Normal Flexible Sigmoidoscopy Research Articles

Randomized controlled trial: Flexible sigmoidoscopy as an adjunct to faecal occult blood testing in population screening.

Flexible sigmoidoscopy screening at around age 60 can reduce colorectal cancer incidence. Insufficient evidence exists on flexible sigmoidoscopy at age 60 in a population being offered biennial faecal occult blood test screening from age 50. This randomized controlled trial assessed if flexible sigmoidoscopy would be an effective adjunct to faecal occult blood test. In the Scottish Bowel Screening Programme between June 2014 and December 2015, 51,769 individuals were randomized to be offered flexible sigmoidoscopy instead of faecal occult blood test at age 60 or to continue faecal occult blood test. Those not accepting flexible sigmoidoscopy and those with normal flexible sigmoidoscopy were offered faecal occult blood test. All with flexible sigmoidoscopy-detected neoplasia or a positive faecal occult blood test result were offered colonoscopy. Overall flexible sigmoidoscopy uptake was 17.8%, higher in men than women, and decreased with increasing deprivation (25.7% in the least to 9.2% in the most deprived quintile). In those who underwent flexible sigmoidoscopy, detection rate for colorectal cancer was 0.13%, for adenoma 7.27%, and for total neoplasia 7.40%. In those who underwent colonoscopy after a positive flexible sigmoidoscopy, detection rate for colorectal cancer was 0.28%, adenoma 8.66%, and total neoplasia 8.83%. On an intention to screen basis, there was no difference in colorectal cancer detection rate between the study and control groups. Adenoma and total neoplasia detection rate were significantly higher in the study group, with odds ratios of 5.95 (95%CI: 4.69-7.56) and 5.10 (95%CI: 4.09-6.35), respectively. In a single screening round at age 60, there was low uptake and neoplasia detection rate. Flexible sigmoidoscopy detected significantly more neoplasia than faecal occult blood test alone.

1092P - Patterns of steroid use in diarrhoea and/or colitis (D/C) from immune checkpoint inhibitors (ICPI)

D/C is reported in up to 30% of patients treated with ICPI. Treatment algorithms advocate corticosteroids (CS) for moderate to severe symptoms. Patterns of endoscopic change and duration of CS are not described. Rates of CS toxicity in this group of patients are unclear. Medical records of melanoma patients treated with ICPI at the Royal Marsden Hospital from 2010-2015 were reviewed. The grade, duration of CS and infliximab (INF) use was recorded for each D/C episode. Patients who had flexible sigmoidoscopy (FS) were labeled as having macroscopic + /-microscopic (macro), microscopic (micro) changes alone or no changes (normal). CS toxicities were noted. 414 ICPI treatment episodes were undertaken in 353 patients. The rate of all-grade D/C was 23% (96/414): 27% (77/282) with ipilimumab, 8% (8/101) with anti-PD-1 agents and 38% (8/21) with combination ipilimumab + nivolumab. Median age 61 years, 54% were male.Tabled 1Steroid use by Flexible Sigmoidoscopy FindingsNReceived CS (%)No CSMedian CS duration days (range)UNK re CS durationOn CS at 3mths (%)UNK re CS at 3mths (%)INF (%)Median days CS to INF (range)Macro2724 (89)369 (5-278)410 (42)4 (15)8 (33)15 (6-60)Micro87 (88)151 (12-162)02 (29)00naNormal FS98 (89)140 (7-156)01 (13)02 (25)11 (2-20)Unknown65 (8)167 (36-91)11 (20)01 (20)9 Open table in a new tab 57% (55/96) required CS. 52% (50/96) underwent FS: 88% (44/50) received CS. Median duration of CS was higher in macro patients compared to a normal FS (69 vs 40 days; p = 0.07) and in micro patients compared to a normal FS (51 vs 40 days; p = 0.32; Table 1). 11% (11/96) of D/C was treated with INF and median CS duration in this population was 91 days, versus 52 days for those who received CS alone. Median time from first steroid to INF was 15 days (range 2-60). 25% (14/55) were on steroids at 3 months. At least 15% (8/55) developed new or worse diabetes, 13% (7/55) had mood change and 16% (9/55) developed an antibiotic-requiring infection. We describe different phenotypes of D/C associated with ICPI therapy. Appearances at FS may predict for duration of CS use. All patients should be monitored for stigmata of CS use and considered for PJP prophylaxis. CS sparing strategies should be prospectively evaluated.

PTH-294 Missed diagnosis of bowel cancer in surgical outpatients – to refer or not to refer for whole colonic imaging? a 22-year study of 29005 patients: Abstract PTH-294 Table 1

Introduction Little is known about the rates or reasons for missing diagnosis of bowel cancer in outpatients. This study determined the number of missed cancers by flexible sigmoidoscopy (FS), barium enema (BE), colonoscopy, CT colonography (CT) and in patients not having whole colonic imaging (WCI) after a normal FS. Method Retrospective cohort analysis using clinical data collected prospectively for 22 years (1986–2007) in a colorectal outpatient clinic in Portsmouth. 29005 patients were analysed. Missed cancers were detected by referral back to clinic, local audit for NBOCAP and comparison with the regional Cancer Registry. Results 1626 patients had bowel cancer. 66.1% (19174/29005) of all patients in the study did not have WCI. 13.8% (3993) had colonoscopy, 17.9% (5206) had BE and 883 (latter 8 years) had CT. 3.9% (63/1626) of cancers were missed; 21 distal (rectum and sigmoid), 41 proximal and 1 unknown site. 1.6% (21/1333) or 1:63 of distal cancers were missed by FS. Twenty-one of all missed cancers were subsequently diagnosed within 1 year (50–358 days) of the outpatient clinic, twenty within 1–2 years and twenty-two between 2–3 years. Twenty-two proximal cancers were subsequently diagnosed with cancer after a normal FS and no WCI, which means the incidence of cancer in this group of patients was 0.1% (22/18252). View this table: Abstract PTH-294 Table 1 Conclusion A policy of outpatient FS with selective WCI resulted in a low rate of missed cancers. The replacement of BE by Colonoscopy and CT should greatly reduce the numbers of missed cancers in those having WCI. Strict diagnostic strategies are required to avoid excessive delay in diagnosis of the few with cancer without over investigation of patients with transient symptoms from benign disease. Disclosure of interest None Declared.

PTH-295 Diagnosis of bowel cancer; most patients don’t require whole colonic imaging (WCI); are nice guidelines misleading?: Abstract PTH-295 Table 1

Introduction NICE guidelines imply that most patients require WCI for bowel cancer diagnosis. This and fear of missing cancer in outpatients is the major reason for over investigation of patients with bowel symptoms. Greater understanding of the way proximal bowel cancer presents is required. Method Retrospective cohort analysis using clinical data collected prospectively for 22 years (1986 to 2007) in a colorectal outpatient clinic in Portsmouth. 29005 patients were analysed to determine symptom combinations, signs and IDA according to site of the colon. Missed cancers were identified from referral back to clinic, local audit and comparison with the regional Cancer Registry. Results 1626 patients had cancer of which 1585 presented with one of three bowel symptoms (change in bowel habit, rectal bleeding or abdominal pain). Only 16% (258/1585) were cancers proximal to the sigmoid colon, of which 44% (113/258) presented with symptoms alone (no IDA, no mass), 223 (113/25191) patients would need WCI to diagnose one proximal cancer in this group. Diagnostic yield of proximal cancer in patients <60 years without a mass or IDA was 0.09% (11/11828). View this table: Abstract PTH-295 Table 1 Conclusion Patients without mandatory reasons for immediate WCI after a normal flexible sigmoidoscopy (particularly those aged <60 years) should be offered a treat watch and wait diagnostic strategy rather than immediate WCI. NICE guidelines may be encouraging over investigation of patients by WCI. Disclosure of interest None Declared.

PWE-054 Flexible Sigmoidoscopy Prior To Ctc Within The Bcsp

IntroductionPatients with abnormal FOBt results within the Bowel Cancer Screening Programme (BCSP) are at increased risk of colorectal neoplasia and are therefore offered colonoscopy. Some patients, with significant co-morbidities, are...

PTH-136 Faecal Calprotectin - Is it Requested Appropriately and is it Cost Effective?

IntroductionFaecal calprotectin is a neutrophil derived protein that can be detected by quantitative enzyme linked immunosorbant assay in stool samples. It reliably predicts the level of mucosal inflammation in the...

PTH-017 Strategy for Colorectal Cancer (CRC) Screening in Individuals with Significant Co-Morbid Conditions

IntroductionWith the advent of the Bowel cancer screening programme (BCSP) in the UK participants who have positive FOB tests are generally offered optical colonoscopy (OC) if considered safe, for early...

PTU-030 Clostridium Difficile Associated Diarrhea (CDAD) in Hospitalized Patients – does Flexible Sigmoidoscopy (FS) Alter Management?

IntroductionClostridium difficile (CD) colitis is a major complication of antibiotic therapy. The most widely used test for diagnosing C. difficile colitis is a test that detects toxins produced by CD...

Screening for Colorectal Cancer with Flexible Sigmoidoscopy: Is a 5-Yr Interval Appropriate? A Comparison of the Detection of Neoplasia 3 Yr versus 5 Yr After a Normal Examination

The recommended interval for colorectal cancer screening with flexible sigmoidoscopy (FS) was recently lengthened from 3 to 5 yr. Direct evidence supporting the longer interval is lacking. The appropriateness of the longer interval has been questioned. To compare the incidence of neoplasia detected on FS in individuals who had undergone an FS either 3 yr or 5 yr after a normal examination. Subjects were drawn from 5,359 individuals who underwent two FS examinations performed for colorectal cancer screening. Examinations were performed by gastroenterologists at a single academic medical center between 1987 and 2002. A total of 2,146 subjects with a normal baseline examination and a follow-up examination 3 and 5 yr later was included. To compare the incidence of neoplasia, including advanced neoplasia, detected 3 yr versus 5 yr after a normal FS. 915 subjects underwent FS at 3 yr and 1,231 subjects at 5 yr after a normal examination. Neoplasia was detected in 3.2% of the 3-yr and 4.3% of the 5-yr subjects (p=0.17). No significant differences were detected in the pathology, multiplicity, or size of neoplasms between the 3- and 5-yr groups. Advanced neoplasms occurred in 0.9% (including one adenocarcinoma) of subjects at 3 yr and 1.1% of subjects at 5 yr (p=0.67). Few individuals will develop rectosigmoid neoplasms 3 or 5 yr after a normal FS. The majority of neoplasms detected are low-risk lesions. A screening interval of 5 yr after a normal FS does not portend an increased risk of advanced neoplasms including cancer. This direct evidence supports the current recommendations of a 5-yr interval for colorectal cancer screening with FS.

Predictive value of diminutive colonic adenoma trial: The PREDICT trial

Background & Aims: Diminutive adenomas (1-9 mm in diameter) are frequently found during colon cancer screening with flexible sigmoidoscopy (FS). This trial assessed the predictive value of these diminutive adenomas for advanced adenomas in the proximal colon. Methods: In a multicenter, prospective cohort trial, we matched 200 patients with normal FS and 200 patients with diminutive adenomas on FS for age and gender. All patients underwent colonoscopy. The presence of advanced adenomas (adenoma ≥ 10 mm in diameter, villous adenoma, adenoma with high grade dysplasia, and colon cancer) and adenomas (any size) was recorded. Before colonoscopy, patients completed questionnaires about risk factors for adenomas. Results: The prevalence of advanced adenomas in the proximal colon was similar in patients with diminutive adenomas and patients with normal FS (6% vs. 5.5%, respectively) (relative risk, 1.1; 95% confidence interval [CI], 0.5-2.6). Diminutive adenomas on FS did not accurately predict advanced adenomas in the proximal colon: sensitivity, 52% (95% CI, 32%-72%); specificity, 50% (95% CI, 49%-51%); positive predictive value, 6% (95% CI, 4%-8%); and negative predictive value, 95% (95% CI, 92%-97%). Male gender (odds ratio, 1.63; 95% CI, 1.01-2.61) was associated with an increased risk of proximal colon adenomas. Conclusions: Diminutive adenomas on sigmiodoscopy may not accurately predict advanced adenomas in the proximal colon.

Glutaraldehyde as a possible cause of diarrhoea after sigmoidoscopy.

An outbreak of proctitis at the start of a colorectal cancer screening programme utilizing flexible sigmoidoscopy prompted scrutiny of the incidence of this complication and the role of glutaraldehyde in its aetiology. Questionnaires completed 1 day and 3 months after sigmoidoscopy were reviewed for 388 patients, and glutaraldehyde levels in the recycled rinse water of the endoscope washing machine were measured. The incidence of symptoms in the subsequent 612 patients after installation of a washer that does not recycle rinse water was examined. Five patients (1.3 per cent) presented to hospital with bloody diarrhoea occurring immediately after a normal flexible sigmoidoscopy. Repeat examination confirmed the presence of proctitis. Symptoms subsided rapidly with either no treatment or steroid enemas. Eight additional patients (2.1 per cent) recorded similar problems but received no treatment and the symptoms settled spontaneously. Glutaraldehyde levels rose progressively in the rinse water after each wash cycle with 2 per cent glutaraldehyde solution. Only one possible case of proctitis (0.2 per cent) was identified from the questionnaires completed by 612 patients after changing to a washer that did not recycle the rinse water. These observations should prompt the careful assessment of cleaning techniques. The use of washing machines that do not recycle rinse water may avoid this complication.

3641 THE PREDICT TRIAL: PREDICTIVE VALUE OF DIMINUTIVE COLONIC ADENOMA TRIAL- INTERIM RESULTS.

BACKGROUND/AIMS: Amoung patients with diminutive (1-9 mm in diameter) adenomatous polyps (DAP) found during flexible sigmoidoscopy (FS), the likelihood of identifying advanced adenomas (i.e., adenomas ≥ one cm in diameter, tubulo-villous or villous adenomas, and adenomas with high grade dysplasia) in the proximal colon is uncertain. Our aims: (1) quantify the relative risk of advanced adenomas in the proximal colon in patients with diminutive adenomas on FS compared to control patients with normal FS; and (2) quantify the risk of finding any adenoma (diminutive or advanced) in the proximal colon in patients with diminutive adenomas on FS compared to control patients with normal FS. METHODS: Inclusion criteria: Consecutive patients with diminutive adenomas on FS and consecutive patients with normal FS were offered screening colonoscopy. Exclusion Criteria: Iron deficiency anemia; occult gastrointestinal bleeding; hematochezia; colonoscopy/barium enema in the past 10 years or normal FS within the past 3 years. Prior to colonoscopy, all patients completed screening CBC and screening FOBT. To insure accurate measurement of polyp diameter, colonoscopic measuring guidewires were used to measure polyp diamter in vivo. DATA ANALYSIS: Relative risk and 95% confidence intervals for the presence of advanced adenoma in the proximal colon and for the presence of any adenomas in the proximal colon were calculated using chi-square analysis with standard software (META-ANAL, McMaster University, Hamiltion, Ontario. RESULTS: 186 patients with normal FS and 190 patients with DAP on FS completed the trial. 5.4% of patients with normal FS (10/186) and 5.8% (11/190) of patients with DAP on FS had advanced adenomas. 22% (40/186) of patients with normal FS and 36% (68/190) of patients with DAP on FS had any size adenoma in the proximal colon. Relative risk for advanced adenoma in the proximal colon of patients with DAP: RR=1.08(95% CI:0.4 to 2.7);p=0.86). Relative risk for any adenoma in the proximal colon of patients with DAP:RR = 1.7(95%CI:1.2 to 2.4;p=0.003). CONCLUSION: Based on an interim analysis, these data suggest that patients with DAP on FS do not have an increased risk of advanced adenomas in the proximal colon compared to patients with normal FS. However, patients with DAP on FS may have an increased risk of any adenoma in the proximal colon compared to patients with normal FS.

Inclusion and exclusion criteria of importance in irritable bowel syndrome trials

Although numerous diseases may mimic or be confused with irritable bowel syndrome (IBS), a detailed and precise clinical history and a normal clinical examination usually lead to an accurate diagnosis of IBS. The presence of symptom criteria and the absence of warning signs must be established. Before entering a clinical trial, several routine tests are generally required: total blood count, erythrocyte sedimentation rate, biochemistry screen, stool culture and examination for occult blood, ova, and parasites, and a recent (<2 years) normal flexible sigmoidoscopy or colonoscopy with biopsy. Blood and stool tests are not necessary for the diagnosis of IBS but are important in the framework of controlled trials. Esophagogastroduodenoscopy, abdominal ultrasonography, and malabsorption tests are needed only in patients with atypical IBS or for phase II trials in certain subgroups of patients. Chronic diseases, drugs, and toxic agents that may mimic IBS symptoms or exacerbate the disorder must be excluded. Errors in patient inclusion will be minimized if the duration and severity of IBS symptoms before inclusion is sufficient and will have little effect on the result of the trial if the new drug is really effective and the study well randomized with a correct calculation of sample size.