History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up
M. Helfand, K. I. Marton, M. J. Zimmer-Gembeck and H. C. Sox Jr
Department of Medicine, Oregon Health Sciences University, Portland 97201-3098, USA.
OBJECTIVE: To determine whether a complaint of visible rectal bleeding that
is elicited by a screening review of systems merits investigation and to
assess the accuracy of a defined protocol to evaluate bleeding. DESIGN:
Prospective cohort study. SETTING: Primary care clinics in a veterans
medical center. PATIENTS: We used an 8-item review of systems to identify
297 individuals with visible rectal bleeding; 201 (68%) of these
individuals completed a specified protocol consisting of double-contrast
barium enema (DCBE) examination, rigid sigmoidoscopy, and follow-up visit
after 6 to 12 months. Ten years later we verified the diagnosis in 131
(93%) of 141 patients whose initial evaluation suggested no cause, or a
benign anorectal cause, of bleeding. MAIN OUTCOME MEASURES: Final diagnoses
after 2 and 10 years; sensitivity and specificity of symptoms, DCBE, and
rigid sigmoidoscopy. RESULTS: We diagnosed serious disease in 48 (24%) of
the 201 patients; 26 had polyps, 9 had inflammatory bowel disease, and 13
(6.5%) had colon cancer. Symptoms did not predict the diagnosis. Neither
DCBE nor rigid sigmoidoscopy alone was sufficiently sensitive to be used
alone, but the combination of DCBE and rigid sigmoidoscopy had a
sensitivity of 0.96 and a specificity of 0.76 for the diagnosis of polyps,
cancer, or inflammatory bowel disease. CONCLUSIONS: Self-reported rectal
bleeding detected by means of a review of systems was associated with a
high likelihood of important pathology. Physicians should ask all adults
about visible rectal bleeding and should visualize the entire colon in
those who report bleeding.
