquartile range 0.5-3.8years). A repeat colonoscopy was performed in 343 patients. The overall ADR on repeat colonoscopy was 30%. Cox regression analysis revealed that age (hazards ratio 1.04; 95% confidence interval 1.03-1.05; P < 0.001) and male sex (hazards ratio 1.35; 95% confidence interval 1.13-1.60; P = 0.001) were independent factors associated with worse overall survival. By contrast, screening colonoscopy was associated with longer survival duration (hazards ratio 0.48; 95% confidence interval 0.36-0.63; P < 0.001). The ADR in NHL patients aged 40-50years was equivalent to that reported in the literature in non-cancer patients aged 50-70years. Early screening colonoscopy may be warranted in NHL patients younger than 50years. Screening colonoscopy significantly improved the overall survival of patients with NHL.

Early colonoscopy cost effective after childhood cancer

Early colonoscopy cost effective after childhood cancer

Adherence to post-polypectomy surveillance guidelines: a systematic review and meta-analysis.

Colorectal cancer (CRC) is a major worldwide cause of cancer-related mortality. Colonoscopy programs based on guideline-recommended surveillance intervals have been put in place to reduce the morbidity and mortality associated with CRC. We were interested to evaluate clinical practice adherence to guideline-recommended surveillance intervals, the potential extent of early repeat colonoscopies, and causes of nonadherence to guideline recommendations. We performed a literature search for articles reporting on guideline adherence for surveillance colonoscopies. Exclusion criteria included inflammatory bowel disease and hereditary CRC syndrome cohorts. Primary outcome was correct interval assignment in patients undergoing surveillance colonoscopy. Groups were assessed for adherence according to their respective guideline recommendations (North American or European). 16 studies were included in the analysis. The mean colonoscopy surveillance interval adherence rate was 48.8 % (95 % confidence interval [CI] 37.3 - 60.4). For North American guidelines, surveillance interval assignments were adherent to guideline recommendations in 44.7 % (95 %CI 24.2 - 66.3) of patients after detection of low risk lesions and in 54.6 % (95 %CI 41.4 - 67.4) after detection of high risk lesions. For European guidelines, surveillance interval assignments were adherent to recommendations in 24.4 % (95 %CI 1.1 - 63.4) of patients after detection of low risk lesions and in 73.6 % (95 %CI 35.5 - 98.8) after detection of high risk lesions. The worldwide adherence to surveillance colonoscopy guidelines was low, with more than 50 % of patients undergoing repeat colonoscopies either too early or too late. Early repeat colonoscopies occurred with the highest frequency for patients in whom only hyperplastic polyps or low risk adenomas were found.

Addressing acute gastrointestinal emergencies: From hemorrhage to obstruction

Background: Gastrointestinal bleeding (GIB) has traditionally been divided into upper and lower gastrointestinal bleeding (UGIB and LGIB). Advances in diagnostic technologies, including capsule endoscopy and balloon-assisted enteroscopy, have refined our understanding of small bowel bleeding, leading to a revised classification system encompassing upper, mid, and lower GIB. The rising incidence of LGIB is attributed to an aging population and increased antithrombotic use. Despite improvements in UGIB management, effective preventive strategies for LGIB remain insufficient, with significant hospitalization and mortality rates. Aim: This review aims to consolidate current knowledge on the initial management of acute LGIB, addressing advancements in predictive scoring systems, risk stratification, and the role of early colonoscopy. Methods: A comprehensive literature review was conducted, focusing on recent advancements and guidelines, including the 2016 American College of Gastroenterology guidelines for acute LGIB and the American Society for Gastrointestinal Endoscopy guidelines on antithrombotic management. Results: The review highlights the challenges in managing acute LGIB, including the diverse etiology of bleeding, the need for effective risk stratification tools, and the optimization of colonoscopy timing. New predictive models, such as the NOBLADS score and other risk scoring systems, provide valuable insights into severe LGIB outcomes.

Initial management for acute lower gastrointestinal bleeding.

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.

Aspects of the Natural History of Sessile Serrated Adenomas/Polyps: Risk Indicators for Carcinogenesis in the Colorectal Mucosa?

Sessile serrated adenomas/polyps are potentially premalignant colorectal lesions that are precursors to colorectal cancer arising via CpG island methylator phenotype. They are caused by the combination of a BRAF mutation and promoter hypermethylation. DNA methylation is an age-dependent phenomenon in the right colon, and we would expect the occurrence and severity of serrated neoplasia to reflect this. The purpose of this study was to document the natural history of sessile serrated adenomas/polyps, including the ages at which they appear and the ranges of their number, size, and associated lesions. This was a retrospective cohort study. The study was conducted at a tertiary referral center. Consecutive patients with sessile serrated adenomas/polyps removed between 2006 and 2015 were included. Patients with IBD, familial adenomatous polyposis, Lynch syndrome, serrated polyposis, and hereditary nonpolyposis colorectal cancer were excluded. Age at which polyps were first diagnosed, location and size of polyps, demographics, and family history were measured. A total of 440 patients had 668 sessile serrated adenomas/polyps, 257 (58%) also had ≥1 adenoma, and 28 (6%) had a history of colorectal cancer. Mean age at diagnosis was 68 ± 11 years, and 45% were men. Two hundred had had ≥1 colonoscopy before the diagnosis of the first sessile serrated adenomas/polyps. A total of 136 patients (31%) had multiple sessile serrated adenomas/polyps, including 24% synchronous and 10% metachronous. The range of total cumulative sessile serrated adenomas/polyps was from 1 to 7. A total of 554 (83%) of 668 sessile serrated adenomas/polyps were right sided; 48% were ≥1 cm diameter and 22% were >2 cm. The size of the first sessile serrated adenomas/polyps in those diagnosed under age 50 years averaged 10 mm, those between 50 and 60 years averaged 12 mm, and those between 60 and 70 years averaged 12 mm. No measurement of methylation or BRAF mutations in polyps or normal mucosa and a lack of subclassification of hyperplastic polyps limited this study. The age of onset of sessile serrated adenomas/polyps varies, but the pattern is consistent with increasing methylation in the mucosa. Early negative colonoscopies predict a low risk of methylator cancers. See Video Abstract at http://links.lww.com/DCR/A736.

Utilization of colonoscopy and colonoscopic findings among individuals aged 40-54 years with a positive family history of colorectal cancer: a cross-sectional study in general practice.

Guidelines recommend early colonoscopy for individuals with a positive family history of colorectal cancer (CRC), but little is known about the utilization of colonoscopy and the frequency of colorectal neoplasms among younger affected individuals in Germany. The aim of this study was to determine the utilization of colonoscopy and the frequency of colorectal neoplasms in this risk group. We conducted a cross-sectional study in a general practice setting. Patients aged 40-54 years with at least one first-degree relative with CRC were identified, counseled on their increased risk, and referred to colonoscopy if they decided to undergo this procedure. We assessed the reported utilization of colonoscopy before study participation with a questionnaire and obtained results of colonoscopies performed during the study period from colonoscopy reports. Out of 484 patients with a positive family history of CRC, 191 (39.5%) fulfilled the inclusion criteria and participated in the study: 54% reported that at least one colonoscopy had been performed before study participation. Out of 191 participants, 86 (45%) underwent a colonoscopy during study period. No CRC was found, but 16.3% had any adenoma, and 7.0% had advanced adenomas. Overall, 155 (82%) study participants underwent a colonoscopy either before or during the study period. The utilization of colonoscopies among participants was remarkably high even before study participation. This rate increased up to 82% after counseling by general practitioners. A relevant number of participants had (advanced) adenomas. It appears worthwhile to involve general practitioners in identifying and counseling younger individuals with familial risk for CRC.

Early Colonoscopy for Diverticular Bleeding Does Not Reduce Risk of Postdischarge Recurrent Bleeding: A Propensity Score Matching Analysis

Colonoscopy within 24 hours (early colonoscopy) is recommended for patients with colonic diverticular bleeding, but it is unclear if this strategy improves postdischarge outcomes. We aimed to determine whether early colonoscopy is associated with decreased risk of rebleeding and hospital re-admission within 30 days. We performed a retrospective cohort study using Marketscan (Truven Health Analytics, Inc, Ann Arbor, MI), a nationwide insurance claims database. From January 2004 through September 2015, patients with a primary diagnosis of diverticular bleeding who underwent inpatient colonoscopy were included. We used propensity score matching to account for differences between recipients of early vs delayed colonoscopy. Multivariable logistic regression was performed to determine the association between early colonoscopy and rebleeding or hospital re-admission within 30 days of discharge. In total, 20,010 patients underwent colonoscopy for diverticular bleeding; 11,690 underwent early colonoscopy. After propensity matching, 8320 pairs of patients were analyzed. In thematched analysis, higher proportions of patients who received early colonoscopy underwent additional colonoscopies (73%), compared with patients who did not receive early colonoscopy (4%) (P < .0001), but lower proportions received endoscopic interventions (3% vs 8%; P < .0001). On multivariable analysis, early colonoscopy (odds ratio [OR], 1.34; 95% CI, 1.08-1.66; P= .007), transfusion requirement (OR, 2.31; 95% CI, 1.88-2.83; P < .0001), and baseline chronic kidney disease (OR, 2.13; 95% CI, 1.49-3.04; P < .0001) were associated with increased risk of rebleeding within 30 days. Early colonoscopy (OR, 1.18; 95% CI, 1.02-1.36; P= .03), endoscopic intervention (OR, 1.37; 95% CI, 1.03-1.81; P= .03), transfusion requirement (OR, 2.17; 95% CI, 1.88-2.51; P < .0001), coronary artery disease (OR, 1.27; 95% CI, 1.06-1.51; P= .009), and chronic kidney disease (OR, 1.98; 95% CI, 1.54-2.54; P < .0001) were associated with increased re-admission to the hospital within 30 days. In a propensity-matched analysis, we associated early colonoscopy with increased risk of rebleeding events and hospital re-admissions. However, these observations might be due to confounding factors.

Does Everyone Need Early Colonoscopy? Select Group of Patients Might Benefit From Early Screening for Colorectal Cancer - An Update

Does Everyone Need Early Colonoscopy? Select Group of Patients Might Benefit From Early Screening for Colorectal Cancer - An Update

Is Adenoma Detection Rate Still the Quality Indicator for Screening Colonoscopy in Younger Patients?

Introduction: Recent guidelines from the American Cancer Society (ACS) recommend to start colon cancer screening at 45 years in average-risk patient population. Previously, it has been established that patients with family history (FH) of colorectal cancer (CRC) at any age should undergo screening at age 40 years. Despite these guidelines, data on the prevalence of adenomas in these patients is scant. We aimed to examine and compare the prevalence of adenomas in 40 to 49-year-old individuals undergoing colonoscopy because of FH of CRC of a first-degree relative (FDR) with CRC versus patients without any family history of CRC. Methods: A retrospective cross sectional study was performed using our electronic endoscopy database. Study subjects (cases) included all 40-49-year-old patients undergoing their index colonoscopy for diagnostic purposes (abdominal pain, diarrhea, weight loss, altered bowel habits, etc) at our center from January 2010 to September 2017. The control group consisted of all 40-49-year-old patients undergoing their index screening colonoscopy for a FDR with CRC. Exclusion criteria included patients who underwent colonoscopy for overt gastrointestinal bleeding, inflammatory bowel disease, patients who had previous colonoscopies, a history of familial adenomatous polyposis, hereditary non polyposis CRC. Results: A total of 2059 patients were included in the study. Mean age of these patients was 44.7 years, and 59.8% were males. Number of patients in the control group were 355, and number in study group was 1704. The adenoma detection rate (ADR) was 27.8% in the control group, and 19.7% (p=0.001) in the study group. The rate of neoplasia detected was 2.2% in patients with FH of CRC, and 1.3% in patients without FH of CRC (p=0.18). Conclusion: The ADR in average-risk 40-49 year old patients is less than the current recommended ADR in patients with average risk undergoing their screening colonoscopy at 50 years of age (i.e. 25%). However, the rate of neoplasia detected was comparable. This suggests that although early colonoscopy is beneficial in detecting CRC, but further studies are needed to look for factors beyond the traditional adenoma-carcinoma pathway in younger individuals. With the advent of the latest ACS guidelines, new quality benchmark for ADR will need to be established in average risk patients younger than 50 years of age undergoing screening colonoscopy. Future large multi-center prospective studies are needed to confirm this finding.225_A Figure 1 No Caption available.225_B Figure 2 No Caption available.

Colorectal cancer in young African Americans: clinical characteristics and presentations

Colorectal cancer (CRC) is the third most common cancer in the USA, and the incidence in young adults has been increasing over the past decade. We studied the clinical characteristics and presentations of CRC in young African American (AA) adults because available data on how age and ethnicity influence its pattern of presentation is limited. We conducted a retrospective study of 109 young adults (75 African Americans) below 50 years, who were diagnosed with CRC between 1 January 1997 and 31 December 2016. Proximal CRC was defined as lesions proximal to the splenic flexure. Independent t-tests and χ-test or Fisher's exact test were performed where appropriate to determine the differences between AA and non-AA patients. The mean age at diagnosis was 42 years (range: 20-49 years). Compared with non-AAs, AAs had more frequent proximal CRC (38.7 vs. 14.7%, P=0.003), lower hemoglobin (10.5 vs. 12.7 g/dl, P<0.001), and more frequent weight loss (21.3 vs. 2.9% P=0.014). Non-AAs presented more frequently with rectal bleeding (52.9 vs. 32.0% P=0.037). There was no statistically significant difference in histology, stage, grade, tumor size, and carcinoembryonic antigen level between groups. When we stratified between proximal and distal disease among patients with CRC, we found larger tumor size in distal disease, which presented more with rectal bleeding and bowel habit changes. Proximal disease presented more as abdominal pain and weight loss. There should be a higher index of suspicion for CRC in young AA adults presenting with anemia, abdominal pain, and weight loss. Early screening colonoscopy should be advocated in AAs because of the predominance of proximal disease.