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Is Colonoscopy Indicated for Small Adenomas Found by Screening Flexible Sigmoidoscopy?

Michael B. Wallace, MD, MPH; James Alan Kemp, MD, MPH; Yvona M. Trnka, MD; Joanne M. Donovan, MD, PhD; and Francis A. Farraye, MD
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From Brigham and Women's Hospital and Harvard Pilgrim Health Care, Boston, Massachusetts; and Brockton/West Roxbury Veterans Affairs Medical Center, West Roxbury, Massachusetts. Acknowledgments: The authors thank Robert Fletcher, MD; Cindy Christiansen, PhD; Christopher Stetter; Kim Horton, PA-C; Natalie Herbert, RNP; and the gastrointestinal staff of Harvard Pilgrim Health Care and the Brockton/West Roxbury Veterans Affairs Medical Center for assistance in the conduct of this study and preparation of the manuscript. Grant Support: By the Harvard Pilgrim Health Care Foundation. Requests for Reprints: Michael B. Wallace, MD, MPH, Division of Gastroenterology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425. Current Author Addresses: Dr. Wallace: Division of Gastroenterology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(4):273-278. doi:10.7326/0003-4819-129-4-199808150-00002
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Background: There is controversy over whether patients who have a small tubular adenoma on screening flexible sigmoidoscopy should undergo colonoscopic examination of the proximal colon.

Objective: To prospectively determine the prevalence of advanced polyps in the proximal colon among patients who have small adenomas on screening sigmoidoscopy.

Design: Prospective cohort study.

Setting: A health maintenance organization and a Veterans Affairs medical center.

Patients: Asymptomatic patients older than 50 years of age who had no risk factors for colon cancer and underwent sigmoidoscopy.

Intervention: At the time of sigmoidoscopy, all polyps were biopsied and characterized. All patients with distal adenomas were offered colonoscopy.

Measurements: The size and histology of polyps identified by sigmoidoscopy and colonoscopy were noted. Polyps were considered advanced if they were larger than 10 mm or were tubulovillous, villous, or malignant. The prevalence of advanced proximal polyps was determined, and patients were stratified by the size and number of distal polyps found by sigmoidoscopy.

Results: Among 4490 patients who underwent sigmoidoscopy, a neoplastic lesion was detected in 401 (8.9%) and colonoscopy was done in 301 (75%). Of 90 patients with a single tubular adenoma 1 to 5 mm in diameter in the distal colon, 0% (95% CI, 0.0% to 4.0%) had an advanced proximal polyp compared with 5.4% (CI, 2.4% to 10.4%) of those who had multiple distal polyps 1 to 5 mm or 6 to 10 mm in diameter and 7.9% (CI, 2.6% to 17.6%) of those who had advanced distal polyps (P = 0.013 for trend). The low-risk group with a single tubular adenoma 1 to 5 mm in diameter represented 44% of all patients with distal adenomas or cancers found at flexible sigmoidoscopy.

Conclusions: Among patients undergoing screening sigmoidoscopy, those with single tubular adenomas of 5 mm or less had a low prevalence of advanced proximal polyps. These patients may not benefit from colonoscopy.





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