Luminary Learning Gastrointestinal Disorder- Issue 1

38  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS Undoubtedly, colonoscopy has remained and solidified its current role as the gold standard for detection and prevention of colorectal cancer. This remains true despite an imperfect score card. There is substantial inconvenience and the low, but not negligible, risk of side effects and complications associated with the procedure. Furthermore, colonoscopy has an estimated miss rate of approximately 6–12% for large adenomas (adenomas with a size greater than or equal to 10 mm) and a miss rate of 5% for colon cancer [9]. Lastly, while the population-wide screen- ing rates have improved in the United States, 40% of Americans aged 50–75 years are still not being screened, and our set goals remain below the recommendations of our screening guidelines [18–20]. Complications Problems and complications may result from the preparation, sedation, or occur during the actual procedure phase but signs and symptoms thereof may be delayed [21]. A high index of suspi- cion, early recognition, and prompt intervention are key to minimizing the morbidity and mor- tality associated with any major complication. Not surprisingly, pure screening procedures have the lowest risk of complications followed by diagnostic and interventional colonoscopies (e.g., polypectomy); both age and comorbid conditions increased the risk for adverse events [22]. Hemorrhage and Perforation The two most serious complications are bleeding and perforation. The former is typically asso- ciated with endoscopic interventions, while the latter may be due to both, interventions or the mechanics of scope advancement and insufflation. The reported risk of colonic perforation increases with age and with the presence of diverticular disease and ranges from 0.01% to 0.2% of examined patients [21, 23]. In a random five-percent sample of Medicare beneficiaries with colo- noscopies compared with a matched control group without colonoscopy, the unadjusted risk of perforation or bleeding increased from 0.1 to 0.6 and from 1.8 to 6.4 per 1000 procedures, respec- tively [22]. The unadjusted risk for gastrointestinal bleeding was more than four times higher in the polypectomy group than the screening alone group without polypectomy (8.7 vs. 2.1 per 1000 procedures, respectively) [22]. Mortality The ultimate complication of death in relation to colonoscopy is rare but not negligible. It may be difficult to distinguish in larger databases whether the mortality was truly related to the interven- tion as such or more the result of a severe underlying disease and comorbidities. In a 2010 review of colonoscopy complications based on prospective studies and retrospective analyses of large clinical or administrative databases, there were 128 deaths reported among 371,099 colonosco- pies, for an unweighted pooled death rate of 0.03% [21].