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CHAPTER 39 D Double Contrast Barium Enema
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Like colonoscopy, barium enema permits examination of the entire colon Barium enema has been an attractive screening technique because it was widely available, relatively inexpensive, and safe However, it is being rapidly supplanted by colonoscopy and CT colonography A recent multicenter trial demonstrated that the sensitivity of barium enema is only 50% for polyps 1 cm and 55 85% for early-stage cancers when compared with colonoscopy At present, barium enema may be recommended when screening of the entire colon is desired and the patient is unable or unwilling to undergo colonoscopy, and expertise in CT colonography is unavailable
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resources are limited or in patients who desire a noninvasive method of screening If FOBT screening is to be used, immunochemical tests may be preferred
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B Flexible Sigmoidoscopy
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Use of a 60-cm flexible sigmoidoscope permits visualization of the rectosigmoid and descending colon It requires no sedation and in many centers is performed by a nurse specialist or physician s assistant Adenomatous polyps are identified in 10 20% and colorectal cancers in 1% of patients (For management of adenomatous polyps identified at sigmoidoscopy, see 14) Case-control studies suggest that screening sigmoidoscopy programs lead to a 60% reduction in colorectal cancer mortality The risk of serious complications (perforation) associated with flexible sigmoidoscopy is less than 1:10,000 patients However, approximately 50% of advanced neoplasms (cancer, adenomas 1 cm in size, polyps with villous histology, or high-grade dysplasia) are proximal to the splenic flexure, ie, above the reach of a flexible sigmoidoscopic examination Up to 60% of such patients do not have an adenomatous polyp distal to the splenic flexure at sigmoidoscopy Therefore, if patients found on screening sigmoidoscopy to have an adenoma of any size subsequently undergo colonoscopy, approximately 70% of all advanced colonic neoplasms will be identified; however, using such a strategy means that 30% of patients with advanced colonic neoplasia located only in the proximal colon will be overlooked
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E CT Colonography (Virtual Colonoscopy)
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Using computer-assisted image reconstruction and rapid helical CT, two- and three-dimensional views can be generated of the colon lumen that simulate the view of colonoscopy This technique is performed rapidly, requires no sedation or intravenous contrast, and has minimal risk except for radiation exposure At this time, it requires a similar bowel cleansing regimen as colonoscopy as well as the insufflation of air into the colon through a rectal tube, which may be associated with discomfort In several recent large studies, the accuracy of virtual colonoscopy compared with colonoscopy has been assessed for the screening of colorectal neoplasia in asymptomatic screening populations In several studies, the sensitivity of virtual colonoscopy for the detection of polyps larger than 8 10 mm is > 90%; however, other studies report sensitivity of only 50 60% Abnormalities identified on CT imaging require assessment by colonoscopy Although most professional guidelines do not yet endorse virtual colonoscopy for routine colorectal screening, it is a reasonable alternative for patients in whom screening of the entire colon is desired but who are unable or unwilling to undergo colonoscopy
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Banerjee S et al CT colonography for colon cancer screening Gastrointest Endosc 2006 Jan;63(1):121 33 [PMID: 16377329] Barclay RL et al Colonoscopic withdrawal times and adenoma detection during screening colonoscopy N Engl J Med 2006 Dec 14;355(24):2542 50 [PMID: 17167137] Bernold DM et al Advances in chemotherapy for colorectal cancer Clin Gastroenterol Hepatol 2006 Jul;4(7):808 21 [PMID: 16797250] Callery MP Combined modality therapy for rectal cancer Gastroenterology 2005 May;128(5):1516 7 [PMID: 15887133] Colon Cancer National Cancer Institute Cancer Net: http:// cancernetncinihgov Davila RE et al ASGE guidelines: colorectal cancer screening and surveillance Gastrointest Endosc 2006 Apr;63(4):546 57 [PMID: 16564851] Farrar WD et al Colorectal cancers found after a complete colonoscopy Clin Gastroenterol Hepatol 2006 Oct;4(10): 1259 64 [PMID: 16996804] Lieberman D Screening for colorectal cancer in average-risk populations Am J Med 2006 Sep;119(9):728 35 [PMID: 16945604] Meyerhardt JA et al Systematic therapy for colorectal cancer N Engl J Med 2005 Feb 3;352(5):476 87 [PMID: 15689586] Morikawa T et al A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population Gastroenterology 2005 Aug;129(2):422 8 [PMID: 16083699]
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