Skip to main content

Advertisement

SpringerLink
Log in

The evaluation of rectal bleeding in adults

A cost-effectiveness analysis comparing four diagnostic strategies

  • Review
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown.

OBJECTIVE: To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding.

DESIGN: Cost-effectiveness analysis using a Markov decision model.

DATA SOURCES: Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry.

TARGET POPULATION: Patients over age 40 with otherwise asymptomatic rectal bleeding.

TIME HORIZON: The patient’s lifetime.

PERSPECTIVE: Modified societal perspective.

INTERVENTIONS: Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy.

OUTCOME MEASURES: Incremental cost-effectiveness ratio.

RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio for colonscopy compared with flexible sigmoidoscopy was $5,480 per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonscopy.

RESULTS OF SENSITIVITY ANALYSES: The cost of colonoscopy was reduced to $1,686 per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above $34,000.

CONCLUSIONS: Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Nelson RL, Abcarian H, Davis FG, Persky V. Prevalence of benign anorectal disease in a randomly selected population. Dis Colon Rectum. 1995;38:341–4.

    Article  PubMed  CAS  Google Scholar 

  2. Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol. 1998;93:2179–83.

    Article  PubMed  CAS  Google Scholar 

  3. Crosland A, Jones R. Rectal bleeding: prevalence and consultation behaviour. BMJ. 1995;311:486–8.

    PubMed  CAS  Google Scholar 

  4. Johnson DA, Gurney MS, Volpe RJ, et al. A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an agerelated risk. Am J Gastroenterol. 1990;85:969–74.

    Google Scholar 

  5. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112:594–642.

    Article  PubMed  CAS  Google Scholar 

  6. Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding. Do other symptoms aid in diagnosis? Dis Colon Rectum. 1989;32:191–6.

    Article  PubMed  CAS  Google Scholar 

  7. Norrelund N, Norrelund H. Colorectal cancer and polyps in patients aged 40 years and over who consult a GP with rectal bleeding. Fam Pract. 1996;13:160–5.

    Article  PubMed  CAS  Google Scholar 

  8. Segal WN, Greenberg PD, Rockey DC, Cello JP, McQuaid KR. The outpatient evaluation of hematochezia. Am J Gastroenterol. 1998;93:179–82.

    Article  PubMed  CAS  Google Scholar 

  9. Metcalf JV, Smith J, Jones R, Record CO. Incidence and causes of rectal bleeding in general practice as detected by colonoscopy. Br J Gen Pract. 1996;46:161–4.

    PubMed  CAS  Google Scholar 

  10. Helfand M, Marton KI, Zimmer-Gembeck MJ, Sox HC Jr. History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up. JAMA. 1997;277:44–8.

    Article  PubMed  CAS  Google Scholar 

  11. Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet. 1986;2:261–5.

    Article  PubMed  CAS  Google Scholar 

  12. Fijten GH, Muris JW, Starmans R, Knottnerus JA, Blijham GH, Krebber TF. The incidence and outcome of rectal bleeding in general practice. Fam Pract. 1993;10:283–7.

    Article  PubMed  CAS  Google Scholar 

  13. Anderson RN. United States Life Tables, 1997. Natl Vital Stat Rep. 1999;47:1–37.

    PubMed  CAS  Google Scholar 

  14. Muto T, Bussey HJ, Morson BC. The evolution of cancer of the colon and rectum. Cancer. 1975;36:2251–70.

    Article  PubMed  CAS  Google Scholar 

  15. Morson BC, Bussey HJ. Magnitude of risk for cancer in patients with colorectal adenomas. Br J Surg. 1985;72(suppl):S23-S25.

    Article  PubMed  Google Scholar 

  16. Eddy DM. Sereening for colorectal cancer. Ann Intern Med. 1990;113:373–84.

    Google Scholar 

  17. Hoff G, Foerster A, Vatn MH, Sauar J, Larsen S. Epidemiology of polyps in the rectum and colon. Recovery and evaluation of unresected polyps2 years after detection. Scand J Gastroenterol. 1986;21:853–62.

    Article  PubMed  CAS  Google Scholar 

  18. Hofstad B, Vatn M, Larsen S, Osnes M. Growth of colorectal polyps: recovery and evaluation of unresected polyps of less than 10 mm, 1 year after detection. Scand J Gastroenterol. 1994;29:640–5.

    Article  PubMed  CAS  Google Scholar 

  19. Hoff G, Larsen S. Epidemiology of polyps in the rectum and sigmoid colon. Discriminant analysis for identification of individuals at risk of developing colorectal neoplasia. Scand J Gastroenterol. 1986;21:848–52.

    Article  PubMed  CAS  Google Scholar 

  20. Stryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987;93:1009–13.

    PubMed  CAS  Google Scholar 

  21. Lewis JD, Brown A, Localio AR, Schwartz JS. Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis. Ann Intern Med. 2002;136:99–110.

    PubMed  Google Scholar 

  22. Wagner JL, Tunis S, Brown M, et al. The cost effectiveness of colorectal cancer screening in average risk adults. In: Young GP, Rozen P, Levin B, eds. Prevention and Early Detection of Colorectal Cancer in Young Adults. Philadelphia, PA: W.B. Saunders; 1996.

    Google Scholar 

  23. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276:1253–8.

    Article  PubMed  CAS  Google Scholar 

  24. Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC. The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine. JAMA. 1996;276:1172–7.

    Article  PubMed  CAS  Google Scholar 

  25. Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for reporting cost-effectiveness analyses. Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276:1339–41.

    Article  PubMed  CAS  Google Scholar 

  26. Khandker RK, Dulski JD, Kilpatrick JB, Ellis RP, Mitchell JB, Baine WB. A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults. Int J Technol Assess Health Care. 2000;16:799–810.

    Article  PubMed  CAS  Google Scholar 

  27. Sonnenberg A, Delco F. Cost-effectiveness of a single colonoscopy in screening for colorectal cancer. Arch Intern Med. 2002;162:163–8.

    Article  PubMed  Google Scholar 

  28. Brown ML, Riley GF, Potosky AL, Etzioni RD. Obtaining long-term disease specific costs of care: application to Medicare enrollees diagnosed with colorectal cancer. Med Care. 1999;37:1249–59.

    Article  PubMed  CAS  Google Scholar 

  29. Fireman BH, Quesenberry CP, Somkin CP, et al. Cost of care for cancer in a health maintenance organization. Health Care Financ Rev. 1997;18:51–76.

    PubMed  CAS  Google Scholar 

  30. Taplin SH, Barlow W, Urban N, et al. Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst. 1995;87:417–26.

    Article  PubMed  CAS  Google Scholar 

  31. Lieberman D. Cost-effectiveness of colon cancer screening. Am J Gastroenterol. 1991;86:1789–94.

    PubMed  CAS  Google Scholar 

  32. Rex DK, Lehman GA, Hawes RH, Ulbright TM, Smith JJ. Screening colonoscopy in asymptomatic average-risk persons with negative fecal occult blood tests. Gastroenterology. 1991;100:64–7.

    PubMed  CAS  Google Scholar 

  33. Ness RM, Holmes AM, Klein R, Dittus R. Utility valuations for outcome states of colorectal cancer. Am J Gastroenterol. 1999;94:1650–7.

    Article  PubMed  CAS  Google Scholar 

  34. Ramsey SD, Andersen MR, Etzioni R, et al. Quality of life in survivors of colorectal carcinoma. Cancer. 2000;88:1294–303.

    Article  PubMed  CAS  Google Scholar 

  35. Tengs TO, Wallace A. One thousand health-related quality-of-life estimates. Med Care. 2000;38:583–637.

    Article  PubMed  CAS  Google Scholar 

  36. Lewis JD, Shih CE, Blecker D. Endoscopy for hematochezia in patients under 50 years of age. Dig Dis Sci. 2001;46:2660–5.

    Article  PubMed  CAS  Google Scholar 

  37. Siba S. Experience with haemoccult screening in Hungary. A multicenter trial. Hepatogastroenterology. 1983;30:27–9.

    PubMed  CAS  Google Scholar 

  38. Vijan S, Hwang EW, Hofer TP, Hayward RA. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001;111:593–601.

    Article  PubMed  CAS  Google Scholar 

  39. Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000;284:1954–61.

    Article  PubMed  CAS  Google Scholar 

  40. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:96–104.

    PubMed  Google Scholar 

  41. U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137:129–31.

    Google Scholar 

  42. Irvine EJ, O’Connor J, Frost RA, et al. Prospective comparison of double contrast barium enema plus flexible sigmoidoscopy v colonoscopy in rectal bleeding: barium enema v colonoscopy in rectal bleeding. Gut. 1988;29:1188–93.

    Article  PubMed  CAS  Google Scholar 

  43. Church JM. Analysis of the colonoscopic findings in patients with rectal bleeding according to the pattern of their presenting symptoms. Dis Colon Rectum. 1991;34:391–5.

    Article  PubMed  CAS  Google Scholar 

  44. Lieberman DA, Smith FW. Screening for colon malignancy with colonoscopy. Am J Gastroenterol. 1991;86:946–51.

    PubMed  CAS  Google Scholar 

  45. Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2000;343:162–8.

    Article  PubMed  CAS  Google Scholar 

  46. Lieberman D. Cost-effectiveness of colonoscopy in screening for colorectal cancer; cost-effectiveness of screening colorectal cancer in the general population. Gastrointest Endosc. 2001;54:537–8.

    Article  PubMed  CAS  Google Scholar 

  47. Ries LAG, Eisner MP, Kosary CL, et al., eds. Surveillance, Epidemiology and End Results Program (SEER) Cancer Statistics Review 1975–2000. Bethesda, MD: National Cancer Institute; 2003.

    Google Scholar 

  48. Kewenter J, Brevinge H, Engaras B, Haglind E. The yield of flexible sigmoidoscopy and double-contrast barium enema in the diagnosis of neoplasms in the large bowel in patients with a positive hemoccult test. Endoscopy. 1995;27:159–63.

    PubMed  CAS  Google Scholar 

  49. Jensen J, Kewenter J, Asztely M, Lycke G, Wojciechowski J. Double contrast barium enema and flexible rectosigmoidoscopy: a reliable diagnostic combination for detection of colorectal neoplasm. Br J Surg. 1990;77:270–2.

    Article  Google Scholar 

  50. Farrands PA, Vellacott KD, Amar SS, Balfour TW, Hardcastle JD. Flexible fiberoptic sigmoidoscopy and double-contrast barium-enema examination in the identification of adenomas and carcinoma of the colon. Dis Colon Rectum. 1983;26:725–7.

    Article  PubMed  CAS  Google Scholar 

  51. Jensen J, Kewenter J, Haglind E, Lycke G, Svensson C, Ahren C. Diagnostic accuracy of double-contrast enema and rectosigmoidoscopy in connection with faecal occult blood testing for the detection of rectosigmoid neoplasms. Br J Surg. 1986;73:961–4.

    Article  PubMed  CAS  Google Scholar 

  52. Saito Y, Slezak P, Rubio C. The diagnostic value of combining flexible sigmoidoscopy and double-contrast barium enema as a one-stage procedure. Gastrointest Radiol. 1989;14:357–9.

    Article  PubMed  CAS  Google Scholar 

  53. Thoeni RF, Petras A. Detection of rectal and rectosigmoid lesions by double-contrast barium enema examination and sigmoidoscopy. Accuracy of technique and efficacy of standard overhead views. Radiology. 1982;142:59–62.

    PubMed  CAS  Google Scholar 

  54. Brewster NT, Grieve DC, Saunders JH. Double-contrast barium enema and flexible sigmoidoscopy for routine colonic investigation. Br J Surg. 1994;81:445–7.

    Article  PubMed  CAS  Google Scholar 

  55. Vellacott KD, Amar SS, Hardcastle JD. Comparison of rigid and flexible fibreoptic sigmoidoscopy with double contrast barium enemas. Br J Surg. 1982;69:399–400.

    Article  PubMed  CAS  Google Scholar 

  56. Beggs I, Thomas BM. Diagnosis of carcinoma of the colon by barium enema. Clin Radiol. 1983;34:423–5.

    Article  PubMed  CAS  Google Scholar 

  57. Brady AP, Stevenson GW, Stevenson I. Colorectal cancer overlooked at barium enema examination and colonoscopy: a continuing perceptual problem. Radiology. 1994;192:373–8.

    PubMed  CAS  Google Scholar 

  58. Rex DK, Rahmani EY, Haseman JH, Lemmel GT, Kaster S, Buckley JS. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology. 1997;112:17–23.

    Article  PubMed  CAS  Google Scholar 

  59. Strom E, Larsen JL. Colon cancer at barium enema examination and colonoscopy: a study from the county of Hordaland, Norway. Radiology. 1999;211:211–4.

    PubMed  CAS  Google Scholar 

  60. Haseman JH, Lemmel GT, Rahmani EY, Rex DK. Failure of colonoscopy to detect colorectal cancer: evaluation of 47 cases in 20 hospitals. Gastrointest Endosc. 1997;45:451–5.

    Article  PubMed  CAS  Google Scholar 

  61. Fork FT. Double contrast enema and colonoscopy in polyp detection. Gut. 1981;22:971–7.

    Article  PubMed  CAS  Google Scholar 

  62. Anderson N, Cook HB, Coates R. Colonoscopically detected colorectal cancer missed on barium enema. Gastrointest Radiol. 1991;16:123–7.

    Article  PubMed  CAS  Google Scholar 

  63. Bolin S, Franzen L, Nilsson E, Sjodahl R. Carcinoma of the colon and rectum. Tumors missed by radiologic examination in 61 patients. Cancer. 1988;61:1999–2008.

    Article  PubMed  CAS  Google Scholar 

  64. Evers K, Laufer I, Gordon RL, Kressel HY, Herlinger H, Gohel VK. Double-contrast enema examination for detection of rectal carcinoma. Radiology. 1981;140:635–9.

    PubMed  CAS  Google Scholar 

  65. Johnson CD, Carlson HC, Taylor WF, Weiland LP. Barium enemas of carcinoma of the colon: sensitivity of double- and single-contrast studies. AJR Am J Roentgenol. 1983;140:1143–9.

    PubMed  CAS  Google Scholar 

  66. Kelvin FM, Maglinte DD, Stephens BA. Colorectal carcinoma detected initially with barium enema examination: site distribution and implications. Radiology. 1988;169:649–51.

    PubMed  CAS  Google Scholar 

  67. Kelvin FM, Gardiner R, Vas W, Stevenson GW. Colorectal carcinoma missed on double contrast barium enema study: a problem in perception. AJR Am J Roentgenol. 1981;137:307–13.

    PubMed  CAS  Google Scholar 

  68. Law RL, Longstaff AJ, Slack N. A retrospective 5-year study on the accuracy of the barium enema examination performed by radiographers. Clin Radiol. 1999;54:80–3; discussion 83–4.

    Article  PubMed  CAS  Google Scholar 

  69. Ott DJ, Scharling ES, Chen YM, Wu WC, Gelfand DW. Barium enema examination: sensitivity in detecting colonic polyps and carcinomas. South Med J. 1989;82:197–200.

    PubMed  CAS  Google Scholar 

  70. Morosi C, Ballardini G, Pisani P, et al. Diagnostic accuracy of the double-contrast enema for colonic polyps in patients with or without diverticular disease. Gastrointest Radiol. 1991;16:345–7.

    Article  PubMed  CAS  Google Scholar 

  71. Jaramillo E, Slezak P. Comparison between double-contrast barium enema and colonoscopy to investigate lower gastrointestinal bleeding. Gastrointest Radiol. 1992;17:81–3.

    Article  PubMed  CAS  Google Scholar 

  72. Durdey P, Weston PM, Williams NS. Colonoscopy or barium enema as initial investigation of colonic disease. Lancet. 1987;2:549–51.

    Article  PubMed  CAS  Google Scholar 

  73. Thoeni RF, Petras A. Double-contrast barium-enema examination and endoscopy in the detection of polypoid lesions in the cecum and ascending colon. Radiology. 1982;144:257–60.

    PubMed  CAS  Google Scholar 

  74. de Roos A, Hermans J, Shaw PC, Kroon H. Colon polyps and carcinomas: prospective comparison of the single- and double-contrast examination in the same patients. Radiology. 1985;154:11–3.

    PubMed  Google Scholar 

  75. Fork FT. Reliability of routine double contrast examination of the large bowel: a prospective study of 2590 patients. Gut. 1983;24:672–7.

    Article  PubMed  CAS  Google Scholar 

  76. Rex DK, Lehman GA, Lappas JC, Miller RE. Sensitivity of double-contrast barium study for left-colon polyps. Radiology. 1986;158:69–72.

    PubMed  CAS  Google Scholar 

  77. Ott DJ, Gelfand DW, Wu WC, Kerr RM. Sensitivity of double-contrast barium enema: emphasis on polyp detection. AJR Am J Roentgenol. 1980;135:327–30.

    PubMed  CAS  Google Scholar 

  78. Cheong Y, Farrow R, Frank CS, Stevenson GW. Utility of flexible sigmoidoscopy as an adjunct to double-contrast barium enema examination. Abdom Imaging. 1998;23:138–40.

    Article  PubMed  CAS  Google Scholar 

  79. Winawer SJ, Stewart ET, Zauber AG, et al. A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med. 2000;342:1766–72.

    Article  PubMed  CAS  Google Scholar 

  80. Hixson LJ, Fennerty MB, Sampliner RE, McGee D, Garewal H. Prospective study of the frequency and size distribution of polyps missed by colonoscopy. J Natl Cancer Inst. 1990;82:1769–72.

    Article  Google Scholar 

  81. Rex DK, Cutler CS, Lemmel GT, et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology. 1997;112:24–8.

    Article  PubMed  CAS  Google Scholar 

  82. Eckardt VF, Kanzler G, Schmitt T, Eckardt AJ, Bernhard G. Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc. 1999;49:560–5.

    Article  PubMed  CAS  Google Scholar 

  83. Isbister WH. Colonoscopy—a ten year Wellington experience. N Z Med J. 1987;100:74–7.

    PubMed  CAS  Google Scholar 

  84. Ure T, Dehghan K, Vernava AMD, Longo WE, Andrus CA, Daniel GL. Colonoscopy in the elderly. Low risk, high yield. Surgical Endoscopy. 1995;9:505–8.

    PubMed  CAS  Google Scholar 

  85. Atkin WS, Hart A, Edwards R, et al. Uptake, yield of neoplasia, and adverse effects of flexible sigmoidoscopy screening. Gut. 1998;42:560–5.

    Article  PubMed  CAS  Google Scholar 

  86. Kewenter J, Brevinge H. Endoscopic and surgical complications of work-up in screening for colorectal cancer. Dis Colon Rectum. 1996;39:676–80.

    Article  PubMed  CAS  Google Scholar 

  87. Lieberman D. Endoscopic screening for colorectal cancer. Gastroenterol Clin North Am. 1997;26:71–83.

    Article  PubMed  CAS  Google Scholar 

  88. Cowen AE, Macrae FA. Gastrointestinal endoscopy: an accurate and safe primary diagnostic and therapeutic modality. Med J Aust. 1992;157:52–7.

    PubMed  CAS  Google Scholar 

  89. Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy and flexible sigmoidoscopy. Gastrointest Endosc Clin N Am. 1996;6:343–77.

    PubMed  CAS  Google Scholar 

  90. Basson MD, Etter L, Panzini LA. Rates of colonoscopic perforation in current practice. Gastroenterology. 1998;114:1115.

    Article  PubMed  CAS  Google Scholar 

  91. Damore LJ II, Rantis PC, Vernava AM III, Longo WE. Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum. 1996;39:1308–14.

    Article  PubMed  Google Scholar 

  92. Orsoni P, Berdah S, Verrier C, et al. Colonic perforation due to colonoscopy: a retrospective study of 48 cases. Endoscopy. 1997;29:160–4.

    PubMed  CAS  Google Scholar 

  93. Church JM. Complete colonoscopy: how often? And if not, why not? Am J Gastroenterol. 1994;89:556–60.

    PubMed  CAS  Google Scholar 

  94. Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg. 1994;179:333–7.

    PubMed  CAS  Google Scholar 

  95. Hureau J, Avtan L, Germain M, Blanc D, Chaussade G. [Colonic perforation during colonoscopy. 100 cases]. Chirurgie. 1992;118:703–15; discussion 715–6. French.

    PubMed  CAS  Google Scholar 

  96. Heath B, Rogers A, Taylor A, Lavergne J. Splenic rupture: an unusual complication of colonoscopy. Am J Gastroenterol. 1994;89:449–50.

    PubMed  CAS  Google Scholar 

  97. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol. 1992;15:347–51.

    Article  PubMed  CAS  Google Scholar 

  98. Ghazi A, Grossman M. Complications of colonoscopy and polypectomy. Surg Clin North Am. 1982;62:889–96.

    PubMed  CAS  Google Scholar 

  99. Katon RM, Keeffe EB, Melnyk CS. Flexible Sigmoidoscopy. Markham, Ontario: Thomas Allen & Sons, Limited; 1985.

    Google Scholar 

  100. Blakeborough A, Sheridan MB, Chapman AH. Complications of barium enema examinations: a survey of UK Consultant Radiologists 1992 to 1994. Clin Radiol. 1997;52:142–8.

    Article  PubMed  CAS  Google Scholar 

  101. Gore RM, Levine MS, Laufer I. Testbook of Gastrointestinal Radiology. Philadelphia, PA: W.B. Saunder; 1995.

    Google Scholar 

  102. Stewart BT, Keck JO, Duncan AV, Santamaria NM, Allen P. Difficult or incomplete flexible sigmoidoscopy: implications for a screening programme. Aust N Z J Surg. 1999;69:19–21.

    Article  PubMed  CAS  Google Scholar 

  103. Freeman B, Engel JJ, Fine MS, DiVita DP. Colonoscopy to the cecum: how often do we get there? Experience in a community hospital. Am J Gastroenterol. 1993;88:789 Letter.

    PubMed  CAS  Google Scholar 

  104. Hay JW, Hay AR. Inflammatory bowel disease: costs-of-illness. J Clin Gastroenterol. 1992;14:309–17.

    Article  PubMed  CAS  Google Scholar 

  105. Trallori G, Messori A. Drug treatments for maintaining remission in Crohn’s disease. A lifetime cost-utility analysis. Pharmacoeconomics. 1997;11:444–53.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Oregon Health & Science University, Portland, OR, USA

    Christina Nicolaidis MD, MPH & Mark Helfand MD, MPH

  2. Portland VA Medical Center, P3-Med, P.O. Box 1034, 97207, Portland, OR

    Elizabeth Allen MD

Authors
  1. Elizabeth Allen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christina Nicolaidis MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mark Helfand MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Elizabeth Allen MD.

Additional information

The authors have no conflicts of interest.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Allen, E., Nicolaidis, C. & Helfand, M. The evaluation of rectal bleeding in adults. J GEN INTERN MED 20, 81–90 (2005). https://doi.org/10.1111/j.1525-1497.2005.40077.x

Download citation

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2005.40077.x

Key Words

Search

Navigation