Is upper gastrointestinal endoscopy indicated in persons with a positive fecal occult blood test and a negative colonoscopy in a population-based colorectal cancer screening program ?




DENIS B
, PERRIN P, VAGNE F, PETER A, PFEIFFER JC, BATTISTELLI D.

Communication orale à la Digestive Disease Week. Chicago 17/05/2005.
Gastroenterology 2005;128:A66.

Introduction        

Whether upper gastrointestinal endoscopy (EGD) is necessary in case of positive fecal occult blood test (FOBT) and negative colonoscopy is controversial. Few studies have addressed this question, only two in a mass screening setting.

Aim        

to evaluate the diagnostic yield and the clinical impact of EGD in persons with a positive FOBT and a negative colonoscopy in a mass screening program.

Methods        

180 566 residents aged 50-74 years of the Haut-Rhin area were invited for a FOBT (Hemoccult II) screening. When FOBT was positive and colonoscopy was complete and negative or yielded small polyps (< 1 cm), an EGD was proposed at the discretion of the endoscopist. All clinical and endoscopic data were prospectively recorded.

Results        

after 14 months, 1933 FOBT were positive and 916 colonoscopic procedures were recorded : 462 were normal and 202 yielded small polyps. 237 EGD were performed in 92 men and 145 women, 203 with normal colonoscopy and 34 with small polyps. 55 persons (23.2%) had significant abnormal upper gastrointestinal findings : 1 esophageal adenocarcinoma pT1, 3 Barrett's esophagus, 21 grade 1 and 2 grade 2 erosive esophagitis, 22 erosive gastritis, 8 gastric polyps (none were adenomas), 1 gastric angiodysplasia, 2 erosive duodenitis and 2 duodenal ulcers. 10 of these lesions were H. pylori positive. The diagnostic yield was significantly greater in men (31.5%) than in women (17.9%)(p<0.02) and in persons with upper gastrointestinal symptoms (37.8%) than in persons without (18.5%)(p<0.01). Age, anemia and aspirin or NSAID use were not significantly associated with abnormal findings. EGD led to a change in clinical management in 35 persons (14.8%) : surgical treatment in 1, endoscopic surveillance in 3, antipeptic therapy in 27, eradication of H. pylori in 10 and discontinuation of NSAID in 4. The impact on clinical management was significantly greater in persons with symptoms (27.3%) than in persons without (12.3%)(p=0.02). The esophageal adenocarcinoma was diagnosed in a symptomatic 66 years old man. Only one clinically important lesion was diagnosed in 130 asymptomatic persons. One minor dental complication was recorded.

Conclusion        

in a population-based colorectal cancer screening program it is unjustified to perform an EGD in asymptomatic persons with a positive FOBT when colonoscopy is normal or yields small polyps. On the other hand, an EGD must be performed in patients with relevant symptoms.



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