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Lower gastrointestinal symptoms and symptoms-based triaging systems are poor predictors of clinical significant disease on colonoscopy
  1. Mohd Syafiq Ismail1,2,
  2. Olufemi Aoko1,
  3. Sandeep Sihag1,
  4. Eimear Connolly1,
  5. Joseph Omorogbe1,
  6. Serhiy Semenov1,2,
  7. Neil O'Morain1,
  8. Anthony O'Connor1,
  9. Niall Breslin1,
  10. Barbara Ryan1,
  11. Deirdre McNamara1,2
  1. 1Gastroenterology, Tallaght University Hospital, Dublin, Ireland
  2. 2Trinity Academic Gastroenterology Group, Trinity College Dublin, Dublin, Ireland
  1. Correspondence to Dr Mohd Syafiq Ismail; syafiq2009{at}


Introduction Lower gastrointestinal symptoms (LGS) are a common cause of referral to the gastroenterology service. International guidelines are available to prioritise referrals. Some studies have reported that symptoms alone are a poor marker of clinically significant disease (CSD) but symptoms remain the main way to prioritise referrals in routine clinical practice.

Aims/background To correlate LGS with colonoscopy findings in an unselected patient cohort and to investigate whether using National Institute for Health and Care Excellence (NICE) guidelines improve risk stratification.

Method Colonoscopy data over a 2-year period were obtained from our endoscopy database. Only patients with assessment of symptoms as their primary indication for colonoscopy were included. Patient records were retrospectively reviewed. Exclusion criteria: known inflammatory bowel disease (IBD), familial cancer syndromes, polyp and colorectal cancer (CRC) surveillance, and prior colonoscopy within 5 years. Demographics, symptoms and colonoscopy findings were recorded and analysed.

Results 1116 cases were reviewed; 493 (44%) males, age 54.3 years (16–91). CSD occurred in only 162 (14.5%); CRC 19 (1.7%), high-risk adenoma 40 (3.6%), inflammation 97 (8.7%) (IBD 65 (5.8%), microscopic colitis 9 (0.8%) and indeterminate-inflammation 23 (2%)), angiodysplasia 6 (0.5%). Diarrhoea gave the highest diagnostic yield for CSD of 5.3% (OR 3.15, 95% CI 2.2 to 4.7, p<0.001), followed by PR bleeding, 2.9% (OR 1.9, 95% CI 1.24 to 2.9, p=0.003). Weight loss gave the lowest diagnostic yield of 0.4%; (OR 0.79, 95% CI 0.28 to 2.24, p=0.65). 592 (53%) and 517 (46%) fitted the NICE guidelines for CRC and IBD, respectively. Using NICE positivity improved detection but overall yield remained low 3% vs 0.4% (OR 7.71, 95% CI 1.77 to 33.56, p=0.0064) for CRC, and 9% vs 2.8% (OR 3.5, 95% CI 1.99 to 6.17, p<0.0001) for IBD.

Conclusions The overall prevalence of CSD in our unselected symptomatic patients is low (14.5%). A holistic approach including combining symptoms and demographics with novel tools including stool biomarkers and minimally invasive colonoscopy alternatives should be applied to avoid unnecessary colonoscopy.

  • colonoscopy
  • colonic diseases
  • IBD
  • colorectal cancer

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors MSI: main author, collected and analysed data, OA, SS, EC, JO and NO: data collection, AO, NB and BR: data collection and study planning, DM: study planning, data analysing, writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared

  • Patient consent Not Required

  • Ethics approval This study has been ethically approved by Tallaght University Hospital / St. James's Hospital Joint Research Ethics Committee (REC).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

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