1. Flexible Sigmoidoscopy And Whole Colon Imaging In The Diagnosis Of Cancer In Patients With Colorectal Symptoms Peter O’Leary Journal Club 13/10/08

2. Aims • Identify patients with colorectal symptoms most likely to benefit from Whole Colon Imaging (WCI) to diagnose colorectal cancer • Identify patients for whom flexible sigmoidoscopy may be sufficient initially

3. Methods • Prospective observational study • 3 Hospitals • 17,271 new referrals • Between 1986 and 2001 • Most patients examined with flexible sigmoidoscopy alone or followed by barium enema, colonoscopy or CT colongraphy

4. Methods • A cancer was defined as missed if • Not detected at initial examination in the colorectal outpatient clinic or after referral for WCI, but was diagnosed within 3 years • Cancers diagnosed using flexible sigmoidoscopy were defined as distal • Cancers not diagnosed with fs but diagnosed with WCI were defined as proximal

5. Methods • Outcome variable was detection of proximal or distal cancer • Other variables collected • Sex, age group (under/over 60 years of age) • Presence/absence of suspicious bowel symptoms • Rectal bleeding • Change in bowel habit • Abdominal pain • Weight loss • Fe deficiency anaemia • Abdominal mass

6. Results • 17,271 new referrals • 838 referrals were excluded • 100 diagnosed at another clinic • 738 had DRE and no further investigation • Remaining 16,433 referrals • 969 patients had multiple referrals • 881 had 2 referrals • 76 had 3 referrals • 11 had 4 referrals • 1 had 5 referrals • Median age of referrals was 61 • 56% of referrals were female • 94.1% of referrals presented with one or more suspicious bowel symptoms outlined • The remaining referrals were for a variety of reasons including positive family history, anal symptoms and incontinence

7. Results

8. Results

9. Discussion • Patients with Fe deficiency anaemia together with an abdominal mass, have a high (15.6%) chance of having a proximal colonic cancer • This group constituted only 3.7% of all patients in this study • By contrast, 96.3% of all patients referred with rectal bleeding, altered bowel habit or abdominal pain without Fe def anaemia or abdominal mass had a 0.2% chance of having a proximal colonic cancer • 24 colorectal cancers were missed from a total of 946 cancers diagnosed • 1.3% miss rate for flexi sigmoidoscopy • 14% miss rate for double contrast barium enema • 0.6% miss rate for colonoscopy • In conclusion, a patient who presents without fe def anaemia, abdominal mass or severe symptoms and has had a normal flexible sigmoidoscopy - ‘treat, wait and watch’ approach is appropriate