Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Outcome measures and effect size ⁴

Comments / author’s conclusion

Lu, 2020

Type of study:

Retrospective observational study.

Setting and country:

Two midwestern institutions in the USA.

Funding and conflicts of interest:

The authors have no conflicts of interest to declare

Inclusion criteria:

• Young adults with age ≤40;
• Patients who had undergone a diagnostic colonoscopy.

Exclusion criteria:

• Patients with familial hereditary colon cancer syndromes;
• Patients who received colonoscopy for colorectal carcinoma screening on account of having a first degree relative diagnosed with colon cancer at age <60;
• Patients with pre-existing diagnosis of IBD.

N total at baseline:

N = 194

Important prognostic factors²:

Age, median (IQR):

32 (27-36) years.

Sex, n/N (%):

76/194 (39.2%)

Indication colonoscopy, n/N (%)

Bright red blood per rectum:

N = 194 (43%)

Describe intervention (treatment/procedure/test):

Colonoscopy

Diagnostic yield in patients with BRBPR

Overall DY, n/N (%):

N=43/194 (22%)

Inflammatory bowel disease, n/N (%):

N=28/194 (15%)

Microscopic colitis, n/N (%):

N=6/194 (3%)

Advanced adenoma/CRC, n/N (%):

N=10/194 (5%)

A significant proportion of young adults presenting with BRBPR had abnormal pathology (22%) justifying endoscopic evaluation. For other lower GI symptoms without BRBPR, necessity of endoscopic evaluation should be determined clinically on a case-to-case basis. The prevalence of MC is low (2%) in young adults below 40 years of age.

Hussian, 2019

Type of study:

Prospective descriptive study

Setting and country:

Gastro-intestinal and Hepatology center at Azadi Teaching hospital in Kirkuk, Irak

Funding and conflicts of interest:

The authors have no financial, consultative, institutional, and other relationships that might lead to bias or conflict of interest. Therefore,we declare that we have no conflict of interest.

Inclusion criteria:

• Patients who attended the outpatient clinics or who were admitted to the hospital;
• Patients who were complaining from mild to moderate lower GIT bleeding with or without diarrhea (passing of loss stool more than three times a day).

Exclusion criteria:

Not described.

N total at baseline:

N = 318

Patients with rectal bleeding: N = 318

Important prognostic factors²:

Sex, n/N (%):

N=197/318 (62%) M

Describe intervention (treatment/procedure/test):

Sigmoidoscopy

Incidence, N (%)

Hemorrhoids, N:

Sigmoidoscopy: N=111

Polyps, N:

Sigmoidoscopy: N=54

Cancer, N:

Sigmoidoscopy: N=23

Proctitis, N:

Sigmoidoscopy: N=36

Solitary rectal ulcer, N:

Sigmoidoscopy: N=16

No visible lesion, N:

Sigmoidoscopy: N=10

At any age group, sigmoidoscopy has indicated in any patient with lower GIT bleeding or chronic diarrhea with blood followed by elective colonoscopy after proper preparation with conscious sedation. The reason of this preparation was to avoid unnecessary and unplanned anorectal surgery or unnecessary empirical medication. Nevertheless, on the base that, the complication rate of total colonoscopy is so negligible, especially with an increase in right-sided colonic pathology including tumer. Furthermore, this study revealed that a colonoscopy is a golden procedure in the diagnosis of colonic pathology and in a colonic screening program.

Comments:

- The study only reports findings for sigmoidoscopy for patients <50 years of age in table 3. Table 4 is not applicable since these numbers are based on the whole cohort with age varying from <10 years of age to 80 years of age.

Muller, 2019

Type of study:

A prospective study

Setting and country:

Coloproctology Clinic within Hospital de Clinicas de Porto Alegre, Southern Brazil.

Funding and conflicts of interest:

Not reported.

Inclusion criteria:

• Patients with complaints of rectal bleeding and subsequently with a diagnosis of anal disorder, which clearly could be the cause of the bleeding, established at the physical examination.

Exclusion criteria:

• Patients with symptoms suggesting the possibility of a colorectal carcinoma, such as melena, weight loss, anemia, and altered bowel habit;
• Patients with inflammatory bowel disease;
• Patients with family history of diverticular disease;
• Patients with anticoagulation;
• Patients with a history of previous colonoscopy;
• Patients with a first-degree family history of CRC, which represents a formal indication to perform a colonoscopy before the age of 50.

N total at baseline:

N = 187

Patients were divided in two groups. The first group consisted of patients with adenoma. The second group consisted of patients without adenoma.

1^st group: N=35

2^nd group: N=152

Important prognostic factors²:

Total population:

Age, mean (SD):

40.2 (6.8) years

Sex, n/N (%):

N=94/187 (50.3%) F

Main symptoms:

Bleeding, n/N (%):

N=125/187 (66.8%)

Anal pain, n/N (%):

N=20/187 (10.7%)

Anal prolapse, n/N (%):

N=15/187 (8.0%)

Drainage of secretion, n/N (%):

N=27/187 (14.4%)

1^st group (adenoma)

Sex, n/N (%)

N=16/35 (45.7%) F

Age, n/N (%):

<40 years of age, n/N (%):

N=12/35 (34.3%)

≥40 years of age, n/N (%):

N=23/35 (65.7%)

Main symptoms:

Bleeding, n/N (%):

N=22/35 (62.9%)

Other, n/N (%):

N=13/35 (10.7%)

2^nd group (no adenoma)

Sex, n/N (%)

N=78/152 (51.3%) F

Age, n/N (%)

<40 years of age, n/N (%):

N=60/152 (39.5%)

≥40 years of age, n/N (%):

N=92/152 (60.5%)

Main symptoms:

Bleeding, n/N (%):

N=103/152 (67.8%)

Other, n/N (%):

N=49/152 (32.2%)

Family history of CRC*

Positive family history of CRC, n/N (%):

N=13/152 (8.5%)

Negative family history of CRC, n/N (%):

N=139/152 (91.5%)

Describe intervention (treatment/procedure/test):

Colonoscopy

Incidence, n/N (%)

Number of findings in the total population

Total colonoscopic findings, N (%):

N=75 (100%)

Specific findings, n/N (%):

Polyp, n/N (%):

N=60/75 (80%)

Malignant tumor, n/N (%):

N=1/75 (1.3%)

Diverticula, n/N (%):

N=10/75 (13.3%)

Non-specific inflammation, n/N (%):

N=3/75 (4%)

Angiodysplasia, n/N (%):

N=1/75 (1.3%)

Number of findings in both groups

Main diagnosis:

Hemorrhoids, n/N (%):

1st group: N=28/35 (80%)

2^nd group: N=102/152 (67.1%)

P=0.107

Anal fissure, n/N (%):

1^st group: N=1/35 (2.9%)

2^nd group: N=25/152 (16.4%)

Anal fistula, n/N (%):

1^st group: N=6/35 (17.1%)

2^nd group: N=25/152 (16.4%)

Despite the limitations of the present study, a single-center study with a somewhat limited number of patients, we addressed a new aspect in colorectal cancer prevention that had not been investigated to this date. We were able to document a high prevalence of adenomatous polyps in patients younger than 50 years of age who initially presented with symptoms related to benign anal problems. Our results seem to be in line with the recently reported increasing incidence of colorectal cancer in young individuals and the new tendency to start screening at an early age. Our data suggested that a colonoscopy might be considered as a valid strategy of investigation in such a frequent clinical situation. Further studies with a larger number of patients and assessment of long-term outcomes are needed to define the ultimate role of colonoscopy in these patients.

Koning, 2010

Opzet:

Retrospectief

Setting:

Ziekenhuis

Land:

Nederland

Patiënten:

N=1910

Group 1: N=861

Group 2: N=1049

Indicaties voor endoscopie: normal clinical indications in daily practice (abdominal complaints, diarrhoea, rectal bleeding, anaemia, changes in bowel habits, family history of colorectal cancer and screening)

Age:

<50: N=97

Describe intervention (treatment/procedure/test):

Colonoscopie versus

Sigmoïdoscopie:

Incidentie, N (%)

Endoscopie

Polyps

33/97 (34%)

Cancer

1/97 (1.03%)

Author’s conclusion

In normal daily practice, especially bright rectal bleeding without further abdominal complaints will mostly be due to haemorrhoids in patients below the age of fifty. In case no other symptoms are present, haemorrhoids are seen during rectal examination, and there is no family history of colorectal cancer, the clinician could refrain from total colonoscopy in these patients. In patients above the age of fifty years endoscopic evaluation of the rectum and colon is advocated.

Khalid, 2011

Opzet:

retrospectief

Setting:

Tertiair ziekenhuis

Land:

Irak

Inclusie criteria:

• 18-50 years;
• PBPR (fresh blood per rectum;
• Red in feces toilet paper (in toilet bowl) in previous 6 months.

Exclusie criteria:

• IBD;
• Colorectal surgery;
• Family history of CRC;
• Bleeding diathesis;
• Iron deficiency anemia;
• Anticoagulant therapy;
• Significant bleeding per rectum requiring blood transfusions and/or emergency room visit.

N total at baseline:

N=379

257 men (67.8 %) and 122 women (32.2 %).

Subgroepen qua leeftijd:

N=131 patients (34.6 %) in the 40 – 50 years age group.

N=248 (65.4%) under 40 years old.

Describe intervention (treatment/procedure/test):

Colonoscopie

Incidentie, N (%)

Hemorroïden:

N=219 (57.8%)

Enkel hemorroïden:

N=198 (52.2%)

Hemorroïden + andere laesies:

N=21 (5.5%)

Adenomateuze poliep/CRC:

<40: N=7 (2.8%)

40-50: N=10 (7.6%)

Nikpour, 2008

Soort onderzoek:

Setting:

Land:

Iran

Excl: colorectal neoplasm, IBD, first degree family history of colorectal neoplasm, history of altered bowel habits, iron deficiency anemia, neoplastic polyps, colorectal carcinoma

Inclusie criteria:

Exclusie criteria:

• Colorectal neoplasm;
• IBD;
• First degree family history of colorectal neoplasm;
• History of altered bowel habits;
• Iron deficiency anemia;
• Neoplastic polyps;
• Colorectal carcinoma.

N total at baseline:

N=401

Male: N=219 (54.5%)

Female: N=183 (45.5%).

Mean age (range)

43.6 ± 15.7 years (13 to 86).

There were another 94 young patients (41 male, 53 female; aged 27.6 ± 5.8 years), who met the eligibility criteria, but did not agree to participate and undergo colonoscopy.

Describe intervention (treatment/procedure/test):

Colonoscopie

Incidentie, N (%)

Hemorrhoiden:

N= (54.2)

<40 jaar: N=62 (35.0%)

Carcinoom: 

<40jr: N=4 (2.3%)

Our study showed that significant lesions in the proximal colon are infrequent in patients with minimal BRBPR. Colonoscopy is recommended for the evaluation of rectal bleeding in patients who are at increased risk for colorectal neoplasms (‘red flags’)[3], but there are no specific recommendations for the appropriate evaluation of the majority of patients who lack these risk factors. The decision about the extent of the evaluation of these patients should be based on the prevalence of clinically significant lesions, potential need for a repeat procedure, costs and availability of the facility. Some experts recommend that young patients do not require further evaluation, if the presentation and history do not suggest an increased risk of cancer and a potential source of bleeding (such as hemorrhoids or an anal fissure) is identified in the clinical evaluation.

Study reference

Bias due to a non-representative or ill-defined sample of patients?¹

(unlikely/likely/unclear)

Bias due to insufficiently long, or   incomplete follow-up, or differences in follow-up between treatment groups?²

(unlikely/likely/unclear)

Bias due to ill-defined or inadequately measured outcome ?³

(unlikely/likely/unclear)

Bias due to inadequate adjustment for all important prognostic factors?⁴

(unlikely/likely/unclear)

Lu, 2020

Unlikely

“Diagnostic colonoscopies performed in young adults with age ≤40 during the study period from the participating institutions were included. Patients with familial hereditary colon cancer syndromes, those who received colonoscopy for CRC screening on account of having a first degree relative diagnosed with colon cancer at age.”

Unlikely

Unlikely

Unlikely

“Univariate logistic regression analysis was performed to identify variables that predict a positive DY. A multivariate analysis was then performed using variables found significant on univariate analysis.”

Hussian, 2019

Unlikely

Patients were selected from the same population.

Unlikely

Unlikely

Unlikely

Muller, 2019

Unlikely

“patients younger than 50 years of age who attend to the Coloproctology Clinic within Hospital de Clínicas de Porto Alegre, Southern Brazil, between January 2014 and January 2018. In order to be included in the study, patients had to present with complaint of rectal bleeding and subsequently had a diagnosis of anal disorder, which clearly could be the cause of the bleeding, established at the physical examination. Patients with symptoms suggesting the possibility of a colorectal carcinoma, such as melena, weight loss, anemia, and altered bowel habit, were not included in the study. Other exclusion criteria were inflammatory bowel disease, family history of inherited colorectal cancer syndrome, history of diverticular disease, anticoagulation, and history of a previous colonoscopy. Patients with a first-degree family history of CRC, which represents a formal indication to perform a colonoscopy before the age of 50, were not included in the study. In addition, patients who failed to achieve adequate bowel preparation for the exam (Boston scale for bowel preparation, scores 0 and 1) were also excluded from the analysis.”

Unlikely

Unlikely

Unlikely

Author and year

Reason for exclusion

He (2019)

Studiepopulatie voldoet niet aan de PICO

Ibrahim (2019)

Studiepopulatie voldoet niet aan de PICO

Cross (2019)

Studiepopulatie voldoet niet aan de PICO

Kim (2018)

Studiepopulatie voldoet niet aan de PICO

Lai (2016)

Studiepopulatie voldoet niet aan de PICO