Marderstein Eric L, Church James M
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Dis Colon Rectum. 2008 Feb;51(2):202-6. doi: 10.1007/s10350-007-9123-1. Epub 2008 Jan 3.
Full diagnostic colonoscopy often is performed to exclude significant pathology in patients presenting with rectal bleeding. In patients with classic "outlet" bleeding, defined as bright red blood after or during defecation, with no family history of colorectal neoplasia or change in bowel habits, we hypothesize that the diagnostic yield of complete colonoscopy will be low. The purpose of this study was to determine whether complete colonoscopy is necessary in the evaluation of patients with "outlet" rectal bleeding.
Information for all patients undergoing colonoscopy by a single endoscopist was prospectively recorded. Before each colonoscopy, a complete history, including indication for the examination, was obtained. Using standard definitions, patients with outlet bleeding, suspicious bleeding, hemorrhage, and occult bleeding were accessed and the findings of their colonoscopies were analyzed. Institutional permission was obtained.
A total of 9,098 patients had colonoscopy recorded in the database, and 703 had the indication of outlet bleeding, 251 suspicious bleeding, 204 occult bleeding, and 67 hemorrhage. Of the patients with outlet bleeding, only 47 (6.7 percent) had significant lesions on colonoscopy (adenomas >1 cm, villous adenomas, cancer in situ, or invasive cancer). By contrast a greater number of significant lesions were present in patients with all other types of bleeding (17.2 percent; P<0.001). The incidence of invasive cancer was significantly lower in the outlet bleeding group compared with other types of bleeding (1 vs. 3.6 percent; P<0.01). Patients with outlet bleeding were much less likely than patients with other bleeding to have isolated right-sided colonic pathology. Younger patients with outlet bleeding have a particularly low yield on colonoscopy. In 182 patients younger than aged 50 years with outlet bleeding, only 3 (1.6 percent) had adenomas >1 cm and no invasive cancers were detected.
In patients with classic outlet bleeding, the yield of a complete diagnostic colonoscopy is low. If the history is classic for outlet bleeding and no other indication for colonoscopy exists, flexible sigmoidoscopy is enough to exclude significant pathology.
对于出现直肠出血的患者，通常会进行全诊断性结肠镜检查以排除严重病变。对于有典型“出口处”出血（定义为排便后或排便时出现鲜红色血液，且无结直肠肿瘤家族史或排便习惯改变）的患者，我们推测全结肠镜检查的诊断阳性率会很低。本研究的目的是确定在评估“出口处”直肠出血患者时全结肠镜检查是否必要。
前瞻性记录由单一内镜医师进行结肠镜检查的所有患者的信息。在每次结肠镜检查前，获取完整病史，包括检查指征。采用标准定义，对出口处出血、可疑出血、出血和隐匿性出血患者进行评估，并分析其结肠镜检查结果。已获得机构许可。
数据库中共有9098例患者进行了结肠镜检查，其中703例有出口处出血指征，251例可疑出血，204例隐匿性出血，67例出血。在出口处出血的患者中，只有47例（6.7%）在结肠镜检查时有严重病变（腺瘤>1 cm、绒毛状腺瘤、原位癌或浸润性癌）。相比之下，所有其他类型出血的患者中存在更多严重病变（17.2%；P<0.001）。与其他类型出血相比，出口处出血组浸润性癌发生率显著更低（1%对3.6%；P<0.01）。出口处出血的患者比其他出血患者发生孤立性右侧结肠病变的可能性小得多。年龄较轻的出口处出血患者结肠镜检查阳性率特别低。在182例年龄小于50岁的出口处出血患者中，只有3例（1.6%）有>1 cm的腺瘤，未检测到浸润性癌。
对于有典型出口处出血的患者，全诊断性结肠镜检查的阳性率很低。如果病史为典型的出口处出血且不存在其他结肠镜检查指征，乙状结肠镜检查足以排除严重病变。
