Consider colonoscopy for young patients with hematochezia
- Nearly 12% of younger patients reporting rectal bleeding in this study had colon adenomas or cancer; thus, strong consideration should be given to colonoscopy in such individuals.
- Colonoscopy is a valuable diagnostic test and can help establish the source of rectal bleeding in nearly 80% of younger patients.
Background Hematochezia is a common complaint in adult patients aged <50 years. Most studies of lower endoscopy for rectal bleeding have concentrated on older patients or have failed to mention the location of lesions.
Objective To determine the findings of complete colonoscopy in adults younger than 50 years with rectal bleeding.
Methods Data were retrieved from medical records and included demographics, indications, endoscopic findings, and histology. Lesions were labeled according to location: proximal to the splenic flexure or distal to (and including) the splenic flexure. Excluded were those with a history of colitis, colorectal cancer, polyps, anemia, significant weight loss, severe bleeding, or strong family history of colorectal cancer.
Results The study included 223 patients with rectal bleeding aged <50 years who had undergone a colonoscopy. Normal findings were recorded for 48 (21.5%). Four (1.8%) were diagnosed with cancer in the distal colon, and 22 (9.9%) were found to have colon adenomas, 6 of whom had proximal adenomas only. Hemorrhoids were present in 135 patients (60.5%). Other findings included colitis, angiodysplasia, diverticulosis, anal fissures, and rectal ulcers.
Conclusions Colon neoplasms may be present even in younger adults with non-urgent rectal bleeding. Though most findings were benign and located in the distal colon, colonoscopy should be strongly considered for this patient group.
The role of colonoscopy is well established for patients aged more than 50 years with positive results on the fecal occult blood test. 1-3 For this population, colonoscopy has beenshown to reduce mortality from colorectal cancer, the second leading cause of cancer-related death in the United States. Colonoscopy has also been useful for diagnosing and treating lower gastrointestinal (GI) bleeding in older persons. 4-10
Some investigators have suggested the entire colon should be visualized in all patients with rectal bleeding. 4-11 Use of investigative colonoscopy has increased dramatically in recent years, particularly for younger patients, while use of sigmoidoscopy has declined. 12
Most of the literature on the investigation of rectal bleeding does not stratify patients by age. 4-8,13-23 Hence, there is no consensus on the proper evaluation of younger adults with rectal bleeding. The literature generally favors colonoscopy over sigmoidoscopy. But for adults aged younger than 50 years, data are sparse.
Rectal bleeding is common among younger patients
In a survey of patients aged 20 to 40 years, a history of rectal bleeding was reported in nearly 20%. 24 The concern with rectal bleeding is that it may indicate potentially serious disease, including colorectal cancer.
Deciding whether to subject a younger adult with non-urgent rectal bleeding to full colonoscopy can be difficult. A valid concern is that the incidence of colon neoplasms may be too low in younger adults to justify the widespread and costly use of colonoscopy. Colonoscopy has a small but finite risk of complications and imposes higher costs, greater discomfort, and more inconvenience for the patient than flexible sigmoidoscopy. On the other hand, the possibility of missing a neoplasm cannot be discounted.
The aim of this study was to review the diagnostic findings of colonoscopy in adults younger than 50 years who had non-urgent rectal bleeding (without alarm symptoms or signs).
Methods
Patients
We included all consecutive patients younger than 50 years who underwent colonoscopy for rectal bleeding at the University of Utah Medical Center or Salt Lake City Veterans Administration Medical Center between March 1997 and November 1999. Rectal bleeding was defined as the passage of bright blood on or within the stool, onto toilet paper, or into the toilet bowl. Patients were excluded if they had a history of colitis, colorectal cancer or polyps, severe bleeding requiring transfusion or hospitalization, unexplained weight loss greater than 5 pounds, iron-deficiency anemia, or a strong family history of colorectal cancer (at least 2 first-degree family members with colorectal cancer or 1 first-degree relative with colorectal cancer before the age of 50 years).
Data collection
Data were collected from medical records retrospectively. Patient demographics, indications for colonoscopy, endoscopic findings, and histology were retrieved.
Endoscopy
Gastroenterology faculty, or fellows under close supervision by the faculty, performed all endoscopic examinations. Informed written consent was obtained from each patient before every procedure. All endoscopic abnormalities were noted and biopsied if indicated, and all polyps were biopsied and removed. The distal colon was defined as that portion from the rectum through the splenic flexure.
