Comparison of CT Colonoscopy and Conventional Colonoscopy in Patients with Lower Gastrointestinal Tract Symptoms
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Abstract:
To estimate the accuracy of CT colonoscopy in patients with lower GI symptoms who have been referred to the department of radiology from the department of gastroenterology at Sree balaji medical college and hospital, Chennai. To compare the findings obtained from CT colonoscopy with conventional colonoscopy and provide better understanding about the use of CT colonoscopy in regular practice and determine the utility, advantages and limitations of virtual colonoscopy in detection and diagnosis of colonic pathologies. In our study CT colonoscopy 80 % sensitivity of detecting hemorrhoids which was lesser compared to that of conventional colonoscopy. CT colonoscopy detected that 38% of the patients had extra colonic findings of whichthe predominant finding was renal calculi. Patient acceptability was better in our study and there was no need for sedation and analgesics.Cite
INTRODUCTION:
Colorectal cancer (CRC) is the fourth most common cancer in men and the third most common in women, with mortality paralleling incidence, in the mid-1970s, approximately 60 cases of colorectal cancer were diagnosed per 100,000 people in the United States, and approximately 51% of those diagnosed survived their disease at least five years. Over the last two decades, incidence rates have fallen by nearly 26% between 1984 and 2004. This decline is likely due to increased colorectal cancer screening, which allows physicians to detect and remove colorectal polyps before they progress to cancer. United States Preventive Services Task Force (USPSTF) recommended screening for CRC should be performed in all persons aged 50 years and older. Yet, incidence is still high: colorectal cancer is the third most commonly diagnosed cancer for both men and women. As of 2004, approximately 48 cases of colorectal cancer were diagnosed per 100,000 people in the United States. About 65% of men and women diagnosed with colorectal cancer now survive their disease at least five years. American Cancer Society recommended the following screening tool for CRC, which includes fecal occult blood test (FOBT) annually, flexible sigmoidoscopy every 5 years as an option, colonoscopy as an option every 10 years, double contrast barium enema recommended every 5 years as an option. Colonoscopy is the gold-standard for evaluation of colonic pathology, but in certain situation where colonoscopy is not possible or incomplete due to procedural pain, colonic stenosis; elongated colon may be found in up to 26% of patients. Thus there has been a need to develop alternative diagnostic procedure to visualize large bowel.
Currently available modalities like Barium enema, which has following drawbacks like 1)
Highly subjective, 2) Bowel loop superimposed with one another without cross sectional image
to see the small lesions, 3) Risk of ionizing radiation.
CT Colonography is another alternative but it carries the risk of excessive ionizing radiation and
contrast exposure. MR Colonography (MRC) is technically similar to CT Colonography with
few advantages.
In recent years major technologic advances in diagnostic MRI have led to improve image quality
particularly with the use of Fast sequence and surface coil. Positive contrast like water/saline can
be used to distend the colonic lumen; hence without radiation and contrast material we can study
the colon using this technique.5,6
Sixty patients with suspected colonic pathology were evaluated, thirty patients underwent
colonoscopy first then MRC, another thirty patients underwent MRC first which was followed by
colonoscopy. Findings in both modalities were compared to know the merits and demerits of
each modality.
AIMS AND OBJECTIVES:
1. To find out the merits and demerits of standard tool colonoscopy and newer modality Magnetic Resonance Colonography (MRC) in assessing the various colonic pathology.
2. To find out the Sensitivity, Specificity. Positive predictive value and Negative predictive value of MRC in comparison with standard tool Colonoscopy.
3. To find out the role of MRC in patients with obstructive type of colonic lesion were further scope passage was not possible.
MATERIALS AND METHODS:
This comparative study between Colonoscopy and MR Colonography was carried out in the Department of medical Gastroenterology and Radiology Department of Madras Medical College,
Chennai. This is the major referral tertiary care center available to the entire Tamilnadu, Pondicherry and neighboring states like Andhra Pradesh and Karnataka.
The study was carried between the February 2008 to January 2010. (24 months). Patients who are attending Medical Gastroenterology Department with clinical diagnosis highly suspicious of colorectal pathology were included in this study. Sixty patients were taken up for study and out of sixty patients thirty patients underwent colonoscopy first then subjected to MR Colonography and another thirty patients were subjected for MR Colonography first then followed by Colonoscopy.
Inclusion Criteria:
1. Patients with bleeding per rectum suggestive of colonic lesion rather than perianal problem like hemorrhoids or fissure.
2. Significant weight loss & Change in bowel habits with Positive FOBT.
3. Abnormal finding during rectal examination.
4. Patients with family history of Colorectal Cancer/ Polyposis with symptoms of bowel disease.
Exclusion criteria:
Patients with metal implants like Hip prosthesis, cardiac pacemaker and intracranial aneurismal coil were excluded from MR Colonography.
SUMMARY AND CONCLUSION:
This study includes total of sixty patients with a mean age of 47 years and the male female ratio of 2:1.
Among the clinical symptoms and abnormal finding on examination the most common symptom being bleeding per rectum seen in 31%, Growth rectum in 21% and suspected IBD-UC in 10% and the remaining 38% constitute all other presentation.
FOBT Positive in 25% of patients with suspected colorectal malignancy, clinically suspected TB abdomen in 11% of patients.
Colonoscopic assessment of the entire colon up to cecum/ileum was possible in forty two patients (70%) and in the remaining eighteen patients (30%) scope not passed up to cecum due to obstructing lesion in sixteen patients (27%) and the patients intolerance to procedure in two patients (3%) in my study.
Biopsy was taken from all patients with colorectal growth and inflammatory lesions, while doing colonoscopy. Biopsy taken from growth arising in Rectum, Sigmoid, and Transverse colon the yield rate was 100% and the Histopathology report (HPE) was Adenocarcinoma. Similarly Ascending colon growth biopsy revealed 100% positive for malignancy.
Biopsy from Suspected Ileocecal TB revealed caseating granulomas in 50% and non-specific inflammatory infiltrate in another 50% of patients.
Biopsy taken in patient with familial adenomatous polyposis showed adenomatous polyp (100%).
Biopsy is very important in planning the management which is possible only with colonoscopy
Out of eight patients with colorectal polyp, polypectomy done for five patients and the remaining
three patients did not report for polypectomy.
The obstructing type of lesions (27%) and poor patient tolerance (3%) accounts for 30%
incomplete study, where in the alternative modality MRC was helpful to evaluate rest of the colon.
Both colonoscopy and MRC detects lesion with same accuracy in thirty four patients (57%), colonoscopy detects lesions missed by MRC in twenty one patients (35%) and MRC detects the lesion missed by Colonoscopy in five patients (8%), because of non-passage of scope. (Fig - 5) Overall accuracy of Colonoscopy is 92% (both modality same accuracy in thirty four patients + colonoscopy scores over MRC in twenty one patients) in assessing colonic lesions. (Fig - 5) Overall accuracy of MRC is 65% (both modality same accuracy in thirty four patients + MRC detects lesion missed by colonoscopy in five patients) in accessing colonic lesion Extracolonic findings were detected by MRC in seven patients in addition to colonic lesions viz. Pelvic nodes, Liver metastasis, Gall stones. Left Renal calculi and Left sided Hydrouretonephrosis.
Statistically while comparing the MRC with standard tool Colonoscopy the Sensitivity - 53%, Specificity – 67%, Positive predictive value – 83% and Negative predictive value – 32% and the p-value is also not significant (>0.05), suggesting MRC is only an alternate modality if colonoscopy is not possible.
In future 3 Tesla MRI with advanced software may play an important role in evaluation of colonic lesions especially for screening Polyposis and Colorectal cancer but still colonoscopy will be needed for tissue diagnosis.
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<p><strong>Aim</strong> <br />To evaluate the pattern of indications and a spectrum of colonic pathology, and to determine appropriateness of indications for colonoscopy in order to improve patient selection for colonoscopy.<br /><strong>Methods <br /></strong>This retrospective study includes 294 patients who were referred to the Gastroenterology Department from a primary care<br />physician in order to approach endoscopic examination. Study data included patients&rsquo; anamnestic data (comorbidities, positive family history, performed radiological examinations) an indication for the procedure, and colonoscopy findings.<br /><strong>Results</strong> <br />Haematochezia was confirmed in 186 (63.26%), positive radiologic finding in183 (62.24%) and anaemia in 157 (53.40%)<br />patients. Adenoma and colorectal carcinoma were detected in 40 (13.6%) and 53 (18%) patients, respectively. A significant association between haematochezia and colorectal neoplasm was confirmed (p=0.019), haematochezia and inflammatory bowel disease (p=0.027), and between radiological finding and colorectal neoplasm (p=0.018). There was no significant association between anaemia and any of the colonoscopic findings. According to EPAGE II criteria indications were appropriate in 187 (63.6%), uncertain in 67 (22.8%) and inappropriate in 40 (13.6%) patients.<br /><strong>Conclusion <br /></strong>This study confirmed a slightly larger number of uncertain and inappropriate indications for colonoscopy compared<br />to other studies that examined indications for colonoscopy, which can be attributed to a high number of patients with functional bowel disorders.&nbsp;</p>
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To compare virtual colonoscopy with optical colonoscopy findings in symptomatic patients.Computer tomographic colonography is an alternative to optical colonoscopy. Studies have shown that two-dimensional computer tomographic colonography does not have sufficient sensitivity. Three-dimensional computerized tomographic virtual colonoscopy compares well with optical colonoscopy for colorectal neoplasia screening in asymptomatic individuals.One hundred patients aged 50 and older underwent same day virtual colonoscopy and optical colonoscopy. The endoscopists were unaware of the radiologist's report until the withdrawal phase of the endoscopy when segmental unblinding occurred. The virtual colonoscopy and optical colonoscopy findings were compared by using the unblinded optical colonoscopy as the reference standard.Pancolonic endoluminal virtual colonoscopy was achieved in 99 patients. Optical colonoscopy caecal intubation occurred in 91 patients. Direct comparison was possible in 90 patients. Both techniques revealed the three cancers detected. Virtual colonoscopy revealed 11 polyps > or = 6 mm diameter in nine patients. Optical colonoscopy revealed 10 polyps > or = 6 mm diameter in nine patients with a further 15-mm polyp discovered after segmental unblinding.In symptomatic patients, three-dimensional virtual colonoscopy is equivalent to optical colonoscopy for diagnosing colon cancer and clinically significant polyps. A case can be made for three-dimensional virtual colonoscopy as a primary modality followed if necessary by same day-targeted optical colonoscopy.
Virtual colonoscopy
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OBJECTIVE To investigate in how many patients with bowel or abdominal complaints, referred by the primary care physician (PCP) for exclusion of colorectal carcinoma (CRC), the more invasive colonoscopy could be avoided on the basis of the findings of CT colonography. DESIGN Retrospective, descriptive. METHODS All consecutive patients who underwent CT colonography in our centre on the request of their PCP from December 2006 to June 2009 were included. Demographic and referral data were collected. CT colonography results were described according to the 'CT Colonography Reporting and Data System'. We also investigated how many patients had to undergo colonoscopy in the 6 months following CT colonography. RESULTS 398 patients (154 men and 244 women) with a median age of 61 years (range: 22-91) were included. Follow-up colonoscopy was indicated by CT colonography in 30 patients (7.5%) for suspected colorectal carcinoma, polyps > 10 mm, or 3 or more polyps 6-9 mm in size. In 33 patients (8.3%) follow-up colonoscopy or CT colonography was indicated for 1 or 2 polyps 6-9 mm in size, or suspicious lesions. 11 of these patients (2.8%) underwent colonoscopy. In 335 patients (84.2%) polyps > 6 mm or malignancies could be excluded. 18 of these patients (4.5%) still had a colonoscopy. In total, colonoscopy was spared in 341 patients (85.7%). Significant or potentially significant extra-colonic pathological abnormalities were found in 63 patients (15.8%). CONCLUSION Our results support the theory that in the vast majority of patients with low or moderate suspicion of CRC referred by their PCP, invasive colonoscopy could be avoided, because CRC and polyps could be excluded by CT colonography. CT colonography could be a valuable additional diagnostic tool in primary care.
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Colonoscopy is a valuable diagnostic and therapeutic tool. In the present series, 12 polyps, a villous adenoma, and three new cases of ulcerative colitis were found in symptomatic patients with negative barium enemas. Surgical intervention was avoided in two patients suspected of having carcinoma. This study proves the safety and the value of colonoscopy to the community hospital surgeon. It also affords a better means of evaluating the patient with inflammatory disease, and avoids the genetic effects of repeated x-rays.
Barium enema
Community hospital
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CT colonoscopy is one of the recent advances in the field of Computed tomography with various post processing techniques. The aim of work is to evaluate and compare the role of CT colonoscopy and conventional colonoscopy in diagnosing and characterizing the colorectal malignancies.
Subject and Methods: Our study included 50 patients with lower GI sypmtoms; 6 of them had colorectal malignancies. They ranged in age from 28 to 60 years. All patients were subjected to CT colonoscopy examination and results were compared to conventional colonoscopy and documented by histopathology in all cases.
Results: The results in our study showed that CT colonoscopy has equal sensitivity and specificity in diagnosing colorectal malignancies when compared to conventional colonoscopy and further helps in delineating the locoregional extent of the lesion.
Histopathology
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Barium enema
Enema
Virtual colonoscopy
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<b><i>Background and Aims:</i></b> This study aims to evaluate the role of an advanced endoscopist to study the entire colon after an incomplete colonoscopy. <b><i>Methods:</i></b> All patients with an elective incomplete colonoscopy performed under deep sedation in our department between January 2010 and October 2016 were included. Patients with a colonic stenosis, an inadequate bowel preparation, or a colonoscopy performed without deep sedation were excluded. Included patients were followed up to evaluate if and what type of subsequent examinations (colonoscopy by an advanced endoscopist, single-balloon enteroscopy [SBE], and/or CT colonography) was performed to complete the study of the entire colon. Lesions found during these subsequent examinations were also recorded. <b><i>Results:</i></b> Ninety-three patients had an incomplete colonoscopy, with no diagnosis of colorectal cancer (CRC) and a high-risk polyp rate of 5.4% (<i>n</i> = 5). Seventy-seven patients with incomplete colonoscopies underwent subsequent examinations, namely CT colonography in 45.5% (<i>n</i> = 35), colonoscopy by an advanced endoscopist in 53.2% (<i>n</i> = 41), and SBE in 13% (<i>n</i> = 10). In the 49 patients who performed either colonoscopy (<i>n</i> = 39) or SBE (<i>n</i> = 10) by an advanced endoscopist, the cecal intubation rate was 100%, and high-risk polyps were found in 26.5% (<i>n</i> = 13) and CRC in 4.1%. CT colonography revealed findings consistent with polyps and CRC in 22.9% (<i>n</i> = 8) and 2.9% (<i>n</i> = 1) of the cases, respectively. Colonoscopy was further repeated in 6 patients with suspected polyps in CT colonography, confirming the initial diagnosis in 5 patients. <b><i>Conclusions:</i></b> Colonoscopy by an advanced endoscopist achieved cecal intubation in all patients, representing a good choice after an incomplete colonoscopy.
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Objective: To compare high-frequency transabdominal ultrasonography (USG) and spiral computed tomography (CT) with colonoscopy in diagnosis of colon cancer. Design: A prospective comparative study of accuracy of USG and CT scan with colonoscopy. Subjects: Sixty patients with a clinical suspicion of colon cancer after a detailed clinical history and a thorough clinical examination were included. Patients with a known diagnosis of colon cancer or in whom histopathological diagnosis could not be established were excluded. Methods: All 60 patients who met the inclusion and exclusion criteria underwent transabdominal USG, CT scan-abdomen & pelvis, followed by colonoscopy. The CT and USG scans were reported by different radiologists without previous knowledge of any findingsof the other test or of the subsequent colonoscopy. The colonoscopy was performed by different clinicians, none of whom was aware of the USG or CT diagnosis. Result: Colonoscopy diagnosed 29 patients with colon cancer out of 60 enrolled patients. USG detected colon cancer in all the 29 patients with a sensitivity of 100% and a specificity of 87.1%. CT scan diagnosed colon cancer in all the 29 patients with a sensitivity of 100% and a specificity of 74.2%. Conclusions: Colonoscopy is still necessary when a suspicious lesion is identified. However, CT and USG can screen out suspected patients who can be subsequently referred for colonoscopy. This would reduce the need for colonoscopy in a large proportion of clinically suspected patients andalso avoidan invasive procedure like colonoscopy as first line investigation in elderly patients suspected of having colonic cancer.
Spiral computed tomography
Abdominal ultrasonography
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Objective: We aimed to determine the efficacy and safety of early (within the first 24 hour from application) endoscopy and colonoscopy in very elderly patients with GIS bleeding.Methods: In this study, 95 patients were included who underwent early endoscopy with the pre‑diagnosis of upper GIS bleeding or endoscopy-colonoscopy with the pre-diagnosis of lower GIS bleeding between 2012 and 2016. Endoscopy and colonoscopy procedures were compared in terms of the development of complications, tolerance of procedure, detection of bleeding site, and rate of therapeutic interventions performed for bleeding. In addition, the adequacy of colonoscopy preparation was evaluated.Results: There was no significant difference between endoscopy and colonoscopy on procedural complication (2.1% vs 2.8%) and tolerance rates (81% vs 74.2), (p>0.05). The bleeding site was detected during endoscopy in 34(56.6%) patients, and an endoscopic intervention was required for 15(25%) of these patients. The bleeding site was detected during colonoscopy in 12(34.3%) patients, and an endoscopic intervention was performed for two (5.7%) patients (p<0.05). In addition, the colonoscopy procedure was suboptimal in 26 of 35 patients (74.2%) because of poor preparations.Conclusion: Early endoscopy and colonoscopy are safe and well tolerated in very elderly patients with GIS bleeding. Upper GIS endoscopy in this patient population enables the detection of the bleeding site and an endoscopic intervention for the bleeding. However, colonoscopy is insufficient for detecting bleeding sites, and colonoscopic treatment of bleeding sites is difficult because of poor or no preparation in this patient population.doi: https://doi.org/10.12669/pjms.331.11616How to cite this:Celik M. Efficacy of early endoscopy and colonoscopy in very elderly patients with gastrointestinal bleeding. Pak J Med Sci. 2017;33(1):187-190. doi: https://doi.org/10.12669/pjms.331.11616This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gastrointestinal bleeding
Therapeutic Endoscopy
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