Upper gastrointestinal endoscopy is not justified 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, KLINKERT D, BATTISTELLI D, PETER A, PFEIFFER JC, VIES JF.
ADECA 68

Communication orale à la United European Gastroenterology Week. Copenhagen 18/10/2005.
Gut 2005;

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.

Aims & Methods        

To evaluate the diagnostic yield and the clinical impact of EGD in persons with a positive FOBT and a negative colonoscopy in a mass colorectal cancer screening program. All 185,000 residents of the Haut-Rhin area aged 50-74 years 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 19 months, 68,777 persons completed a FOBT, 2,559 were positive and 1,705 colonoscopies were recorded : 605 were normal and 397 yielded small polyps. 366 (36.6%) EGD were performed, 305 in persons with normal colonoscopy and 61 with small polyps. 80 persons (21.9%) had significant abnormal upper gastrointestinal findings : 1 esophageal adenocarcinoma pT1, 3 Barrett's esophagus, 28 grade 1 and 5 grade 2 erosive esophagitis, 26 erosive gastritis, 1 gastric ulcer, 12 gastric polyps (none were adenomas), 2 gastric angiodysplasia, 5 erosive duodenitis and 2 duodenal ulcers. 18 of these lesions were H. pylori positive. The diagnostic yield was significantly greater in men (27.6%) than in women (17.7%)(p=0.02) and in persons with upper gastrointestinal symptoms (37.2%) than in persons without (15%)(p<0.01). Age, the presence of a documented anemia and the use of aspirin or NSAIDs were not significantly associated with abnormal findings. EGD prompted a change in clinical management in 50 persons(15%) : surgical treatment in 1, Argon plasma coagulation in 1, endoscopic follow-up in 3, antipeptic therapy in 46, eradication of H. pylori in 18 and discontinuation of NSAIDs in 4. The impact on clinical management was significantly greater in persons with symptoms (25.6%) than in persons without (10.8%)(p<0.01). The esophageal adenocarcinoma was diagnosed in a symptomatic 66 years old man. Clinically important lesions were diagnosed in only 3.3% of 213 asymptomatic persons. In this group, the number needed to screen with EGD in order to detect one clinically important lesion was 30. One minor dental complication was recorded.

Conclusion        

In a population-based colorectal cancer screening program it is not justified to perform an EGD in asymptomatic persons with a positive FOBT when colonoscopy is normal or yields small polyps, the diagnostic yield being too low. On the other hand, an EGD must be performed in patients with relevant upper symptoms.



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