Luminary Learning Gastrointestinal Disorder- Issue 1

Current Guidelines for Colonoscopy •  41 pouch, Kock pouch) [31]. It is therefore recommended to perform surveillance of the pouch and the ATZ cuff every 1–3 years by means of a flexible pouchoscopy and random biopsies. Colorectal Screening for Elderly While there is a general broad consensus about the age of when to initiate CRC screening and surveillance, there remains significant controversy and silence about when to end it. As pre- viously noted, this question does not or only to a lesser degree apply to the indications for a diagnostic workup for respective clinical symptoms, which are generally an accepted reason to perform a colonoscopy even in patients of advanced age and have been associated with a high yield of advanced neoplasms in 26–30% [32]. However, in absence of symptoms the potential screening benefits of prolonging cancer-free survival have to be weighed against the risks, the lower estimated gain in life expectancy (compared to younger individuals), and the cost of pro- phylactic screening for cancer in any patient subgroup. In the elderly population (as defined by an age above 75–80 years), the patient’s overall performance status and non-CRC life expectancy have a much higher impact and should be taken into consideration [32–34]. A strict limitation based on a rigid age threshold would result in underuse of appropriate screening efforts in fit older individuals; at the same time, it would carry the potential of overusing it in otherwise less healthy younger individuals with limited life expectancy [35]. Unfortunately, elderly patients have been commonly excluded from participation in high-quality, randomized trials including colorectal cancer screening trials that aim at studying the efficacy of the screening colonoscopy. As such, the current screening colonoscopy recommendations have largely failed to address the impact of comorbidities, functional status, and life expectancy in general and particularly in the elderly [34]. Pearls and Pitfalls zz The start age and screening intervals recommended for the use of screening colonoscopies are patient dependent and rely largely on the patient population and associated underlying risk factors. Critical population characteristics and risk factors include: „„ Age (dependent on family history, race, and known genetic predisposition) „„ Family history (history of CRC and known genetic predispositions) „„ Personal medical history (including genetic predispositions, underlying inflammatory bowel disease, findings on prior screening colonoscopies). zz Appropriate preparation prior to the screening colonoscopy is critical for a clinically meaning- ful examination; this preparation includes the adoption of an appropriate diet and the comple- tion of a recommended bowel-cleansing regimen. zz Colonoscopy guidelines for the purpose of identifying early disease in asymptomatic patients (screening), have no role in defining the appropriate use of colonoscopies with alternate roles (diagnostic or therapeutic colonoscopies) for identifying and treating pathology in the symp- tomatic patient.