Flexible sigmoidoscopy: an archaic tool for 40 – 50-year-old patients with fresh bleeding per rectum

We read with great interest the article by Khalid et al. [1] who reported an incidence of 7.6 % of adenomatous polyps and malignant lesions in 40 – 50-year-old patients with fresh bleeding per rectum undergoing full colonoscopic examination. Interestingly, 10 % of the lesions were located in the proximal colon. In patients younger than 40 years, adenomatous polyps or malignant lesions were found in 2.8 % of cases, and all were located in the distal colon. Therefore, their conclusions suggest that flexible sigmoidoscopy could be a reasonable evaluation tool in patients aged less than 40 years who have no alarm symptoms other than fresh bleeding per rectum. However, no recommendations are made in the article for 40 – 50-year-old patients.

Their findings are an important contribution to the discussion on the use of flexible sigmoidoscopy as a screening modality in 40 – 50-year-old patients with fresh bleeding per rectum who are referred for full colonoscopy. A prospective study in 10 French endoscopy units involving 2000 patients undergoing colonoscopy was conducted in order to define quality-control indicators for colonoscopy procedures [2]. Of the 2000 procedures, 30 % were carried out at general hospitals, 20 % at university hospitals, and 50 % in private practices. Among 40 – 50-year-old patients, 72 underwent colonoscopy due to fresh bleeding per rectum; 21 % of these patients had adenomatous polyps or malignant lesions. Lesions were located in the proximal colon in 47 % of cases. Our findings are consistent with those of other studies [3] [4] [5].

In the Khalid et al. study, the incidence of colorectal carcinoma (CRC) was 3.8 % compared with 1.4 % in our study. This confirms that CRC is diagnosed at a younger age in South Asian individuals than in their Caucasian counterparts [6]. As a consequence, some European countries, including France, have developed CRC screening programs for patients over 50 years. As there are no screening programs for patients under 50 years, French guidelines recommend full colonoscopic examination for patients under 50 years who present with fresh bleeding per rectum [7]. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) recommends sigmoidoscopy in healthy patients under 40 years with a benign source of bleeding such as hemorrhoids or anal fissures and colonoscopy in patients over 50 years of age [8]. No specific recommendation has been made for 40–50-year-old patients with fresh bleeding per rectum.

Fresh bleeding per rectum has always been considered an alarm symptom for possible organic pathology in the colon. Furthermore, improvement in rates of CRC survival is directly related to early diagnosis. With this in mind, we consider that full colonoscopy should be systematically performed in 40–50-year-old patients reporting fresh bleeding per rectum.

References

• 1 Khalid A B, Majid S, Salih M et al. Is full colonoscopic examination necessary in young patients with fresh bleeding per rectum?.  Endoscopy. 2011;  43 692-696
• 2 Coriat R, Lecler A, Cassaz C et al. Évaluation des pratiques professionnelles en endoscopie: étude multicentrique de faisabilité d’une méthode simple et reproductible d’évaluation de la qualité de la coloscopie dans des structures privées et publiques.  Gastroenterol Clin Biol. 2009;  33 175
• 3 Lieberman D A, Weiss D G, Bond J H et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.  New Engl J Med. 2000;  343 162-168
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• 8 Davila R E, Rajan E, Adler D G et al. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding.  Gastrointest Endosc. 2005;  62 656-660