![]() ![]() Furthermore, included patients also had to have undergone subsequent colonic investigations. ![]() To be included in the study, patients had to have entered the CRC fast track pathway with one or more of these three alarm features. Patients can also enter the pathway through findings on medical imaging, rigid sigmoidoscopy or digital rectal examination suggestive of CRC 18 however, those patients who did not have anaemia, visible rectal bleeding or CIBH were not included in this study. if no obvious cause is found on, for example, rigid sigmoidoscopy ( Figure 1). Of these three alarm features, only CIBH leads to an immediate referral for colonoscopy in contrast, patients with only anaemia and/or visible rectal bleeding must first undergo outpatient clinic evaluation and are referred for fast track colonoscopy if deemed appropriate, i.e. Three alarm features prompt further investigation according to this pathway: anaemia, visible rectal bleeding and/or CIBH for over 4 weeks in patients over 40 years of age without other explanation. ![]() The study design was based on the Swedish national fast track pathway for CRC. These hospitals receive patients from both urban and rural districts of Västra Götaland, a region in southwestern Sweden. We performed a retrospective cohort study on all CRC fast track patients referred over a one-year period to the three endoscopy units at the Sahlgrenska University Hospital and to Kungälv Hospital (from May 2016 to May 2017). without anaemia and/or bleeding, who were under 55 years of age. We hypothesised that there would be a low diagnostic yield for CRC in patients presenting with CIBH only, i.e. With this in mind, we aimed to appraise the Swedish colonoscopy fast track referral system, in particular with regard to the diagnostic yield of CIBH for CRC within different age categories. 19 Moreover, given that IBS commonly affects young to middle-aged adults, the Scandinavian guidelines may lead to such individuals being unnecessarily fast-tracked for a colonoscopy. 16 – 18 The discrepancies between country guidelines may be due to the lack of conclusive evidence for CIBH as an alarm symptom for CRC, as well as the non-specific nature of the symptom indeed, CIBH can also be caused by common functional bowel disorders, such as irritable bowel syndrome (IBS). 15 However, in Sweden, Norway and Denmark, a lower threshold has been chosen with regard to CIBH these Scandinavian countries recommend fast track colonoscopy for CIBH of over 4 weeks in patients over 40 years of age. 13 In the United Kingdom, the National Institute for Health and Care Excellence recommends all patients aged 60 years or older with CIBH to get a prompt colonoscopy. 11, 14 The American College of Gastroenterology does not recommend performing colonoscopies on non-bleeding patients with CIBH. 11 – 13 However, CIBH as a sole trigger for fast track colonoscopy evaluation is disputed: a 2008 meta-analysis and a 2011 systematic review found overall poor positive and negative likelihood ratios for CIBH, with a statistical heterogeneity of results between the included studies. 10 Unexplained visible rectal bleeding and iron deficiency anaemia are well-established CRC alarm features that often lead to prompt referrals for colonoscopy. 9 The most common symptoms and clinical features include weight loss, anaemia, abdominal pain, rectal bleeding and change in bowel habit (CIBH). Presenting features of CRC are often non-specific and vary considerably between individuals. Although screening programmes are highly effective for early diagnosis and prevention, 6, 7 the majority of CRC patients still encounter healthcare services only after symptom manifestation. ![]() 4, 5 In an attempt to establish earlier diagnoses, health authorities across Europe have implemented different national screening programmes and symptom-based investigative pathways for CRC. 3 Although 5-year survival rates for CRC are over 90% when diagnosed early, they decrease considerably with cancer stage progression. 2 Overall, CRC has a higher prevalence in men than in women, and the likelihood of developing the condition increases markedly after 50 years of age. Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death in Europe, 1 with a predicted 98,000 deaths in 2018. ![]()
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