Colonoscopy for colonic wall thickening at computed tomography: a worthwhile pursuit?

BACKGROUND: In the absence of official guidance for the management of colonic wall thickening identified by computed tomography (CT), a common clinical dilemma surrounds the volume of colonoscopies subsequently performed. METHODS: To identify whether colonic wall thickening identified at CT consistently warrants colonoscopy, consecutive colonoscopies performed at Leeds Teaching Hospitals Trust in 2008 and recorded as "possible colonic lesion on cross-sectional abdominal CT" in an endoscopic database were retrospectively analyzed. Clinical, radiologic, colonoscopic, and histologic data were obtained from medical records. RESULTS: Of 4,702 colonoscopies, 94 (2%) had a full data set meeting the inclusion criteria. The primary diagnoses were normal condition (n = 11, 11.7%), adenocarcinoma (n = 25, 26.6%), adenoma (n = 23, 24.5%), diverticular disease (n = 12, 12.8%), nonspecific colitis (n = 6, 6.4%), Crohn's disease (n = 4, 4.3%), and hyperplastic polyp (n = 3, 3.2%). Computed tomography and colonoscopy were concordant for specific pathology in 79.8% of the cases (n = 75). Compared with diagnosis after histology, colonoscopy alone correctly identified specific pathology in 18.1% of the cases (n = 17), and CT alone was correct in 4.3% of the cases (n = 4)), whereas both were incorrect in 3.2% of the cases (n = 3). Computed tomography had a sensitivity of 72.3% (95% confidence interval [95% CI], 61.9-80.8%), a specificity of 96.5% (95% CI, 94.9-97.6%), a positive predictive value of 72.3%, and a negative predictive value of 96.5%. In 63.8% of the cases (n = 60), CT identified pathology necessitating further intervention at the time of colonoscopy or afterward, and in 28.7% of the cases (n = 27), CT identified pathology requiring no additional intervention. In the remaining 7.4% of the cases (n = 7), CT detected no new pathology. CONCLUSION: Computed tomography is highly predictive of colonic pathology compared with final outcome after colonoscopy and biopsy. For patients without a pre-existing diagnosis, colonic wall thickening demonstrated at CT warrants further investigation with colonoscopy.

Cancer of appendix as a presenting feature of Crohn's disease.

Appendiceal neoplasms are rare. Colonic malignancies, including appendiceal carcinomas, have been rarely reported in Crohn's disease patients. The involvement of the appendix in Crohn's disease is not often seen. We report an interesting case in which a caecal Crohn's disease patient presented for the first time with an appendiceal adenocarcinoma.