Skip to main content

Is a fecal occult blood test a useful tool for judging whether to perform capsule endoscopy in low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy?

Journal of Gastroenterology volume 52, pages 194–202 (2017)Cite this article

Abstract

Background

Aspirin use is reportedly not to be associated with fecal immunochemical occult blood test (FIT) false-positive results for the detection of colorectal cancer. The need for additional small bowel exploration in FIT-positive, low-dose aspirin users with a negative colonoscopy is controversial. The aim of this study was to assess the ability of FIT to judge whether capsule endoscopy (CE) should be performed in low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy findings by comparing FIT results with CE findings.

Methods

A total of 264 consecutive low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy who were scheduled to undergo CE at five hospitals in Japan were enrolled. Patients had been offered FIT prior to the CE. The association between the FIT results and the CE findings was then assessed.

Results

One hundred and fifty-seven patients were included in the final analysis. Eighty-four patients (53.5 %) had positive FIT results. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of positive FIT results for small bowel ulcers were 0.56, 0.47, 0.30, and 0.73, respectively. Furthermore, the NPV of positive FIT results for severe small bowel injury (Lewis score ≥790) was markedly high (0.90). When the analysis was performed only in low-dose aspirin users with anemia, the sensitivity of the positive FIT results was notably improved (0.72).

Conclusions

Small bowel evaluation using CE is not recommended for FIT-negative, low-dose aspirin users. However, small bowel evaluation using CE should be considered in both FIT-positive and anemic low-dose aspirin users.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

Abbreviations

BMI:

Body mass index

CE:

Capsule endoscopy

CI:

Confidence interval

FIT:

Fecal immunochemical occult blood test

FOBT:

Fecal occult blood test

NPV:

Negative predictive value

NSAID:

Nonsteroidal anti-inflammatory drug

OR:

Odds ratio

PPV:

Positive predictive value

References

  1. van Rossum LG, van Rijn AF, Laheij RJ, et al. Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population. Gastroenterology. 2008;135:82–90.

    Article  PubMed  Google Scholar 

  2. Guittet L, Bouvier V, Mariotte N, et al. Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population. Gut. 2007;56:210–4.

    CAS  Article  PubMed  Google Scholar 

  3. Levi Z, Rozen P, Hazazi R, et al. A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med. 2007;146:244–55.

    Article  PubMed  Google Scholar 

  4. Park DI, Ryu S, Kim YH, et al. Comparison of guaiac-based and quantitative immunochemical fecal occult blood testing in a population at average risk undergoing colorectal cancer screening. Am J Gastroenterol. 2010;105:2017–25.

    Article  PubMed  Google Scholar 

  5. Levi Z, Rozen P, Hazazi R, et al. Sensitivity, but not specificity, of a quantitative immunochemical fecal occult blood test for neoplasia is slightly increased by the use of low-dose aspirin, NSAIDs, and anticoagulants. Am J Gastroenterol. 2009;104:933–8.

    CAS  Article  PubMed  Google Scholar 

  6. Brenner H, Tao S, Haug U. Low-dose aspirin use and performance of immunochemical fecal occult blood tests. JAMA. 2010;304:2513–20.

    CAS  Article  PubMed  Google Scholar 

  7. Awtry EH, Loscalzo J. Aspirin. Circulation. 2000;101:1206–18.

    CAS  Article  PubMed  Google Scholar 

  8. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Article  Google Scholar 

  9. Patrono C, García Rodríguez LA, Landolfi R, et al. Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med. 2005;353:2373–83.

    CAS  Article  PubMed  Google Scholar 

  10. Weil J, Colin-Jones D, Langman M, et al. Prophylactic aspirin and risk of peptic ulcer bleeding. BMJ. 1995;310:827–30.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. Patrono C. Aspirin as an antiplatelet drug. N Engl J Med. 1994;330:1287–94.

    CAS  Article  PubMed  Google Scholar 

  12. Graham DY, Opekun AR, Willingham FF, Qureshi WA. Visible small-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol. 2005;3:55–9.

    Article  PubMed  Google Scholar 

  13. Maiden L, Thjodleifsson B, Theodors A, et al. A quantitative analysis of NSAID-induced small bowel pathology by capsule endoscopy. Gastroenterology. 2005;128:1172–8.

    Article  PubMed  Google Scholar 

  14. Maiden L, Thjodleifsson B, Seigal A, et al. Long-term effects of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 selective agents on the small bowel: a cross-sectional capsule enteroscopy study. Clin Gastroenterol Hepatol. 2007;5:1040–5.

    Article  PubMed  Google Scholar 

  15. Goldstein JL, Eisen GM, Lewis B, Investigators, et al. Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo. Clin Gastroenterol Hepatol. 2005;3:133–41.

    Article  PubMed  Google Scholar 

  16. Goldstein JL, Eisen GM, Lewis B, et al. Small bowel mucosal injury is reduced in healthy subjects treated with celecoxib compared with ibuprofen plus omeprazole, as assessed by video capsule endoscopy. Aliment Pharmacol Ther. 2007;25:1211–22.

    CAS  Article  PubMed  Google Scholar 

  17. Endo H, Hosono K, Inamori M, et al. Incidence of small bowel injury induced by low-dose aspirin: a crossover study using capsule endoscopy in healthy volunteers. Digestion. 2009;79:44–51.

    CAS  Article  PubMed  Google Scholar 

  18. Endo H, Hosono K, Inamori M, et al. Characteristics of small bowel injury in symptomatic chronic low-dose aspirin users: the experience of two medical centers in capsule endoscopy. J Gastroenterol. 2009;44:544–9.

    CAS  Article  PubMed  Google Scholar 

  19. Endo H, Higurashi T, Hosono K, et al. Efficacy of Lactobacillus casei treatment on small bowel injury in chronic low-dose aspirin users: a pilot randomized controlled study. J Gastroenterol. 2011;46:894–905.

    Article  PubMed  Google Scholar 

  20. Endo H, Sakai E, Higurashi T, et al. Differences in the severity of small bowel mucosal injury based on the type of aspirin as evaluated by capsule endoscopy. Dig Liver Dis. 2012;44:833–8.

    CAS  Article  PubMed  Google Scholar 

  21. Endo H, Kato T, Sakai E, et al. Small bowel injury in low-dose aspirin users. J Gastroenterol. 2015;50:378–86.

    CAS  Article  PubMed  Google Scholar 

  22. Nadatani Y, Watanabe T, Tanigawa T, et al. Incidence and risk factors of gastrointestinal bleeding in patients on low-dose aspirin therapy after percutaneous coronary intervention in Japan. Scand J Gastroenterol. 2013;48:320–5.

    CAS  Article  PubMed  Google Scholar 

  23. Chiba H, Sekiguchi M, Ito T, et al. Is it worthwhile to perform capsule endoscopy for asymptomatic patients with positive immunochemical faecal occult blood test? Dig Dis Sci. 2011;56:3459–62.

    Article  PubMed  Google Scholar 

  24. Efthymiou M, Allen PB, Jayasekera C, et al. Value of fecal occult blood test as a screening test before capsule endoscopy. Eur J Gastroenterol Hepatol. 2011;23:690–4.

    CAS  Article  PubMed  Google Scholar 

  25. Levi Z, Gal E, Vilkin A, et al. Fecal immunochemical test and small bowel lesions detected on capsule endoscopy: results of a prospective study in patients with obscure occult gastrointestinal bleeding. Eur J Gastroenterol Hepatol. 2011;23:1024–8.

    CAS  PubMed  Google Scholar 

  26. Endo H, Sakai E, Taniguchi L, et al. Risk factors for small-bowel mucosal breaks in chronic low-dose aspirin users: data from a prospective multicenter capsule endoscopy registry. Gastrointest Endosc. 2014;80:826–34.

    Article  PubMed  Google Scholar 

  27. Gralnek IM, Defranchis R, Seidman E, et al. Development of a capsule endoscopy scoring index for small bowel mucosal inflammatory change. Aliment Pharmacol Ther. 2008;27:146–54.

    CAS  Article  PubMed  Google Scholar 

  28. Endo H, Hosono K, Higurashi T, et al. Quantitative of low-dose aspirin-associated small bowel injury using a capsule endoscopy scoring index. Dig Endosc. 2011;23:56–61.

    Article  PubMed  Google Scholar 

  29. Matsumoto T, Kudo T, Esaki M, et al. Prevalence of non-steroidal anti-inflammatory drug-induced enteropathy determined by double-balloon endoscopy: a Japanese multicenter study. Scand J Gastroenterol. 2008;43:490–6.

    CAS  Article  PubMed  Google Scholar 

  30. Manetas M, O’Loughlin C, Kelemen K, et al. Multiple small-bowel diaphragms: a cause of obscure GI bleeding diagnosed by capsule endoscopy. Gastrointest Endosc. 2004;60:848–51.

    Article  PubMed  Google Scholar 

  31. Watanabe T, Tanigawa T, Nadatani Y, et al. Risk factors for severe nonsteroidal anti-inflammatory drug-induced small intestinal damage. Dig Liver Dis. 2013;45:390–5.

    CAS  Article  PubMed  Google Scholar 

  32. Kobayashi Y, Watabe H, Yamada A, et al. Impact of fecal occult blood on obscure gastrointestinal bleeding: observational study. World J Gastroenterol. 2015;21:326–32.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Nakama H, Zhang B, Fattah AS. A cost-effective analysis of the optimum number of stool specimens collected for immunochemical occult blood screening for colorectal cancer. Eur J Cancer. 2000;36:647–50.

    CAS  Article  PubMed  Google Scholar 

  34. Wong BC, Wong WM, Cheung KL, et al. A sensitive guaiac faecal occult blood test is less useful than an immunochemical test for colorectal cancer screening in a Chinese population. Aliment Pharmacol Ther. 2003;18:941–6.

    Article  PubMed  Google Scholar 

  35. Rockey DC, Koch J, Cello JP, et al. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. N Engl J Med. 1998;339:153–9.

    CAS  Article  PubMed  Google Scholar 

  36. Hsia PC, Al-Kawas FH. Yield of upper endoscopy in the evaluation of asymptomatic patients with Hemoccult-positive stool after a negative colonoscopy. Am J Gastroenterol. 1992;87:1571–4.

    CAS  PubMed  Google Scholar 

  37. Bini EJ, Rajapaksa RC, Valdes MT, et al. Is upper gastrointestinal endoscopy indicated in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy? Am J Med. 1999;106:613–8.

    CAS  Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported in part by a Grant from the Japan Society for the Promotion of Science (JSPS), Japan [Grant-in-Aid for Young Scientists (B)], to H.E.

Author information

Affiliations

  1. Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan

    Hiroki Endo, Takayuki Kato, Eiji Sakai, Takuma Higurashi, Hidenori Ohkubo, Takashi Nonaka, Masahiko Inamori & Atsushi Nakajima

  2. Department of Gastroenterology, Chigasaki Municipal Hospital, Chigasaki, Japan

    Leo Taniguchi & Yasuo Hata

  3. Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Japan

    Jun Arimoto & Takashi Sakaguchi

  4. Department of Gastroenterology, Odawara Municipal Hospital, Odawara, Japan

    Harunobu Kawamura

  5. Department of Gastroenterology, Yokohama Rosai Hospital, Yokohama, Japan

    Hajime Nagase

  6. Department of Biostatistics and Epidemiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan

    Masataka Taguri & Takeharu Yamanaka

Authors
  1. Hiroki Endo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takayuki Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eiji Sakai
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Leo Taniguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jun Arimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Harunobu Kawamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Takuma Higurashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hidenori Ohkubo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Takashi Nonaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Masataka Taguri
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Masahiko Inamori
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Takeharu Yamanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Takashi Sakaguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Yasuo Hata
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Hajime Nagase
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Atsushi Nakajima
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hiroki Endo.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Endo, H., Kato, T., Sakai, E. et al. Is a fecal occult blood test a useful tool for judging whether to perform capsule endoscopy in low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy?. J Gastroenterol 52, 194–202 (2017). https://doi.org/10.1007/s00535-016-1212-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00535-016-1212-2

Keywords

  • Fecal immunochemical occult blood test
  • Capsule endoscopy
  • Small bowel
  • Low-dose aspirin