Abstract
Background & Aims
There is an unclear role for colonoscopy in evaluation of symptomatic individuals younger than 50 years old. We aimed to determine the prevalence of large polyps (>9 mm) or tumors in individuals 40–49 years old who underwent colonoscopy for various signs and symptoms, and compare the results with those from average-risk individuals age 50–54 years old who underwent screening colonoscopy.
Methods
We collected data from a national endoscopy database, 2000 through 2012, and identified patients 40–49 years old who underwent colonoscopy for bleeding and nonbleeding indications. The prevalence of large polyps (>9 mm) or tumors was compared to the prevalence in a reference group (n=99,713 average-risk individuals age 50 to 54 undergoing screening colonoscopy).
Results
A total of 65,892 patients 40–49 years old underwent colonoscopy for a variety of indications. Significantly larger proportions of male and female patients with hematochezia without anemia or iron deficiency anemia (IDA) had large polyps or tumors (7.2%) compared to the reference group (men: 7.2% vs 6.2%; P=.0001 and women: 5.5% vs 4.1%; P<.0001). Patients with weight loss, anemia or IDA, or hematochezia with anemia or IDA did not have a significantly higher prevalence of large polyps or tumors than the reference group. Significantly lower proportions of patients with general gastrointestinal symptoms (pain, bloating, or change in bowel habits) had advanced neoplasia compared to the reference group (men: 3.9% vs 6.2%; P<.0001 and women: 2.7% vs 4.1%; P<.0001).
Conclusions
An analysis of a national endoscopy database supports the role of colonoscopy to evaluate hematochezia in patients 40–49 years old. A lower proportion of patients with anemia, weight loss, and general abdominal symptoms had large polyps or tumors compared to average-risk patients, 50–54 years old. A significantly lower proportion of patients younger than 50 years with general gastrointestinal symptoms had large polyps—these patients are therefore less likely to benefit from colonoscopy.
Keywords: colon, detection, colorectal cancer, blood
INTRODUCTION
The prevalence of clinically significant findings on colonoscopy in patients 40–50 years, such as advanced adenomas, has historically been low1–3 and thus has brought into question its utility in this age group. In the average risk patient, current recommendations are to initiate colorectal cancer screening at age 504. However, in the presence of symptoms such as hematochezia, anemia, abdominal pain and change in bowel habits, patients under the age of 50 often undergo colonoscopy. Several studies have attempted to define the role of lower endoscopy in evaluating patients under age 50 with rectal bleeding, however, these studies have had different methods and have reached varying conclusions. Furthermore, since neoplastic and non-neoplastic colorectal and anal conditions can coexist, the literature is divided as to whether colonoscopy should be the first line evaluation in young patients with rectal bleeding5–10. Aside from rectal bleeding, there has been limited prior study of colonoscopy indications in other symptomatic patients age 40–50 years. It is therefore unclear if there are specific gastrointestinal symptoms in this age group that predict clinically significant findings on colonoscopy such as large polyps or tumors. Identification of such “high risk” signs and symptoms would help improve the prediction of patients in this age group who would benefit from evaluation with colonoscopy.
We hypothesize that 40–49 year old patients with hematochezia are more likely to have a clinically significant finding of large polyps (>9 mm) or tumors compared with other indications for colonoscopy in 40–49 year-old patients and also compared with averagerisk screening 50–54 year old patients, for whom screening colonoscopy is recommended. The aim of this study was to evaluate the prevalence of large polyps or tumors, as a surrogate for advanced neoplasia, in 40–49 year old patients, stratified by indication. We aim to compare this prevalence to a reference cohort of 50–54 year old average-risk individuals undergoing screening colonoscopy.
METHODS
The Clinical Outcomes Research Initiative (CORI) was established in 1995 with the goal of creating a consortium of clinical practice settings to determine utilization and outcomes of endoscopic procedures. Endoscopists use a structured computerized endoscopic report generator to produce endoscopic reports. The data that is transmitted from the local site to the National Endoscopic Database does not contain most patient or provider identifiers and qualifies as a Limited Data Set under 45 C.F.R. Section 164.514(e)(2). After completion of quality control checks, data from all sites are merged in the data repository for analysis. Procedure counts are monitored on a weekly basis for atypical activity. The repository is checked for anomalies on a daily basis. Any unusual activity prompts follow-up contact by CORI staff.
Patient Population
We identified the first colonoscopy performed in the CORI database among all patients aged 40 to 49 years during 2000 – 2012, and categorized them into a hierarchy of indications that were of clinical interest. This hierarchy was necessary in order to create mutually exclusive indication categories, as the CORI report may include multiple procedure indications. Indications that were selected for study, in hierarchical order, were: hematochezia without anemia or iron deficiency anemia (IDA), hematochezia with anemia or IDA, anemia or IDA without hematochezia, weight loss, and general abdominal symptoms (defined as abdominal pain, bloating, change in bowel habits, constipation, and diarrhea). The indication of hematochezia in the CORI endoscopic report is not consistently differentiated into frank hemorrhage and outlet type bleeding by the endoscopist. Thus hematochezia in this study includes any passage of blood per rectum, including frank hemorrhage, blood mixed with stool, blood in the toilet bowl, blood on the toilet paper, or blood before or after defecation. Colonoscopies in a higher level of the hierarchy could include indications of interest in a lower hierarchy group. All colonoscopies performed for any other indications not specified in a hierarchy were excluded. As a reference group, we selected average-risk individuals 50–54 years old undergoing screening colonoscopy. We chose this group in order to compare the findings in patients with gastrointestinal (GI) signs and symptoms to an asymptomatic cohort of roughly the same age. Since colon cancer screening exams are not routinely performed in patients age 40 to 49 years, we selected the 50–54 year old screening cohort as the primary comparator group.
Clinical outcome
Our endpoint was the finding of one or more polyps sized more than 9mm or described as a suspected malignant tumor, here forth large polyp. This endpoint is a surrogate for advanced neoplasia and a previous CORI analysis of 13,992 screening examinations with histopathology, demonstrated that this surrogate was robust11. In this analysis, 4.8% of large polyps (sized more than 9mm) did not have advanced histology, and 2.9% of small polyps (1–9mm) did have advanced histology, and would be misclassified with our surrogate endpoint.
These endoscopic findings were stratified by gender and indication. The location of the polyp findings were classified as distal if the location was distal to the splenic flexure. All other locations were classified as proximal.
Statistical Analysis
Comparisons of categorical data were performed using Pearson’s chi-square tests while continuous variables were compared using analysis of variance. All analyses were performed using SAS software v 9.4 (SAS Institute, Inc., Cary, NC).
RESULTS
Between 2000 and 2012, 135,955 colonoscopies were performed in patients age 40 to 49 years. Of these, 65,892 (48%) had a colonoscopy with an indication that met our inclusion criteria and 70,063 (52%) had a colonoscopy for other indications and were excluded from our study (Figure 1). For subsequent comparison, the large polyp detection rate in the excluded patients is provided in Figure 1. The reference group consisted of 99,713 average-risk screening colonoscopies in those age 50–54 years during the same time period.
Figure 1.
Flow chart of excluded patients with large polyp detection rate
The demographics of the 40–49 year old study cohort and reference group and procedure indications for the study group are presented in Table 1. The majority of colonoscopies (>70% across all indications) were performed on white non-Hispanic patients in the community/HMO site type. In the study group, men were more likely to have colonoscopy for hematochezia without anemia and less likely to have colonoscopy for anemia, weight loss and general symptoms, compared to the average risk screening reference group.
Table 1.
Patient demographics
| 50–54 year-old reference group |
40–49 year-old by procedure indication | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Average Risk Screening |
Hematochezia and anemia/IDA |
P value1 | Hematochezia without anemia/IDA |
P value1 | Anemia/IDA without hematochezia |
P value1 | Weight loss | P value1 | General abdominal symptoms |
P value1 | |
| Total N | 99,713 | 804 | 29,901 | 7,265 | 1,197 | 26,725 | |||||
| Mean age (SD) | 51.7 | 44.8 (2.9) | 45.0 (2.9) | 45.3 (2.8) | 45.2 (2.8) | 45.1 (2.8) | |||||
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | ||||||
| Male gender | 52,462 (52.6) | 388 (48.3) | 0.014 | 16,459 (55.0) | <.0001 | 2,193 (30.2) | <.0001 | 535 (44.1) | <.0001 | 9,073 (34.0) | <.0001 |
| Male gender exclude VA/Military | 44,292/89,091 (49.7) | 316/708 (44.8) | 0.009 | 14,036/29,916 (52.2) | <.0001 | 1,702/6,417 (26.5) | <.0001 | 458/1,104 (41.5) | <.0001 | 8,015/25,117 (31.9) | <.0001 |
| Race/Ethnicity2,3 | |||||||||||
| White | 81,361 (81.6) | 434 (54.0) | <.0001 | 22,483 (75.2) | <.0001 | 4,515 (62.2) | <.0001 | 965 (80.6) | 0.386 | 21,295 (79.7) | <.0001 |
| Black | 6,774 (6.8) | 167 (20.8) | 2,369 (7.9) | 1,020 (14.0) | 80 (6.7) | 1,556 (5.8) | |||||
| Asian/PI | 2,282 (2.3) | 24 (4.2) | 713 (2.4) | 227 (3.1) | 27 (2.3) | 427 (1.6) | |||||
| Native American | 440 (0.4) | 39 (4.9) | 379 (1.3) | 158 (2.2) | 8 (0.7) | 287 (1.1) | |||||
| Multiracial | 181 (0.2) | 0 (0) | 52 (0.2) | 19 (0.3) | 5 (0.4) | 42 (0.2) | |||||
| Hispanic | 8,306 (8.3) | 123 (15.3) | 3,468 (11.6) | 1,235 (17.0) | 98 (8.2) | 2,816 (10.5) | |||||
| Other | 182 (0.2) | 1 (0.1) | 16 (0.2) | 16 (0.2) | 6 (0.5) | 37 (0.1) | |||||
| Unknown | 187 (0.2) | 6 (0.8) | 397 (1.3) | 75 (1.0) | 8 (0.7) | 265 (1.0) | |||||
| Site Type | |||||||||||
| Community/HMO | 80,978 (81.2) | 577 (71.8) | <.0001 | 24,031 (80.4) | <.0001 | 5,335 (73.4) | <.0001 | 977 (81.6) | 0.0001 | 22,649 (84.8) | <.0001 |
| Academic | 8,113 (8.1) | 129 (16) | 2,885 (9.7) | 1,082 (14.9) | 127 (10.6) | 2,468 (9.2) | |||||
| VA/Military | 10,622 (10.7) | 98 (12.2) | 2,985 (10.0) | 848 (11.7) | 93 (7.8) | 1,608 (6.0) | |||||
All p-values are calculated by comparison with the reference group (average risk screening)
All race values are non-Hispanic. Hispanic is any patient with Hispanic ethnicity, regardless of race
White non-Hispanic vs non-White was used to calculate the race/ethnicity p-values listed
The prevalence of large polyps stratified by indication and gender is summarized in Table 2. Compared to the average-risk reference group, men and women aged 40–49 who underwent colonoscopy for the indication of hematochezia without anemia/IDA had a higher prevalence of large polyps than the average-risk reference group (men: 7.2 vs 6.2%;p<0.0001; women: 5.5% vs 4.1%; p<0.0001). Stratification of these results by gross hematochezia vs outlet rectal bleeding could not be performed as previously stated. Study group patients with weight loss, anemia/IDA, and hematochezia with anemia/ IDA did not have a significantly higher prevalence of large polyps compared to the reference group. Study group patients with general abdominal symptoms had a significantly lower prevalence of large polyps compared to the reference group (men: 3.9% vs 6.2%; p<0.0001; women: 2.7% vs 4.1%; p<0.0001).
Table 2.
Prevalence of Large Polyps by Indication Group
| Procedure Indication | Men with large polyps (%) |
P value | Women with large polyps (%) |
P value |
|---|---|---|---|---|
| Average Risk 50–54 year-old | 3,231/52,462 (6.2) | Reference | 1,938/47,251 (4.1) | Reference |
| 40–49 year-old Procedure Indications | ||||
| Hematochezia and Anemia/IDA1 | 30/388 (7.7) | 0.199 | 22/416 (5.3) | 0.225 |
| Hematochezia without Anemia/IDA2 | 1,190/16,459 (7.2) | 0.0001 | 737/13,442 (5.5) | < .0001 |
| Anemia/IDA without Hematochezia3 | 133/2,193 (6.1) | 0.858 | 186/5,072 (3.7) | 0.136 |
| Weight loss4 | 26/535 (4.9) | 0.213 | 26/662 (3.9) | 0.823 |
| General Abdominal Symptoms5 | 351/9,073 (3.9) | < .0001 | 481/17,652 (2.7) | < .0001 |
Must have hematochezia plus either anemia or iron deficiency without anemia or both. May have weight loss, abdominal pain, change in bowel habits, diarrhea, constipation or routine/average risk screening but no other indications
Must have hematochezia and not have either anemia or iron deficiency without anemia or both. May have weight loss, abdominal pain, change in bowel habits, diarrhea, constipation or routine/average risk screening but no other indications
Must have anemia and/or iron deficiency without anemia and cannot have hematochezia. May have weight loss, abdominal pain, change in bowel habits, diarrhea, constipation or routine/average risk screening but no other indications
Must have weight loss and cannot have hematochezia, anemia, or iron deficiency without anemia. May have abdominal pain, change in bowel habits, diarrhea, constipation or routine/average risk screening but no other indications
Must have at least one of the following: abdominal pain, change in bowel habits, diarrhea, constipation and cannot have hematochezia, anemia, iron deficiency without anemia, weight loss. May have routine/average risk screening
Table 3 presents the colon location of large polyps by gender and indication. Study group patients who underwent colonoscopy to evaluate hematochezia (with and without anemia/IDA) were more likely to have distal large polyps compared to study patients with other indications for colonoscopy (72.7% vs 56.7%; p<0.0001).
Table 3.
Polyp location by indication
| 50–54 year old reference group |
40–49 year-old by procedure Indication | |||||
|---|---|---|---|---|---|---|
| Average-risk screening |
Hematochezia and anemia/IDA |
Hematochezia without anemia/IDA |
Anemia/IDA without hematochezia |
Weight loss | General abdominal symptoms |
|
| MALE | n (%) | n (%) | n (%) | n (%) | n (%) | n (%) |
| Large polyp | 3,231/52,462 (6.2) | 30/388 (7.7) | 11,90/16,459 (7.2) | 133/2,193 (6.1) | 26/535 (4.9) | 351/9,073 (3.9) |
| Location* | ||||||
| Proximal | 1,250 (38.7) | 6 (20.0) | 280 (23.5) | 67 (50.4) | 8 (30.8) | 122 (34.8) |
| Distal | 1,799 (55.7) | 22 (73.3) | 855 (71.9) | 57 (42.9) | 17 (65.4) | 221 (63.0) |
| Both | 180 (5.6) | 2 (6.7) | 54 (4.5) | 9 (6.8) | 1 (3.9) | 8 (2.3) |
| Unknown | 2 (0.1) | 0 (0) | 1 (0.1) | 0 (0) | 0 (0) | 0 (0) |
| FEMALE | ||||||
| Large polyp | 1,938/47,251 (4.1) | 22/416 (5.3) | 737/13,442 (5.5) | 186/5,072 (3.7) | 26/662 (3.9) | 481/17,652 (2.7) |
| Location* | ||||||
| Proximal | 892 (46.0) | 5 (22.7) | 167 (22.2) | 85 (45.7) | 13 (50.0) | 194 (40.3) |
| Distal | 988 (51.0) | 16 (72.7) | 543 (73.7) | 97 (52.2) | 13 (50.0) | 277 (57.6) |
| Both | 57 (2.9) | 1 (4.6) | 25 (3.4) | 4 (2.2) | 0 (0) | 10 (2.1) |
| Unknown | 1 (0.1) | 0 (0) | 2 (0.3) | 0 (0) | 0 (0) | 0 (0) |
Distal = distal to splenic flexure
Proximal = proximal and including splenic flexure
DISCUSSION
In a large national endoscopic database of diverse practice types, patients aged 40–49 years with hematochezia with or without anemia had a higher prevalence of large polyps compared with average-risk 50–54 year old patients undergoing screening colonoscopy and also compared with patients in the same age group with general abdominal symptoms. This study contributes to the sparse literature on colonoscopy in this age group. While some of these patients likely had hematochezia from benign anorectal etiologies and may not require full colonoscopy, these results show a strong association between any hematochezia and the presence of large polyps in patients age 40 to 49.
Our study evaluated the risk of large polyps associated with specific lower GI symptoms. Hematochezia and anemia/IDA are two common reasons for colonoscopy referrals in patients age 40 to 49 years, representing 28% of procedures (n=37,970) in this age group. The prevalence of large polyps in patients with hematochezia alone is 7.2% in men and 5.5% in women, which is significantly greater than the prevalence in our reference group of 50–54 year old average-risk subjects. A recent study evaluating adults under age 50 with hematochezia/rectal bleeding demonstrated similar findings with 5.9% prevalence of advanced neoplasia12. Since 40 to 49 year old patients with hematochezia have a higher prevalence of advanced neoplasia than our screening cohort, for which colonoscopy is routinely recommended, colonoscopy should be strongly considered in the this group of symptomatic younger patients.
There are few studies of colonoscopy in average-risk asymptomatic patients under the age 50. A Korean study, which included 28,504 patients under age 50, evaluated risk factors for overall colorectal neoplasia in a cohort of patients who underwent a colonoscopy as part of a comprehensive health screening program required for employees of various companies and local government organization. The prevalence of advanced neoplasia in their 40 to 49 yo asymptomatic cohort was 2.4%, which is similar to prior studies1,13. Independent risk factors for colorectal neoplasia in this group were male gender, smoking, metabolic syndrome, obesity, fasting blood glucose >100 mg/dL, triglycerides >150 mg/dL, family history of colorectal cancer, and alcohol intake >20g/day14. The subjects in this study, however, were reportedly asymptomatic and therefore, the results do not provide insight into indications associated with more significant findings in this age group.
Several studies have evaluated the utility of lower endoscopy and the type of lower endoscopic evaluation (flexible sigmoidoscopy vs full colonoscopy) in patients under the age of 50 who present with rectal bleeding, but these studies have had different methods and reached varying conclusions. Lewis et al. found any neoplasm (including cancer, advanced adenomas, and low grade adenomas) in 10.9% of patients age 40 to 50 who presented with any type of hematochezia, which was significant higher than in patients under age 40 with hematochezia7. They also found 58% of patients with any neoplasm and 43% of patients with advanced neoplasm had concomitant anal disease; thus, the authors recommend patients age 40 to 50 with hematochezia undergo full colonoscopy. In contrast, Marderstein and Church found that colonoscopy was particularly low yield in patients under age 50 years evaluated for outlet bleeding (defined as bright red blood during or after defecation, on the toilet paper, or in the toilet bowl with no family history of colorectal cancer and no change in bowel habits) with only 1.6% of patients found to have an adenoma >1 cm and no invasive cancers were detected10. In the present study, we found that approximately 20–24% of advanced neoplasia were proximal to the splenic flexure and would have been missed in patients age 40 to 49 with hematochezia who underwent only flexible sigmoidoscopy rather than full colonoscopy.
An additional study evaluated the outcomes of upper and lower endoscopy in patients with iron deficiency anemia and did not find any GI cancers in patients under age 50 years. Common findings included celiac disease, H. pylori, and gastritis. The authors suggested that patients with iron deficiency anemia be evaluated initially with upper endoscopy prior to lower endoscopy, given the higher prevalence of upper GI findings15. On the other hand, Bini et al. evaluated the GI tract of 186 premenopausal women with iron deficiency anemia and found a clinically important upper or lower gastrointestinal lesion in 12% of patients with 5% of patients having either colon cancer or polyp larger than 2 cm, suggesting that endoscopy yields important findings in this population16. When colonoscopy outcomes were studied in patients with anemia with and without iron deficiency, the authors found patients with anemia and a ferritin level <100 ng/mL were almost five times more likely to harbor advanced neoplasia than patients with anemia and a ferritin level >100 ng/mL after adjusting for age17. In our study, 40–49 year old patients with anemia (without hematochezia), or weight loss did not have statistically different rates of large polyps compared to our reference group of average-risk 50–54 year olds. Further study is needed to determine the benefits of colonoscopy in these patients.
It has been estimated that approximately 30% of colonoscopies in patients under age 50 are performed to evaluate irritable bowel syndrome (IBS) symptoms18. In our study, we aggregated nonspecific abdominal symptoms such as abdominal pain, bloating, change in bowel habits, constipation, and diarrhea as general abdominal symptoms similar to that associated with IBS. More women were referred for general abdominal symptoms than for any other indication in our study. We found that men and women who were evaluated for this indication had a significantly lower prevalence of large polyps compared to the reference group and compared to other patients in the 40–49 year-old group. Of the 26,725 patient with general GI symptoms, 1,764 (6.6%) had any mucosal abnormality or colitis and only 182 (0.7%) had suspected ulcerative colitis or Crohn’s disease. Some proponents of colonoscopy in patients under age 50 with IBS type symptoms have suggested that a negative endoscopic evaluation may provide reassurance to such patients and improve health-related quality of life (HRQOL). Spiegel et al. provided questionnaires to patients age 18 to 49 with IBS to further evaluate this question and found no independent association between a negative colonoscopy and reassurance or improved HRQOL in IBS patients under age 5019. While there may be other important endoscopic findings in these patients, our data suggest these patients have a very low prevalence of premalignant and malignant lesions, compared to our reference group, which can help reassure patients and providers of patients with IBS symptoms who are concerned for an underlying malignancy.
Our study was not designed to evaluate the benefit of average-risk screening in patients age 40–49 years. However, if we assume that our study cohort with general abdominal symptoms might have a similar risk of CRC as asymptomatic individuals, we find that rates of advanced neoplasia are low, relative to the 50–54 year old reference group (men 3.9% vs 6.2%; women 2.7% vs 4.1%). We cannot comment about whether specific groups, such as asymptomatic 40–49 year old Black men and women might have higher rates from our study, but other work did not find differences between average-risk white and Blacks in this age group20.
There are several limitations to this study. The primary outcome of this study was large polyps or suspected malignant tumors and is intended to identify malignant or premalignant lesions. The finding is a surrogate for advanced neoplasia which is in turn associated with colorectal cancer. Prior CORI studies have demonstrated that large polyps is a valid surrogate for advanced neoplasia11. Polyp size was determined by the endoscopist; prior studies have shown endoscopists are able to differentiate between polyps larger than and smaller than 9 mm21. In the CORI endoscopic database indications and findings of colonoscopy are entered by the endoscopist and are susceptible to human error and bias. When there were multiple indications of interest for a procedure we used a hierarchal system to create mutually exclusive indication groups, which could create misclassification bias. Although primary indication is a required field to complete the report, variations in the indication such as severity of anemia or iron deficiency and type of hematochezia (outlet bleeding vs frank hemorrhage vs blood clots etc) is not consistently described. We recognize that hematochezia could represent intermittent outlet type bleeding or more significant hemorrhage, although we think the prevalence of the latter is likely very low in our cohort since the subjects were nearly all outpatient procedures. This distinction in type of bleeding may be clinically significant however we are not able to further stratify our data based on this due to the inconsistent entry by the endoscopist. We did consider if anemia was also reported with hematochezia, which could support a degree of chronicity or severity to the bleeding. Our results suggest that hematochezia, irrespective of associated anemia, is associated with a higher risk of large polyps compared with other indications in the 40 to 49 year old age group. Future studies should distinguish outlet type bleeding from more significant hematochezia.
CORI collects endoscopic data from diverse practice sites in attempt to provide an accurate representation of endoscopic practice in the U.S. CORI participating sites are comfortable using computers for endoscopic reporting and sharing data from their practice. These practices may differ in important ways from those which will not use computerized databases nor share their data to monitor quality in their practice. The CORI database includes very little endoscopic data from procedures performed by non-GI physicians. Therefore, its data may not be entirely representative of endoscopy practice in the U.S. because it has been estimated that approximately 15–20% of all endoscopies are performed by non-gastroenterologists.
Despite these limitations, our results are clinically relevant and may inform decisions about the role of colonoscopy in patients age 40 to 49. Additional strengths include it provides data on colonoscopy in those under 50, where little exists currently, and is the largest colonoscopy study in patients under age 50 to date.
In summary, these data provide support for colonoscopy in men and women age 40 to 49 years with hematochezia. Future studies should stratify patients with hematochezia to determine if they have outlet type bleeding, or more significant lower GI bleeding. Patients less than 50 with general GI symptoms such as pain, bloating, change in bowel habits had significantly lower rates of large polyps, and may be less likely to benefit from colonoscopy. Further studies are needed to evaluate the benefits of colonoscopy to evaluate other indications in patients under age 50.
Acknowledgments
Grant Support: This project was supported with funding from NIDDK U01DK57132 and R33-DK61778-01. In addition, the practice network (Clinical Outcomes Research Initiative) has received support from the following entities to support the infrastructure of the practice-based network: AstraZeneca, Novartis, Bard International, Pentax USA, ProVation, Endosoft, GIVEN Imaging, and Ethicon. The commercial entities had no involvement in this research.
Dr. Lieberman is the executive director of CORI, a non-profit organization that receives funding from federal and industry sources. This potential conflict of interest has been reviewed and managed by the OHSU and Portland VA Conflict of Interest in Research Committees. All other authors have no potential conflicts of interests to disclose.
Abbreviations
- IDA
iron deficiency anemia
- CORI
clinical outcomes research initiative
Footnotes
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Author Contributions
KS: Study concept and design, data analysis and interpretation, drafting of manuscript, critical manuscript revision
BKE: Data analysis and interpretation, critical manuscript revision
JLH: Study concept and design, acquisition of data, data analysis and interpretation, critical revision of manuscript
DL: Study concept and design, data analysis and interpretation, critical manuscript revision
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