Adenoma and advanced neoplasia detection rates increase from 45 years of age

BACKGROUND Colonoscopy is considered a valid primary screening tool for colorectal cancer(CRC). The decreasing risk of CRC observed in patients undergoing colonoscopy is correlated with the adenoma detection rate(ADR). Due to the fact that screening programs usually start from the age of 50, very few data are available on the risk of adenoma between 40 and 49 years. However, the incidence of CRC is increasing in young populations and it is not uncommon in routine practice to detect adenomas or even advanced neoplasia during colonoscopy in patients under 50 years.AIM To compare the ADR and advanced neoplasia detection rate(ANDR) according to age in a large series of patients during routine colonoscopy.METHODS All consecutive patients who were scheduled for colonoscopy were included.Exclusion criteria were as follows: patients scheduled for partial colonoscopy or interventional colonoscopy(for stent insertion or stenosis dilation).Colonoscopies were performed in our unit by a team of 30 gastroenterologists in2016. We determined the ADR and ANDR in each age group in the whole population and in the population with an average risk of CRC(excluding patients with personal or family history of advanced adenoma or cancer).RESULTS6027 colonoscopies were performed in patients with a median age of 57 years(range, 15-96). The ADR and ANDR were 28.6% and 9.7%, respectively, in the whole population. When comparing patients aged 40-44(n = 382) and 45-49 years (n = 515), a strong increase in all parameters from 45 years was observed, with the ADR rising from 9.7% in patients aged 40-44 to 21.2% between 45 and 49(P 0.001) and the ANDR increasing from 3.1% in patients aged 40-44 to 6.4% in those aged 45-49 years(P 0.03). With regard to patients aged 50-54(n = 849), a statistically significant increase in the ADR and ANDR was not observed between patients aged 45-49 and those aged 50-54 years. In the population with an average risk of CRC, the ADR and ANDR were still significantly higher in patients aged 45-49 compared with those aged 40-44 years.CONCLUSION This study shows a significant two-fold increase in the ADR and ANDR in patients aged 45 years and over.     

Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy

BACKGROUND AND AIMS: Both advancing age and male gender are known predictors of adenomas and large adenomas at colonoscopy. However, the importance of endoscopist compared with both age and gender as predictors of adenomas is not known. In this study, we assessed the adenoma detection rates of nine endoscopists performing colonoscopy and the effects of endoscopist on adenoma detection compared with the established predictors of advancing age and male gender. METHODS: Consecutive colonoscopy reports by nine attending gastroenterologists at Indiana University Hospital between January 1999 and January 2004 were obtained. Patients with indications for inflammatory bowel disease (IBD), inherited colon cancer syndromes, or who were referred for polypectomy were excluded. RESULTS: There were 10,034 included colonoscopies. The overall mean age (yr) +/- SD for the entire cohort was 56.0 +/- 13.5, range 14-93 yr. Multivariate analysis indicated that both advancing age and male gender were powerful predictors of adenomas, both for the overall cohort and in those >or=50 of age (Por=50 yr of age, the range of detection of at least one adenoma per colonoscopy by nine colonoscopists was 15.5-41.1%, at least two adenomas was 4.9-20.0%, at least three adenomas was 0.8-10.8%, and at least one adenoma >or=1.0 cm was 1.7-6.2%, and the range of adenomas detected per colonoscopy was 0.21-0.86. Differences between endoscopists were significant (P < 0.001). CONCLUSION: Who performs the procedure can be more important than age and gender in predicting adenomas at colonoscopy. Our results underscore the need to measure adenoma detection rates in the continuous quality improvement process and to report them to endoscopists. Additional data are needed to determine whether corrective measures can reduce variation in adenoma detection rates.     

The prevalence rate and anatomic location of colorectal adenoma and cancer detected by colonoscopy in average-risk individuals aged 40-80 years

BACKGROUND: The role of screening colonoscopy for colorectal (CR) neoplasia in average-risk population, remains to be determined. OBJECTIVES: To evaluate the prevalence and anatomic location of CR adenoma and carcinoma and the morbidity of colonoscopy in individuals at average risk for CR cancer (CRC). METHODS: A retrospective prevalence study of subjects aged 40-80 yr, with no cancer-related symptoms, personal or family history of CR neoplasia, who underwent a colonoscopy. RESULTS: Enrolled were 1,177 persons; 183 aged 40-49 yr (young), 917 aged 50-75 yr, and 77 aged 76-80 yr (elderly). The prevalence of overall CR neoplasia, advanced neoplasia, and cancer was 20.9%, 6.3%, and 1.1%, respectively. In the 50-75 age group, the prevalence of overall adenoma, advanced neoplasia, and cancer was 21.3%, 6.7%, and 1.2%, respectively. Of the 206 neoplasia cases, 21-43% harbored proximal neoplasia beyond the reach of sigmoidoscopy, without distal lesions. Among the elderly, the prevalence of overall adenoma, advanced neoplasia, and cancer reached 26.0%, 14.3%, and 2.6%, respectively. In the young group, 9.8% had overall neoplasia, 1.1% had advanced adenoma, and none had CRC. Procedure-related morbidity rate was 0.1%, with no perforations, bleedings, or mortality. CONCLUSIONS: Screening colonoscopy in average-risk subjects demonstrated a considerable prevalence of CR neoplasia and proximal lesions beyond the reach of sigmoidoscopy. The morbidity rate was negligible. Primary screening colonoscopy should be considered in health programs for the average-risk population, beginning at the age of 50 yr. The significantly high rate of advanced and proximal neoplasia in the elderly, encourages the inclusion of healthy subjects aged 76-80 yr in future prospective studies.     

Screening colonoscopy in 40- to 50-year-old first-degree relatives of patients with colorectal cancer is efficient: a controlled multicentre study

Background and aims Persons with a familial risk of colorectal cancer (CRC) account for about 25% of all CRC cases. The adenoma prevalence in relatives of CRC patients 50–60 years of age is 17–34%; data on younger individuals are scarce. Our aim was to prospectively define the adenoma prevalence in 40- to 50-year-old first-degree relatives of CRC patients compared to controls.Patients and methods CRC patients were identified via the regional cancer registry, and their 40- to 50-year-old first-degree relatives (risk group) were invited for screening colonoscopy. Additional probands and controls of the same age were recruited by newspaper articles and radio or television broadcastings. Using high-resolution video colonoscopy, each detected polyp was removed and histopathologically assessed. Each participant completed demographic and epidemiological questionnaires. Results Of 228 subjects in the risk group 36.4% had polypoid lesions compared to 20.9% of 220 controls (p<0.001). Forty-three (18.9%) subjects in the risk group had adenomas compared to 18 (8.2%) in the control group (p=0.001). High-risk adenomas (>10 mm and/or of villous type) were found in 12 persons in the risk group compared to 5 controls (not significant). In the risk group most lesions (52%) were located proximal to the sigmoid colon compared to 29% in controls.Conclusions Subjects between 40–50 years with first-degree relatives with CRC demonstrate a significantly higher prevalence of adenomas than controls, with a tendency towards a more proximal location. These data support a screening colonoscopy in persons with familial risk already between 40 and 50 years.     

The appropriateness of surveillance colonoscopy intervals after polypectomy

BACKGROUND:

Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload.

OBJECTIVE:

To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC.

METHODS:

Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval.

RESULTS:

A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared.

CONCLUSION:

Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.     

Risk factors for colorectal adenomas among immediate family members of patients with colorectal cancer in Taiwan: a case-control study

OBJECTIVES: The incidence of colorectal cancer or adenoma among first-degree relatives of patients with colorectal cancer is significantly high. However, a well defined screening and surveillance consensus has not been developed for these families in Taiwan. We conducted this study to evaluate the colorectal adenoma prevalence pattern in screened immediate family members in Taiwan, and to derive implications for future screening programs. METHODS: A total of 234 immediate family members (aged 51.6 +/- 21.5 yr) of 186 patients with colorectal cancer were offered a colonoscopy. Each relative examined was then paired with two control subjects for age, sex, and symptoms. The prevalence of colorectal adenomas was then compared using multiple logistic regression analysis. RESULTS: The estimated risk of developing adenomas among immediate family members of patients with colorectal cancer was significantly increased (OR = 2.33; 95% CI, 1.43-3.78; p < 0.001). This trend was more striking for men (OR = 2.46; 95% CI, 1.40-4.31; p = 0.001). Immediate family members were at an increased risk for high-risk adenomas (> or = 1.0 cm, with a villous component, and/or with severe dysplasia) (OR = 4.5; 95% CI, 1.91-10.60; p = 0.002), and developed adenomas at an earlier age than did controls. Individuals with index cancer relatives diagnosed at < 50 yr of age or male relatives posed a higher risk of developing colorectal adenomas. CONCLUSIONS: The prevalence of colorectal adenoma in persons with a colorectal cancer family history in Taiwan is similar to that reported in Western countries. This high-risk population should be offered a screening colonoscopy beginning at 40 yr of age.     

The impact of body weight on dysplasia of colonic adenomas: a case-control study

Abstract

Objective: Colorectal cancer (CRC) is common across countries in males and females. Most cases originate from adenomas harboring high grade dysplasia. Among risk factors, weight excess has been suggested to positively influence dysplasia progression. In this study, the relationship between dysplasia grade of adenomas and body mass index (BMI) categories was analyzed.

Methods: This was a retrospective case-control study. A total of 4745 charts (59.8% females) from patients undergoing colonoscopy were collected. Data regarding age, sex, smoking habits, occupation, residence, personal history of CRC, personal history of polyps and BMI were retrieved. Adenomas with high-grade dysplasia were labeled as advanced.

Results: They were 970 (20.4%) subjects with adenomas (cases: mean age 64.67?±?11.35?years) and 3775 without (controls: mean age 56.43?±?16.56?years). As expected, adenomas were significantly associated with overweight or obesity. After adjusting for all covariates the presence of advanced adenoma was significantly associated with age, male sex, smoking habits, personal history of CRC, overweight (OR = 1.298, IC 95% 1.092–1.697) and obesity (OR = 1.780, IC 95% 1.260–2.515).

Conclusions: Our findings support the protective effect a normal weight against advanced adenomas. Reduction of BMI value should be pursued in healthy programs.     

Association of Adenoma Detection Rate and Adenoma Characteristics With Colorectal Cancer Mortality After Screening Colonoscopy

Background & AimsThe adenoma detection rate (ADR) and characteristics of previously resected adenomas are associated with colorectal cancer (CRC) incidence and mortality. However, the combined effect of both factors on CRC mortality is unknown.Patients and methodsUsing data of the Austrian quality assurance program for screening colonoscopy, we evaluated the combined effect of ADR and lesion characteristics on subsequent risk for CRC mortality. We analyzed mortality rates for individuals with low-risk adenomas (1–2 adenomas <10 mm), individuals with high-risk adenomas (advanced adenomas or ≥3 adenomas), and after negative colonoscopy (negative colonoscopy or small hyperplastic polyps) performed by endoscopists with an ADR <25% compared with ≥25%. Cox regression was used to determine the association of combined risk groups with CRC mortality, adjusted for age and sex.ResultsWe evaluated 259,885 colonoscopies performed by 361 endoscopists. A total of 165 CRC-related deaths occurred during the follow-up period, up to 12.2 years. In all risk groups, CRC mortality was higher when colonoscopy was performed by an endoscopist with an ADR <25%. Compared with negative colonoscopy with an ADR ≥25%, CRC mortality was similar for individuals with low-risk adenomas irrespective of ADR (for ADR ≥25%: adjusted hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.59–2.49; for ADR <25%: adjusted HR, 1.25; 95% CI, 0.64–2.43) and after negative colonoscopy with ADR <25% (adjusted HR, 1.27; 95% CI, 0.81–2.00). Individuals with high-risk adenomas were at significantly higher risk for CRC death if colonoscopy was performed by an endoscopist with an ADR <25% (adjusted HR, 2.25; 95% CI, 1.18–4.31) but not if performed by an endoscopist with an ADR ≥25% (adjusted HR, 1.35; 95% CI, 0.61–3.02).ConclusionsOur study adds important evidence for mandatory assessment and monitoring of performance quality in screening colonoscopy. High-quality colonoscopy was associated with a lower risk for CRC death, and the impact of ADR was strongest for individuals with high-risk adenomas.     

Colonoscopy screening in the elderly: when to stop?

OBJECTIVES: The age to begin colorectal cancer (CRC) screening is based on the risk of neoplasia and is published in screening guidelines. The age to stop screening is unknown but should be based, in part, on the same principle. The purpose of this study was to establish whether the prevalence of neoplasia detected by colonoscopy diminished with advancing age, to warrant ceasing colonoscopic screening. METHODS: The endoscopic and pathology reports of all asymptomatic subjects undergoing colonoscopy for the purpose of CRC screening or an evaluation of abdominal pain or change in bowel habits between 1997 and 2000 were reviewed. A multivariate logistic regression analysis was used to assess the effect of age, gender, and indication for examination on the prevalence of neoplasia, as well as on having more than two adenomas, advanced adenomas (tubulovillous, villous, severe dysplasia, or size > or = 1 cm), and invasive cancers. RESULTS: A total of 915 patients were included. Of these, 50% were male, with a mean age of 65 yr (range 50-100). Neoplasia peaked in the seventh decade, with a fall thereafter (p = 0.009). Numerous adenomas, advanced adenomas, and invasive cancers increased with age. The yield for overall neoplasia, advanced adenomas, and more than two adenomas was higher in the screening group than in the symptomatic group. More invasive cancers were found in the symptomatic group compared with the asymptomatic group, but this did not achieve statistical significance (4 vs 1, p = 0.44). CONCLUSIONS: The prevalence of advanced neoplasia continues to increase with age. Subjects undergoing colonoscopy for screening had a greater risk for neoplasia than did subjects with symptoms. There is no decline in yield of advanced neoplasia to justify stopping screening colonoscopy in the elderly.     

Colonoscopy surveillance of individuals at risk of familial colorectal cancer

BACKGROUND: Individuals with first degree relatives affected with colorectal cancer (CRC) at a young age, or more than one relative affected but who do not fulfil the Amsterdam criteria for a diagnosis of hereditary non-polyposis colon cancer (HNPCC), are believed to be at an increased risk of CRC. However, there is a paucity of prospective data on the potential benefit of colonoscopic surveillance in such groups categorised by empiric family history criteria. We report a prospective study of 448 individuals seeking counselling about their perceived family history of CRC. PATIENTS AND METHODS: Following pedigree tracing, verification, and risk assignment by genetic counsellors, colonoscopy was undertaken for those at a moderate or high risk (HNPCC). Those classified as low risk were reassured and discharged without surveillance. Here we report our findings at the prevalence screen in the 176 patients of the 448 assessed who underwent colonoscopy. RESULTS: Fifty three individuals had a family history that met Amsterdam criteria (median age 43 years) and 123 individuals were classed as moderate risk (median age 43 years). No cancers were detected at colonoscopy in any group. Four individuals (8% (95% confidence limits (CL) 0.4-15%)) in the high risk group had an adenoma detected at a median age of 46 years and all four were less than 50 years of age. Five (4% (95% CL 0.6- 8%)) of the moderate risk individuals had an adenoma at a median age of 54 years, two of whom were less than 50 years of age. CONCLUSIONS: These findings indicate that the prevalence of significant neoplasia in groups defined by family history is low, particularly in younger age groups. These prospective data call into question the value of colonoscopy before the age of 50 years in moderate risk individuals.     

Distribution trends of colorectal adenoma and cancer: a colonoscopy database analysis of 11,025 Chinese patients

Background and Aim: A left‐to‐right shift of colorectal cancer (CRC) has been reported in Western studies. However, few Asian studies have investigated the anatomic distribution of colorectal adenoma and CRC. We aimed to describe the time trends in the distribution of colorectal adenoma and CRC in a Chinese population. Methods: A colonoscopy database was reviewed, and all consecutive patients with lower gastrointestinal symptoms who underwent colonoscopy from 1998 to 2009 were identified. Data, including patients' sex, age, symptoms, and the number and anatomic locations of colorectal adenoma and CRC, were documented. Results: A total of 11 025 patients were included in the final analysis; 1012 and 363 patients were diagnosed with colorectal adenoma and CRC, respectively. Overall, there were more distal than proximal adenomas (54.4% vs 37.9%), and the proportion of proximal adenomas remained stable from 1998–2006 to 2007–2009 (38.2% vs 37.6%). Similarly, there were more distal than proximal CRC (56.5% vs 42.4%), and the proportion of proximal CRC declined from 45.8% in 1998–2006 to 38.4% in 2007–2009. Colorectal adenoma and CRC were equally distributed among both sexes. For elderly patients (> 50 years), there was a non‐significant trend towards more proximal adenoma and CRC. Conclusions: The present study suggests no distal‐to‐proximal shift of colorectal adenoma and CRC among the Chinese population in Shanghai over the past 12 years. The distribution pattern of colorectal adenoma and CRC of Chinese patients is different from that of Western patients, who had more colorectal lesions located in the distal part.     

Is there a role for sigmoidoscopy in symptomatic patients? Analysis of a study correlating distal and proximal colonic neoplasias detected by colonoscopy in a symptomatic population

BACKGROUND: Colonoscopy is the gold standard exam to investigate patients with colonic complaints. However, its availability is limited in developing countries. Sigmoidoscopy has been advocated as a first procedure in colorectal cancer screening strategies, in order to select those who need colonoscopy. AIM: To study the correlation between distal and proximal colonic neoplasias in symptomatic patients 50 years or older and patients 40 to 49 years old who underwent colonoscopy at a gastrointestinal endoscopy unit in 1999 and 2000 with the purpose to evaluate its role in a symptomatic population. METHODS: All colonoscopies performed in our Department in 1999-2000 were reviewed. The distal colon was defined as the colonic segment aboral to the splenic flexure. Advanced neoplasias were defined as adenomas larger than 10 millimeters and adenocarcinomas. RESULTS: Of the 2,701 colonoscopies retrieved, 1,125 were enrolled in this study. Prevalence rates for adenoma, advanced adenoma and carcinoma were 28.9%, 4.6% and 4% in the group of 830 patients 50 years or older (mean age 65 years, 491 women). The finding of one small (<10 mm) adenoma in the distal bowel doubled the likelihood of finding a proximal neoplasia (OR = 2.12, 95% CI, 1.27-3.54), and multiple (OR = 3.99, 95% CI, 1.72-9.28) or advanced (OR = 3.73, 95% CI, 1.81-7.7) adenomas increased this risk even further. Of the patients without adenoma or carcinoma in the distal colon, 1.93% had proximal advanced neoplasia. In the group of 40 to 49-year-old patients (n = 395; mean age 44.8 years, 208 women) the prevalence of adenomas (14.9%), advanced adenomas (3.4%), and carcinomas (1.7%) was lower. CONCLUSIONS: The likelihood of finding a proximal lesion is greater in patients with distal neoplasias. This likelihood is further increased when adenomas are multiple or larger than 10 mm. One out of 52 patients 50 years or older with an apparently normal distal colon has advanced proximal neoplasia. Sigmoidoscopy is not an adequate exam for symptomatic patients aged 50 years or older.     

The yield of colonoscopy in average-risk patients with non-specific colonic symptoms

OBJECTIVES: The need for full colonoscopies in average-risk patients with non-specific colonic symptoms is controversial. We aimed to evaluate: (1) the yield of full colonoscopy; (2) the prevalence of proximal neoplasia in these patients; (3) the yield if any of doing full colonoscopies to diagnose proximal lesions in patients in whom the distal colon was clear; (4) the significance of this yield with respect to age. DESIGN: This is a retrospective analysis to assess the value of open access colonoscopy. PATIENTS AND METHODS: All patients who underwent a colonoscopy in our Endoscopy Unit during January 1996 to December 1999 were assessed (n = 3357). RESULTS: We analysed 945 patients with average risk and non-specific colonic symptoms (significant risk factors excluded). The overall yield of adenomas was 5.8%. The yield of distal adenomas in patients > or= 50 years of age was 8.2% (37 out of 450) versus 0.2% in the 50 years group (one out of 495; = 0.0001). The proximal adenoma yield in > or= 50 year olds was 3.8% (17 out of 495) versus 0.2% in < 50 year olds (one out of 495) (P = 0.0001). CONCLUSIONS: In a cohort of average-risk patients with non-specific colonic symptoms attending an "open access" colonoscopy clinic, the yield for proximal adenomas is small in the < 50 years group. In patients aged < 50 years, distal colonic examination is all that is required, whereas a full colonoscopy may be justified in patients > or = 50 years old.     

Clinical identification and long-term surveillance of 22 hereditary non-polyposis colon cancer Italian families

OBJECTIVE: To assess the efficacy of a hereditary non-polyposis colon cancer (HNPCC) identification and surveillance policy. METHODS: Familial clustering of colorectal cancer (CRC) and extracolonic cancers (ECs) was investigated in 1520 consecutive CRC patients and relatives. HNPCC was identified by Amsterdam criteria, and individuals at risk were offered biennial colonoscopy and other examinations, starting from age 25 years. RESULTS: Twenty-two HNPCC families were identified. The CRC prevalence was 27.8% (121/435), decreasing from 59.4% in the first generation to 24.4% and 8% in the second and third generation, respectively. Twenty-nine patients had multiple CRC and 34 patients (in 12 families) had ECs.A total of 199/331 at-risk individuals accepted surveillance. The mean follow-up was 48+/-32 months. CRCs were detected at first surveillance in four out of 199 surveilled individuals (2%); in two surveilled individuals (1%), three CRCs developed during follow-up. The overall CRC incidence was 7/199 (3.5%) in surveilled individuals and 5/132 (3.7%) in unsurveilled individuals. CRCs were less advanced in surveilled than in unsurveilled patients. Eleven individuals had 22 adenomas (one with high-grade dysplasia). Three individuals had adenomas at first surveillance; two of them and eight more individuals during surveillance. Seven surveilled individuals and six unsurveilled individuals, all belonging to families with a history of EC, had EC during the study period.All patients with CRC detected by surveillance are alive. One of the unsurveilled patients who had CRC died 18 months after the diagnosis. CONCLUSIONS: Data confirm the importance of the family history collected in each patient with CRC for identification of HNPCC and support the efficacy of repeated colonoscopies for early diagnosis and prevention of CRC in at-risk members. Reasons for surveillance failure could be an accelerated progression of small adenomas and a lesion missing at colonoscopy. Longer follow-up is required to assess the efficacy of surveillance for EC.     

Nonalcoholic fatty liver disease: an independent risk factor for colorectal neoplasia

Stadlmayr A, Aigner E, Steger B, Scharinger L, Lederer D, Mayr A, Strasser M, Brunner E, Heuberger A, Hohla F, Steinwendner J, Patsch W, Datz C (Oberndorf Hospital, Oberndorf; Paracelsus Medical University, Salzburg, Austria). Nonalcoholic fatty liver disease: an independent risk factor for colorectal neoplasia. J Intern Med 2011; 270 : 41–49.

Abstract.

Background and aims. Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of insulin resistance (IR), and IR is associated with an increased risk of colorectal carcinoma (CRC). Increased echogenicity suggesting NAFLD is a frequent incidental finding on ultrasound examination. We aimed to systematically evaluate whether NAFLD is an independent risk factor for colonic neoplasia. Patients and methods. One thousand two hundred and eleven patients (603 males, 60.6 ± 9.6 years; 608 females, 61.1 ± 10.3 years) who underwent screening colonoscopy according to national screening recommendations for CRC were evaluated in a cross‐sectional study. Colorectal adenomas were classified as tubular adenoma, advanced adenoma (villous features, size ≥1 cm or high‐grade dysplasia) or carcinoma. NAFLD was diagnosed by increased echogenicity on ultrasound examination after serological exclusion of infectious, immunological, hereditary or alcoholic aetiology. Results. Nonalcoholic fatty liver disease was diagnosed in 367 (60.8%) males and in 265 (43.5%) females. The total rate of adenomas was increased in subjects with NAFLD (243/367 vs. 107/236 in males, P = 0.010; 94/265 vs. 78/343 in females; P = 0.014). In particular, more tubular adenomas (127/367 vs. 56/236; P = 0.006), adenomas of the rectum (40/367 vs. 8/236; P = 0.004) and more cancers (6/367 vs. 1/236; P < 0.001) were observed in males with NAFLD. In females with NAFLD, more tubular adenomas (59/265 vs. 48/343; P = 0.011) and adenomas of the proximal colon (51/265 vs. 40/343; P = 0.041) were observed. Multivariate regression analyses demonstrated an independent association of colorectal adenomas with hepatic steatosis after adjustment for age, sex, body mass index and glucose intolerance (OR 1.47; 95% CI 1.079–2.003; P = 0.015). Conclusion. Patients with NAFLD undergoing screening colonoscopy reveal significantly more CRC precursor lesions and early CRC compared with subjects without NAFLD. This elevated risk is independent from other manifestations of IR. These findings suggest that detecting fatty liver on ultrasound should heighten the awareness for referral to screening colonoscopy.     

prevalence of colorectal neoplasms in young,average risk individuals: A turning tide between East and West

AIM To determine the prevalence of colorectal neoplasia in average risk persons 40-59 years of age in Israel and to compare the results with other populations. METHODS We reviewed the results of asymptomatic average-risk subjects, aged 40 to 59 years, undergoing their first screening colonoscopy between April 1994 and January 2014. The detection rates of adenoma, advanced adenoma(AA) and colorectal cancer(CRC) were determined in the 40's and 50's age groups by gender. The prevalence of lesions was compared between age groups. After meticulous review of the literature, these results were compared to published studies addressing the prevalence of colorectal neoplasia in similar patient groups, in a variety of geographical locations.RESULTS We included first screening colonoscopy results of 1750 individuals. The prevalence of adenomas, AA and CRC was 8.3%, 1.0% and 0.2% in the 40-49 age group and 13.7%, 2.4% and 0.2% in the 50-59 age group, respectively. Age-dependent differences in adenoma and AA rates were significant only among men(p 0.005). Literature review disclosed 17 relevant studies. As expected, in both Asian and Western populations, the risks for overall adenoma and advanced adenoma was significantly higher in the 50's age group as compared to the 40's age group in a similar fashion. The result of the current study were similar to previous studies on Western populations. A substantially higher rate of adenoma, was observed in studies conducted among Asian populations in both age groups.CONCLUSION The higher rate of colorectal neoplasia in Asian populations requires further investigation and reconsideration as to the starting age of screening in that population.     

A prospective study of the clinical, genetic, screening, and pathologic features of a family with hereditary mixed polyposis syndrome

In 1997, hereditary mixed polyposis syndrome (HMPS) was described in an Ashkenazi pedigree having colorectal polyps with mixed histology and risk for colorectal cancer (CRC). The mutation is now localized to 15q13-14. Since 1980, compliant relatives of an HMPS family were seen annually, tested genetically, and had colonoscopy offered every 1 to 2 yr from age 20 yr. The Israeli pedigree has 37 members (17 clinically affected by CRC or polyps), and seven of 13 available relatives entered our screening program. The others, followed-up elsewhere, provided clinical information. Half of our screened group had rectal bleeding; others were asymptomatic. Colonoscopy, performed a mean of four times, identified polyps in all seven patients (mean age 28 yr). Polyps were removed and included juvenile adenomas, mixed juvenile adenomas, hyperplastic polyps, mixed hyperplastic adenomas, serrated adenomas, and tubular adenomas. None of our screened patients developed CRC or extracolonic neoplasia. Linkage analysis localized their mutation to 15q13-14. This high-penetrance founder mutation so far is described only in Ashkenazim. The CRC pathway seems to be through juvenile and hyperplastic polyps. Mutation identification will aid screening for and evaluation of HMPS prevalence in Jewish and non-Jewish populations. Meanwhile, a cancer pedigree and correct classification of polyps will identify HMPS families. They require early and frequent colonoscopy, polypectomy, and elective extensive colectomy when indicated.     

Colonoscopic screening examination of relatives of patients with colorectal cancer. I. A comparison with an endoscopically screened normal population.

First-degree relatives (n = 206) of patients operated on for colorectal cancer (CRC) (n = 181) were offered a colonoscopic screening examination; 169 relatives (82%) attended. The findings were compared with those in a normal population sample with no CRC in first-degree relatives (n = 308), aged 50-59 years, who had been screened by means of flexible sigmoidoscopy. Three carcinomas and 176 polyps were found in 56 of 95 male relatives (57%) and 34 of 74 female relatives (46%). The adenoma prevalence rate was 37 (39%) and 26 (35%) for male and female relatives, respectively. In the 50- to 59-year age group, the adenoma prevalence rates for both sexes collectively and for women separately were significantly higher among relatives than among the population without CRC relatives. Hyperplastic polyps were larger, whereas adenomas were similar in size among relatives compared with the normal population. Colonoscopy may be a suitable method of choice for screening first-degree relatives of patients with CRC.     

Screening of first degree relatives of patients operated for colorectal cancer: evaluation of fecal calprotectin vs. hemoccult II.

Fecal calprotectin (CPT) is elevated in the majority of patients with known colorectal cancer (CRC), but the specificity is not clarified. AIM: To evaluate if a CPT test (PhiCal ELISA) was more sensitive than Hemoccult II test in detecting colorectal neoplasia, and to obtain reference values in subjects with normal colonoscopy. To evaluate a possible relation between number and extent of dysplasia of adenomas in first degree relatives of patients with CRC and the stage of the carcinoma in the index casus. Further to study the prevalence of CRC and adenomas in the first degree relatives of patients operated for CRC. METHOD: In a multicenter study, 253 first degree relatives of patients with CRC, aged 50-75 years (mean age 60 years) underwent colonoscopy after having delivered stool samples and three Hemoccult II slides. RESULTS: In 237 first degree relatives from 148 patients with CRC, polyps were found in 118 (50%). Seventy three (31%) had adenomas and 17 had adenomas > or =10 mm. Five had asymptomatic cancers. The specificity of fecal CPT for adenomas at cut off levels 15 mg/l. The sensitivity of Hemoccult II for adenomas was 8%, and 4/5 of patients with carcinoma had negative Hemoccult II. The specificity for adenomas was 95%. CONCLUSION: Fecal CPT test was more sensitive than Hemoccult II in detecting colorectal neoplasia but the specificity was lower. In a high risk group like first degree relatives of patients with CRC, there are good reasons to consider fecal CPT as a first test in selecting patients for endoscopy.     

Screening colonoscopy among persons 50 to 60 years of age with and without familial risk of colorectal cancer - a prospective multicenter trial

BACKGROUND: In Germany screening colonoscopy was introduced into the National program on colorectal cancer prevention in Oktober 2002. The prevalence of neoplasia in patients with and without familiar risk was determined together with patient satisfaction with screening colonoscopy. Methods: Asymptomatic subjects from 50 to 60 years underwent screening colonoscopy and were stratified in two groups with and without familiar risk (first-degree relatives with CRC) in a multicenter trial among German gastroenterologists. Advanced neoplasia was defined as an adenoma at least 1 cm in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. After recovery from sedation all subjects were asked if they would agree to a control colonoscopy and the pain score was recorded on a scale from 0 to 6. Results: A total of 557 subjects (322 at average risk and 235 with familiar risk) underwent screening colonoscopy. The prevalence of advanced neoplasia in subjects without/with familiar risk was not significantly different in persons from 50 to 54 years (9 vs. 15 %) in contrast to persons from 55 to 60 years (10 vs. 22 %, p = 0.004) where the relative risk was doubled. Compared to younger patients, the prevalence of all neoplasia (including small adenomas) was significantly different only for older patients with familiar risk (44 vs. 23 %, p < 0.0001). The mean value of the pain-score was 0.76 + 1.0. Subjects examined without medication had significantly higher pain scores than subjects under medication. Colonoscopy performed under disoprivan resulted in similar pain-scores compared to midazolam at dosages > 5 mg. All patients agreed to a control colonoscopy. CONCLUSION: Screening colonoscopy is an effective and well-accepted method. The high prevalence of advanced neoplasia even in persons from 50 to 54 years suggests that screening should start at the age of 50.