Digestive Endoscopy
Endoscopic findings in the upper gastrointestinal tract of faecal occult blood-positive, colonoscopy-negative patients

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Abstract

Background

Detection of faecal occult blood is recommended for colorectal cancer screening in average risk populations. However, many subjects do not have any cause found in the colon to account for the occult blood loss.

Aims

To determine the prevalence of upper gastrointestinal tract disease in faecal occult blood-positive, colonoscopy-negative patients.

Patients and methods

Retrospective audit of 99 patients (56 females; mean age 60 years, range 18–83) who underwent same-day colonoscopy and upper gastrointestinal endoscopy over a 2-year period.

Results

Fifty-two of the 99 patients had a normal colonoscopy, 16 had diverticulosis and 2 had hyperplastic polyps; these 70 patients comprised the colonoscopy-negative group. Significant upper gastrointestinal tract disease was noted in 25 (36%) of the colonoscopy-negative group compared with 10 (34%) of the 29 colonoscopy-positive group (p = ns). Most of the upper gastrointestinal tract lesions identified were benign. Within the colonoscopy-negative group, patients with anaemia or upper gastrointestinal tract symptoms had a higher prevalence of positive findings in the upper gastrointestinal tract, but this association was not statistically significant.

Conclusions

Endoscopic examination of the upper gastrointestinal tract in faecal occult blood-positive individuals reveals mostly benign disease, with an equal prevalence in colonoscopy-negative and colonoscopy-positive patients. Routine performance of upper gastrointestinal endoscopy in faecal occult blood-positive individuals is not indicated and should be undertaken only for appropriate symptoms.

Introduction

Detection of faecal occult blood (FOB) by means of guaiac-based tests, followed by colonoscopy, is recommended for colorectal cancer screening in average risk populations [1]. However, approximately 60% of screened subjects do not have any cause found in the colon to account for the occult blood loss [2], [3]. There is no general consensus regarding the further management of these ‘FOB-positive, colonoscopy-negative’ individuals. Whilst false-positive FOBs may arise due to the peroxidase activity of ingested foods [4], it has also been demonstrated that small amounts of blood loss from the upper gastrointestinal tract (UGIT) can be detected by guaiac-based FOB tests [5]. Some previous studies have suggested that there is a high prevalence of UGIT pathology, including cancer, in FOB-positive, colonoscopy-negative individuals [6], [7], [8], [9]. However, as the upper gastrointestinal endoscopy (UGIE) was performed at variable or unspecified times after the colonoscopy in these studies, it is possible that the UGIT pathology may have changed in the time between the two endoscopic procedures. Same-day UGIE and colonoscopy, referred to as ‘bi-directional endoscopy’, would overcome this problem. We have reviewed our own experience of bi-directional endoscopy in order to determine the prevalence of UGIT pathology in FOB-positive, colonoscopy-negative patients.

Section snippets

Methods

A retrospective audit was conducted of all patients who underwent same-day UGIE and colonoscopy in the endoscopy unit at our institution between January 2000 and December 2001. Patients were identified from the endoscopy record books; case notes and endoscopy reports were retrieved for data extraction. Information was collected on FOB status, blood haemoglobin level, symptoms, medication (aspirin, non-steroidal anti-inflammatory drugs [NSAIDs], anticoagulants) and the endoscopic findings. The

Results

A total of 292 patients were identified who underwent bi-directional endoscopy during the 2-year study period. Of these, 193 patients were excluded: 94 – FOB status not recorded, 59 – negative FOB test, 28 – incomplete colonoscopy, 12 – acute gastrointestinal haemorrhage or known pathology to account for a positive FOB. The demographic details, including primary indications for colonoscopy, of the remaining 99 patients are shown in Table 1.

The colonoscopy findings are shown in Table 2. The

Discussion

The management of FOB-positive, colonoscopy-negative individuals poses a clinical dilemma; it is uncertain how extensively these subjects should be investigated in order to identify a cause for the occult blood loss. We found that approximately two-thirds of our FOB-positive patients had no colonic source of blood loss identified, a similar proportion to that reported from previous studies [2], [3]. Endoscopic examination of the UGIT revealed significant pathology in approximately one-third of

References (17)

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