Investigating the frail elderly patient with lower bowel symptoms: what do we do now and can we improve?

Abstract

-Aims: To assess the utility of flexible sigmoidoscopy (FS) and minimal preparation CT (MPCT) in investigating lower gastrointestinal (LGI) symptoms in elderly patients who are too frail to undergo colonoscopy or spiral CT. IntroductionColonic symptoms are common in the general population. Options for investigating these include flexible sigmoidoscopy (FS), colonoscopy, barium enema and contrast computer-tomography (CT) studies. Colonoscopy is seen as the 'gold standard' test for visualising the whole colon directly, excluding neoplasia and obtaining histological samples, but it might not be the best choice in the frail elderly. The risks of sedation, the patient's ability to take and retain the bowel preparation and cope with the ensuing diarrhoea and dehydration, and the requirement to change position during the test must be carefully assessed, and other investigations considered. 1 In patients who are unlikely to tolerate colonoscopy safely or effectively, FS can be used with or without minimal preparation CT (MPCT). FS requires an enema only and is performed without sedation. Preparation for MPCT requires 700 ml oral contrast without laxative the night before and another 700 ml oral contrast on the day of the examination. This technique has a sensitivity of 85-90% for detecting advanced neoplasia. [2][3][4][5] MPCT allows views of the whole colon, which are poorer than those provided by CT colonography or colonoscopy, and have resulted in patients often having FS as well. ObjectivesThe aim of this study was to investigate the utility of flexible sigmoidoscopy as a diagnostic tool in the assessment of frail older patients with colonic symptoms who were not perceived to be medically fit for colonoscopy or spiral CT colonography. We evaluated the indications, yield of positive findings and patient tolerance of FS and examined whether FS findings correlate with those from imaging. In particular, we assess whether FS is useful at all for this discrete and vulnerable population, and if so, in what situations. Methods Patient selectionWe reviewed all flexible sigmoidoscopies performed in patients over 70 years between 1 January and 31 December 2008 in University Hospital Lewisham. Information was collected prospectively using an endoscopy database. Data that were analysed included: age, gender, indication for procedure, patient's American Society of Anesthesiologists (ASA) grade, adequacy of preparation, extent of examination, endoscopic diagnosis and need for further lower GI investigation. Key points1 There is a need to rationalise lower gastrointestinal investigations in elderly patients who are too frail to undergo colonoscopy or CT colonography.

Minimal preparation CT: A literature review of a minimally invasive imaging technique for colorectal cancer in a frail, aged population

“…Of the remainder, one described MPCT findings of caecal carcinoma, one described the spectrum of extra‐colonic findings on MPCT, one was a meta‐analysis, one assessed the prognostic value of MPCT, two compared different MPCT protocols . One paper investigated utility of flexible sigmoidoscopy (FS) with MPCT correlation …”

“…Seventeen papers were found. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Of these, 10 papers evaluated the clinical utility of MPCT. Results are summarized in Table 2.…”

“…18,20 One paper investigated utility of flexible sigmoidoscopy (FS) with MPCT correlation. 22 Most studies had small cohorts ranging from 37 to 391 patients. There was a single large study 11 with a cohort 1031.…”

“…Minimal preparation computed tomography is also useful for patients who have failed other investigations. Jamil et al . reported that 24% of patients referred for FS had inadequate preparation.…”

“…Minimal preparation computed tomography is also useful for patients who have failed other investigations. Jamil et al 22 reported that 24% of patients referred for FS had inadequate preparation. Robinson et al 12 reported that 50% of their patients had non-diagnostic OC, DCBE or both.…”