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Random colonic biopsies in macroscopically normal colonoscopies: is there any benefit? A two-centre audit of current
Vidya Seenarain1, Marwan Idrees2, Jessie Mogridge3
1Department of General Surgery, Rockingham General Hospital, Perth, Western Australia, Australia.
Insights
Random colonic biopsies (RCBs) in patients with normal-appearing colons have a low yield for diagnosing microscopic colitis and are expensive. Guidelines should prioritize RCBs for patients with a high suspicion of chronic diarrhea causes.
Area of Science:
- Gastroenterology
- Colorectal Cancer Screening
- Diagnostic Yield
Background:
- British Society of Gastroenterology guidelines recommend random colonic biopsies (RCBs) for chronic diarrhea to detect microscopic colitis.
- Evidence suggests RCBs have low diagnostic yield and high costs, with cost-effectiveness not previously assessed.
- Recent data indicates a need to re-evaluate the utility and cost of RCBs in routine practice.
Purpose of the Study:
- To audit the diagnostic yield of RCBs in macroscopically normal colonic mucosa for microscopic colitis.
- To compare practice patterns and outcomes between gastroenterologists and general surgeons regarding RCBs.
- To calculate the cost-effectiveness of RCBs for diagnosing microscopic colitis.
Main Methods:
- A two-center audit of colonoscopies with RCBs performed between January 2009 and June 2018.
- Inclusion of 872 cases with endoscopically normal colonic mucosa.
- Analysis of indications for RCBs, diagnostic yield, and associated costs (consumables, endoscopy time, histopathology).
Main Results:
- 48.7% of RCBs were performed for diarrhea; only 1.5% yielded a diagnosis of microscopic colitis.
- Microscopic colitis was diagnosed in 3.1% of patients with diarrhea.
- The cost per positive diagnosis of microscopic colitis was calculated at $10,862.42, with only one patient receiving treatment.
Conclusions:
- RCBs in normal colonic mucosa demonstrate poor diagnostic yield and are costly.
- Current local guidelines should be revised to recommend RCBs only for patients with a high clinical suspicion of organic causes for chronic diarrhea.
- Targeted biopsy strategies may improve cost-effectiveness in diagnosing microscopic colitis.
Background:
Recent guidelines from the British Society of Gastroenterology published in April 2018, recommended performing random colonic biopsies (RCB) in endoscopically normal colonic mucosa when investigating chronic diarrhoea in adults to rule out microscopic colitis; however, cost effectiveness was not accounted for due to poor evidence base. There is now more evidence that RCBs are of low yield and of significant cost.
Methods:
A two-centre audit of current practice was conducted at Rockingham General Hospital and Fremantle Hospital in Western Australia, aiming to determine the yield of RCB in macroscopically normal mucosa for microscopic colitis, from 1 January 2009 to 30 June 2018, with comparisons of practice and results between gastroenterologists and general surgeons. Variability in the indications (diarrhoea and non-diarrhoea indications) for RCBs was determined and the cost of consumables, additional endoscopy time and histopathology analysis were calculated.
Results:
A total of 872 normal colonoscopies with RCBs were included; 48.7% of colonoscopies with RCB were for diarrhoea. Only 1.5% of RCBs were positive for microscopic colitis; 3.1% of patients with diarrhoea had microscopic colitis. Only one patient received pharmacologial treatment as a result of the test. The calculated cost per positive diagnosis of microscopic colitis was $10 862.42.
Conclusion:
RCBs from normal colonic mucosa have poor yield and are costly. Local guidelines should be updated, so RCBs are performed only in patients with a high degree of suspicion of an organic cause of chronic diarrhoea.
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