Adverse events after screening and follow-up colonoscopy

Carolyn M. Rutter; Eric Johnson; Diana L. Miglioretti; Margaret T. Mandelson; John Inadomi; Diana S. M. Buist

doi:10.1007/s10552-011-9878-5

Cancer Causes & Control

February 2012, Volume 23, Issue 2, pp 289–296 | Cite as

Adverse events after screening and follow-up colonoscopy

Authors
Authors and affiliations

Carolyn M. RutterEmail author
Eric Johnson
Diana L. Miglioretti
Margaret T. Mandelson
John Inadomi
Diana S. M. Buist

Original paper

First Online: 22 November 2011

Received: 19 May 2011

Accepted: 10 November 2011

3 Shares
298 Downloads
35 Citations

Abstract

Objective

We provide new information about how the risk of adverse events following colonoscopy varies by age and indication (screening vs. follow-up performed to evaluate a positive result from another screening modality).

Methods

We constructed a retrospective cohort comprised of 43,456 individuals aged 40–85 years enrolled in a large integrated healthcare organization in Washington State who underwent outpatient colonoscopy between 1994 and 2009. We calculated rates of serious adverse events (perforation, hemorrhage, and acute diverticulitis) in the 30 days following colonoscopy and compared rates using log-binomial regression models.

Results

We observed 4.7 serious adverse events per 1,000 screening colonoscopies and 6.8 per 1,000 follow-up colonoscopies. Polypectomy increased the rate of serious adverse events (relative rate [RR], 2.64; 95% confidence interval [CI], 1.97–3.56). Older age was associated with increased risk of serious adverse events, after adjusting for polypectomy, gender, and indication. Compared to individuals aged 50–64 years, risk was elevated for those aged 65–74 (RR, 1.93; 95% CI, 1.40–2.65) and 75–85 (RR, 3.21; 95% CI 2.14–4.86). We observed similar age effects in individuals with and without significant comorbid conditions.

Conclusions

The risks of serious adverse events following colonoscopy performed as part of screening are low but increase with age and are more likely after polypectomy.

Keywords

Colorectal cancer screening Polypectomy Age trends Comorbidity

This is a preview of subscription content, to check access.

Notes

Acknowledgments

This work was supported by NCI U01 CA97427 and NCI U01 CA152959.

Appendix: Exclusion criteria

Here, we describe specific codes found in automated data that we used to exclude colonoscopies from our sample. These are based on ICD-9 diagnosis, procedure, and v-codes, and CPT-4 and HCPCS procedure codes. First, we excluded colonoscopies based on procedure codes. We excluded therapeutic and high-risk colonoscopies. HCPCS code G0105 and CPT codes 45337, 45355, 45379, 45382, 45386, 45387, 45391, 45392. We also excluded colonoscopies through a colotomy: CPT codes 45355, 44388, 44390, 44391, 44392, 44393, 44394, 44397, 44489.

Next, we excluded colonoscopies that may have been symptom-drive, based on visit diagnosis in the 6 months prior to the index colonoscopy, including abdominal pain (ICD-9 789.X), gastrointestinal bleeding (ICD-9 codes 45.43, 285.1, 562.13, 578.1, 558.9, 578.9, 998.1–998.13), diarrhea (ICD-9 codes: infectious: 009.X, NOS 787.91), anemia (iron deficiency: ICD-9 280.X, screening for iron deficiency anemia ICD-9 V78.0, or unspecified anemia ICD-9 285.9), drop in hematocrit (ICD-9 790.01), fecal incontinence (ICD-9 787.6), protozoal intestinal disease (ICD-9 007.X), functional digestive disorder (ICD-9 564.X), vascular insufficiency of the intestine (ICD-9 557.X), diverticulitis of the intestine with or without hemorrhage (ICD-9 562.11,562.13), other gastroenteritis or colitis (ICD-9 558, 558.1-558.3, 558.9), anal fissure or fistula (ICD-9 565.X), intestinal obstruction (ICD-9 560.X), intestinal malabsorption (ICD-9 579.X), and other disorders of the intestine (ICD-9 569.X).

Third, we excluded colonoscopies in individuals who had an upper endoscopy in the 7 days before colonoscopy, based on ICD-9 codes (45.11, 45.12, 45.13, and 45.16), CPT codes (43200–44386), and an HCPCS code indicating referral for upper endoscopy (3132F). We also excluded colonoscopies in individuals with abdominal imaging in the 90 days prior to colonoscopy:

ICD-9 codes: 87.5X, 87.6X, 87.7X, 87.8X, 87.91, 87.92, 87.94, 87.99, 88.0–88.03, 88.09, 88.1X, 88.7, 88.74–88.76, 88.79, 88.9X, 92.0X
CPT codes: 72170, 72190, 72192–72194, 73540, 74000–74170, 74181–74183, 74190, 74220, 74240, 74241, 74245–74330, 74363, 74400–74471, 74720–74741, 74760, 75980–75983, 76010, 76081, 76380, 76700–76705, 76770, 76775, 76778, 76830, 76831, 76855–76873, 76925, 76948, 78185, 78186, 78201–78232, 78240, 78258–78264, 78270–78272, 78276, 78278, 78280, 78283, 78290, 78291, 78298, 78299, 78700–78799,
HCPCS codes: Q9954, S8037, G0163–G0165, G0213–G0215, G0226–G0228, G0231

We excluded individuals in whom colonoscopy may be used to guide treatment, including those with a prior diagnosis of ulcerative colitis (ICD-9 556.X), regional enteritis (Crohn’s disease, ICD-9 555.X), vascular insufficiency of the intestine (ICD-9 557.X), neurogenic bowel (ICD-9 564.81), and other and unspecified noninfectious gastroenteritis and colitis (ICD-9 558.1–558.3, 558.9). We also excluded individuals who underwent colonoscopies after colonic resection (ICD-9 45.7X, 45.8; CPT 44202–44212). We excluded individuals who were not eligible for usual screening based on personal or family history of malignant neoplasms in the gastrointestinal tract (ICD-9 V10.05, V16.0, V18.51, V12.72), benign neoplasm (polyp) of the colon (ICD-9 211.3) or rectum or anal canal (ICD-9 211.4) or neoplasm uncertain behavior stomach, intestines, or rectum (ICD-9 235.2). While we relied primarily on SEER data to exclude individuals with prior cancer diagnoses, we also used electronic medial record data to exclude individuals with colon or rectal cancer based on ICD-9 (153.x, 154.X, and 197.5) and HCPCS (G0213, G0214, G0215, and G0231) codes.

Finally, we excluded individuals with an internal defibrillator who may be at increased risk following colonoscopy, particularly if they undergo electrocautery (ICD-9: 37.94–37.99, CPT: 33215–33223, 33249, 93745, HCPCS: C1721,C1722,C1899, ICD-9: V53.32)

References

1.
Lieberman D (2010) Progress and challenges in colorectal cancer screening and surveillance. Gastroenterology 138(6):2115–2126 [PMID: 20167216]PubMedCrossRefGoogle Scholar
2.
Levin B, Lieberman DA, McFarland BG, Andrews KS, Brooks D, Bond J et al (2008) Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American cancer society, the US multi-society task force on colorectal cancer, and the american college of radiology. Gastroenterology 134(5):1570–1595 [PMID: 18384785]PubMedCrossRefGoogle Scholar
3.
Whitlock EP, Lin JS, Liles E, Beil TL, Fu R (2008) Screening for colorectal cancer: a targeted, updated systematic review for the US preventive services task force. Ann Intern Med 149(9):638–658 [PMID: 18838718]PubMedGoogle Scholar
4.
US Preventive Services Task Force (2008) Screening for colorectal cancer: US preventive services task force recommendation statement. Ann Intern Med 149(9):627–637 [PMID: 18838716]Google Scholar
5.
Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM (2009) American college of gastroenterology guidelines for colorectal cancer screening [corrected]. Am J Gastroenterol 104(3):739–750 [PMID: 19240699]PubMedCrossRefGoogle Scholar
6.
Edwards BK, Ward E, Kohler BA, Eheman C, Zauber AG, Anderson RN et al (2009) Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116(3):544–573 [PMID: 19998273]CrossRefGoogle Scholar
7.
Schenck AP, Peacock SC, Klabunde CN, Lapin P, Coan JF, Brown ML (2009) Trends in colorectal cancer test use in the medicare population, 1998–2005. Am J Prev Med 37(1):1–7 [PMID: 19423273]PubMedCrossRefGoogle Scholar
8.
Richardson IC, Rim SH, Plescia M (2010) Vital signs: colorectal cancer screening among adults aged 50–75 years—United States, 2008. MMWR Morb Mortal Wkly Rep 59:808–812 [PMID: 20613704]Google Scholar
9.
Holden DJ, Harris R, Porterfield DS, Jonas DE, Morgan L, Reuland D et al (2010) Enhancing the use and quality of colorectal cancer screening. Evidence Report/Technology Assessment no 190. Agency for Healthcare Research and Quality; AHRQ publication no 10-E002. Rockville, MD, http://www.ahrq.gov/downloads/pub/evidence/pdf/crcuse/crcuse.pdf. Accessed 17 Nov 2011 [PMID 20726624]
10.
Levin TR, Zhao W, Conell C, Seeff LC, Manninen DL, Shapiro JA et al (2006) Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 145(12):880–886 [PMID: 17179057]PubMedGoogle Scholar
11.
Singh H, Penfold RB, DeCoster C, Kaita L, Proulx C, Taylor G et al (2009) Colonoscopy and its complications across a Canadian regional health authority. Gastrointest Endosc 69(3 Pt 2):665–671 [PMID: 19251007]PubMedCrossRefGoogle Scholar
12.
Warren JL, Klabunde CN, Mariotto AB, Meekins A, Topor M, Brown ML et al (2009) Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 150:849–857 [PMID: 19528563]PubMedGoogle Scholar
13.
Ko CW, Riffle S, Michaels L, Morris C, Holub J, Shapiro JA et al (2010) Serious complications within 30 days of screening and surveillance colonoscopy are uncommon. Clin Gastroenterol Hepatol 8(2):166–173 [PMID: 19850154]PubMedCrossRefGoogle Scholar
14.
Shih YC, Zhao L, Elting LS (2006) Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Health Aff (Millwood) 25(4):1153–1162 [PMID: 16835198]CrossRefGoogle Scholar
15.
Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J et al (2003) Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology 124(2):544–560 [PMID: 12557158]PubMedCrossRefGoogle Scholar
16.
Rabeneck L, Paszat LF, Hilsden RJ, Saskin R, Leddin D, Grunfeld E et al. (2008) Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 135(6):1899–1906, 1906.e1 [PMID: 18938166]Google Scholar
17.
Cheon JH, Kim WH (2007) Recent advances of endoscopy in inflammatory bowel diseases. Gut Liver 1(2):118–125 [PMID: 20485627]PubMedCrossRefGoogle Scholar
18.
Greenstein AJ, Sachar DB, Smith H, Janowitz HD, Aufses AH Jr (1981) A comparison of cancer risk in Crohn’s disease and ulcerative colitis. Cancer 48(12):2742–2745 [PMID: 7306930]PubMedCrossRefGoogle Scholar
19.
Konda A, Duffy MC (2008) Surveillance of patients at increased risk of colon cancer: inflammatory bowel disease and other conditions. Gastroenterol Clin North Am 37(1):191–213, viii [PMID: 18313546]Google Scholar
20.
Klabunde CN, Potosky AL, Legler JM, Warren JL (2000) Development of a comorbidity index using physician claims data. J Clin Epidemiol 53(12):1258–1267 [PMID: 11146273]PubMedCrossRefGoogle Scholar
21.
Rutter CM, Yu O, Miglioretti DL (2007) A hierarchical non-homogenous Poisson model for meta-analysis of adenoma counts. Stat Med 26(1):98–109 [PMID: 16372387]PubMedCrossRefGoogle Scholar
22.
Sharma VK, Nguyen CC, Crowell MD, Lieberman DA, de Garmo P, Fleischer DE (2007) A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 66(1):27–34 [PMID: 17591470]PubMedCrossRefGoogle Scholar

Copyright information

Authors and Affiliations

Carolyn M. Rutter
- 1
- 2
- 3
Email author
Eric Johnson
- 1
Diana L. Miglioretti
- 1
- 2
Margaret T. Mandelson
- 4
John Inadomi
- 5
Diana S. M. Buist
- 1
- 3
- 4

1.Group Health Research InstituteSeattleUSA
2.Department of Biostatistics, School of Public HealthUniversity of WashingtonSeattleUSA
3.Department of Health Services, School of Public HealthUniversity of WashingtonSeattleUSA
4.Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleUSA
5.Division of Gastroenterology, Department of MedicineUniversity of WashingtonSeattleUSA

Adverse events after screening and follow-up colonoscopy

Abstract

Objective

Methods

Results

Conclusions

Keywords

Notes

Acknowledgments

References

Copyright information

Authors and Affiliations

Personalised recommendations

Cite article