Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding.

BACKGROUND & AIMS: Acute kidney injury (AKI) is conventionally evaluated by a dynamic change of serum creatinine (Scr). Cystatin C (CysC) seems to be a more accurate biomarker for assessing kidney function. This retrospective multicenter study aims to evaluate whether AKI re-defined by CysC can predict the in-hospital outcomes of patients with liver cirrhosis and acute gastrointestinal bleeding. METHODS: Overall, 677 cirrhotic patients with acute gastrointestinal bleeding, in whom both Scr and CysC levels were detected at admissions, were screened. eGFRScr, eGFRCysC, and eGFRScr-CysC were calculated. MELD-Na score and AKI were re-evaluated by CysC instead of Scr. Odds ratios (ORs) were calculated in the logistic regression analyses. The receiver operating characteristic (ROC) curve analyses were performed. RESULTS: Univariate logistic regression analyses demonstrated that baseline Scr and CysC levels, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, MELD-Na score re-defined by CysC, and AKI re-defined by CysC, but not conventional AKI defined by Scr, were significantly associated with in-hospital death. ROC analyses showed that baseline CysC level, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, and MELD-Na score re-defined by CysC, but not baseline Scr level, could significantly predict the risk of in-hospital death. CONCLUSIONS: AKI re-defined by CysC may be superior for predicting the in-hospital mortality of cirrhotic patients with acute gastrointestinal bleeding.

Plasma YAP1 predicts esophageal varices and the risk of variceal bleeding in liver cirrhosis.

Aim: To explore the predictive value of plasma YAP1 for esophageal varices (EV) and high-risk EV (HRV) in patients with liver cirrhosis. Materials & methods: A total of 208 patients with liver cirrhosis were enrolled and categorized into four groups. Correlation analysis, logistic regression analysis and receiver operating characteristic curve analysis were performed to evaluate the diagnostic performance of plasma YAP1 for EV and HRV. Results: Plasma YAP1 levels were significantly elevated with the occurrence and progression of EV in cirrhotic patients. The multivariate logistic regression analysis revealed that plasma YAP1 is an independent predictor for EV and HRV. For predicting EV and HRV, the YAP1 cut-off values of 5.43 and 6.98 ng/ml yielded the area under the receiver operating characteristic curves of 0.944 and 0.955, respectively. Conclusion: Plasma YAP1 is a potential novel noninvasive biomarker for predicting EV and HRV in patients with liver cirrhosis.

Predictive performance of blood urea nitrogen to serum albumin ratio in elderly patients with gastrointestinal bleeding.

INTRODUCTION: Acute gastrointestinal (GI) bleeding is one of the most important and the common causes of patients visiting the emergency department. Dehydrated state leads to increased blood urea nitrogen (BUN) and decreased albumin level. Many scoring systems had been developed to predict outcomes for patients with GI bleeding. Among the many scoring systems, the AIMS65 score was a simple and accurate risk assessment scoring tool. Therefore, in this study, we evaluated the prognostic performance of the blood urea nitrogen to serum albumin ratio (B/A ratio) compared to the AIMS65 score tool in elderly patients with GI bleeding. MATERIAL AND METHODS: This was a retrospective cohort study of patients with GI bleeding in our institution from February 2018 through May 2020. Baseline characteristic data were obtained. The data were compared with the prevalence of ICU admission and in-hospital mortality. The B/A ratio and the AIMS65 score as predictors of ICU admission and in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. RESULTS: In the 596 patients included in the study, of whom 188 (31.5%) were admitted to the ICU and 36 (6.0%) died during hospitalization. Multivariate logistic regression analysis revealed that the B/A ratio was significant predictors of ICU admission and in-hospital mortality. In addition, the B/A ratio was significant higher in ICU admission patients and non-survivors. The AUROC value of the B/A ratio was 0.682 and that of the AIMS65 score was 0.699 for predicting ICU admission. For predicting in-hospital mortality, the AUROC value was 0.770 and 0.763, respectively. CONCLUSION: The B/A ratio is as simple and useful tool for predicting outcomes for old aged GI bleeding patients as the AIMS65 score.

Transfusion with Cryoprecipitate for Very Low Fibrinogen Levels Does Not Affect Bleeding or Survival in Critically Ill Cirrhosis Patients.

BACKGROUND: Fibrinogen (FIB) levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients. OBJECTIVE: We aimed to determine if treatment with cryoprecipitate (CRYO) for low FIB levels is associated with bleeding outcomes or survival. METHODS: A total of 237 cirrhosis patients admitted to an intensive care unit at a tertiary care liver transplant center with initial FIB levels less than 150 mg/dL were retrospectively assessed for CRYO transfusion, bleeding events, and survival outcomes. RESULTS: The mean MELD score was 27.2 (95% confidence interval [CI]: 26.0-28.3) and CLIF-C acute on chronic liver failure score was 53.4 (51.9-54.8). Ninety-nine (41.8%) were admitted for acute bleeding and the remainder were admitted for nonbleeding illnesses. FIB level on admission correlated strongly with disease severity. After adjusting for disease severity, FIB on admission was not an independent predictor of 30-day survival (hazard ratio [HR]: 0.99, 95% CI: 0.99-1.01, p = 0.68). CRYO transfusion increased FIB levels but had no independent effect on mortality or bleeding complications (HR: 1.10, 95% CI: 0.72-1.70, p = 0.65). CONCLUSION: In cirrhosis patients with critical illness, low FIB levels on presentation reflect severity of illness but are not independently associated with 30-day mortality. Treatment of low FIB with CRYO also does not affect survival or bleeding complications, suggesting FIB is an additional marker of severity of illness but is not itself a direct factor in the pathophysiology of bleeding in critically ill cirrhosis patients.

Prealbumin and D-dimer as Prognostic Indicators for Rebleeding in Patients with Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND: Determining the risk stratification of nonvariceal upper gastrointestinal bleeding (NVUGIB) plays a vital role in treating upper gastrointestinal bleeding (UGIB). Traditional scores like Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score have been widely utilized in UGIB practice, however exhibiting limited practical use due to relative lack of user-friendly characters. Prealbumin as a nutritional indicator and d-dimer as a fibrinolytic activity monitor, are generally used to evaluate the overall nutritional and fibrinolytic condition in UGIB patients. AIMS: Here, we explored the predictive value of these two markers in NVUGIB for evaluating severity and prognosis including rebleeding and surgery intervention. METHODS: One hundred and eighty-five patients suffering NVUGIB were enrolled. Their GBS, RS, and AIMS65 score, routine laboratory test results including prealbumin and d-dimer were determined after admission. Multivariate regression analysis was performed to define the independent predictors of rebleeding. ROC curves were generated to compare the suitability of prealbumin, d-dimer, and scores for rebleeding prediction. RESULTS: The NVUGIB patients with rebleeding exhibited higher scores, white blood cell counts, d-dimer, CRP, proportion of surgery intervention, and longer hospital stay, but lower hematocrit, hemoglobin, calcium, prealbumin, and fibrinogen than those without rebleeding. The multivariate regression analysis demonstrated that prealbumin and d-dimer were independent predictors for rebleeding. Values of prealbumin and d-dimer were correlated with hospital stay, ulcer degrees, and surgery demand. The ROC curve analyses showed that prealbumin and d-dimer exhibited superior prediction value over the scoring systems. CONCLUSIONS: Prealbumin and d-dimer are promising predictors for severity and prognosis in NVUGIB practice.

Endoscopic band ligation compared to thermal therapy for gastric antral vascular ectasia: A systematic review and meta-analysis.

BACKGROUND: Gastric antral vascular ectasia is an infrequent cause of gastrointestinal-related blood loss manifesting as iron-deficiency anemia or overt gastrointestinal bleeding, and is associated with increased healthcare burdens. Endoscopic therapy of gastric antral vascular ectasia most commonly involves endoscopic thermal therapy. Endoscopic band ligation has been studied as an alternative therapy with promising results in gastric antral vascular ectasia. AIMS: The primary aim was to compare the efficacy of endoscopic band ligation and endoscopic thermal therapy by argon plasma coagulation for the management of bleeding gastric antral vascular ectasia in terms of the mean post-procedural transfusion requirements and the mean hemoglobin level change. Secondary outcomes included a comparison of the number of sessions needed for cessation of bleeding, the change in transfusion requirements, and the adverse events rate. METHODS: PubMed, Medline, SCOPUS, Google Scholar, and the Cochrane Controlled Trials Register were reviewed. Randomized controlled clinical trials and retrospective studies comparing endoscopic band ligation and endoscopic thermal therapy in bleeding gastric antral vascular ectasia, with a follow-up period of at least 6 months, were included. Statistical analysis was done using Review Manager. RESULTS: Our search yielded 516 papers. After removing duplicates and studies not fitting the criteria of selection, five studies including 207 patients were selected for analysis. Over a follow-up period of at least 6 months, patients treated with endoscopic band ligation had significantly lower post-procedural transfusion requirements (MD -2.10; 95% confidence interval (-2.42 to -1.77)) and a significantly higher change in the mean hemoglobin with endoscopic band ligation versus endoscopic thermal therapy (MD 0.92; 95% confidence interval [0.39-1.45]). Endoscopic band ligation led to a fewer number of required sessions (MD -1.15; 95% confidence interval [-2.30 to -0.01]) and a more pronounced change in transfusion requirements (MD -3.26; 95% confidence interval [-4.84 to -1.68]). There was no difference in adverse events. CONCLUSION: Results should be interpreted cautiously due to the limited literature concerning the management of gastric antral vascular ectasia. Compared to endoscopic thermal therapy, endoscopic band ligation for the management of bleeding gastric antral vascular ectasia led to significantly lower transfusion requirements, showed a trend toward more remarkable post-procedural hemoglobin elevation, and a fewer number of procedures. Endoscopic band ligation may improve outcomes and lead to decreased healthcare burden and costs.

Post-transfusion hemoglobin response in patients with cirrhosis: Can we expect a 1 g/dL rise per unit transfused?

BACKGROUND: A patient's hemoglobin is typically expected to rise by 1 g/dL/unit transfused PRBCs. However, it has been theorized that mechanisms such as hyperbilirubinemia and splenomegaly might lead to either a direct lysis or sequestration of red blood cells that could decrease this proportionate response. STUDY DESIGN AND METHODS: Patients with resolved GI bleeding but still requiring transfusion to correct anemia were compared in cirrhosis and control groups. A retrospective chart review between 2015 and 2020 was conducted at a single institution. Data collected included age, sex, BMI, GI bleed diagnosis, number of PRBCs transfused, presence of splenomegaly and spleen size, alcohol use history, type of cirrhosis, MELD-Na at admission, GFR, and pre-and post-transfusion labs: total bilirubin, ALT, hemoglobin, hematocrit. A logic regression was performed for each group looking at which factors were associated with a successful response (defined as >0.9 g/dL hemoglobin per unit transfused). RESULTS: Mean change in hemoglobin was 0.77 g/dL in patients with cirrhosis compared to 1.46 g/dL in patients without (P < .001, N = 103). Odds ratios for presence of splenomegaly (0.22, N = 78) and female sex (4.39, N = 102) in predicting adequate response (>0.9 g/dL/unit) were both significant (P = .002) as well as portal hypertensive bleed diagnosis (0.28, N = 85, P = .0015). Factors that did not contribute included: age, race, BMI, alcohol use, GFR, change in ALT, and change in total bilirubin. CONCLUSIONS: Patients with cirrhosis have an approximately 50% decreased response to transfusion with PRBCs after resolution of a gastrointestinal bleed in comparison to patients without cirrhosis. Risk factors included splenomegaly, portal hypertension, and male sex.

Hemoglobin Monitoring in Acute Gastrointestinal Bleeding: Are We Monitoring Blood Counts Too Frequently?

BACKGROUND: Gastrointestinal hemorrhage is a common cause of hospital admission. However, there are little data to inform practice around blood count monitoring-a cornerstone of management. We hypothesized that more frequent testing leads to increased resource utilization without improvement in patient outcomes. METHODS: This retrospective observational cohort study examined all patients admitted to a large academic medical institution primarily for gastrointestinal bleeding between July 10, 2014, and January 1, 2018. We identified 1150 patients admitted for gastrointestinal hemorrhage. Patients under 18, who developed bleeding while hospitalized, or who were transferred were excluded. The primary outcome was the number of complete blood counts collected in the first 48 hours of admission. Propensity matched analysis was performed to assess blood transfusion, units of blood transfused, time-to-endoscopy, mortality, and 30-day readmission rate. RESULTS: On average, 5.6 complete blood counts were collected in the first 48 hours; 67% of the cohort was transfused (average of 2.6 units of packed red blood cells). When matched for comorbidity, anticoagulant use, location (ward vs. intensive care unit), vital signs, hemoglobin level, and international normalized ratio, patients having more frequent monitoring had similar hospital length of stay and mortality rates, but were more likely to receive a blood transfusion (0.93 vs 0.76, P < .05), and if transfused, receive more blood (4 vs 2 units, P < .05). CONCLUSIONS: Blood count monitoring occurs more frequently than is likely necessary, is associated with a higher likelihood of blood transfusion, and does not affect patient outcomes, suggesting patient care may be improved by less frequent monitoring.

Regulation of Angiopoietin-2 Before and After Mechanical Circulatory Support Therapy.

Gastrointestinal bleeding (GIB) during mechanical circulatory support (MCS) is a major unsolved comorbidity. Inadequate activation of angiopoietin-2-related systems is considered as a major cause of GIB. However, the regulation of angiopoietin-2 remains unknown. Consecutive 20 patients who received continuous-flow MCS therapy (MCS group) and 12 with advanced heart failure (HF; HF group) were prospectively enrolled and their angiopoetin-2 levels were compared. Angiopoietin-2 level had a moderate correlation with log10 B-type natriuretic peptide (BNP; r = 0.39, p < 0.001). The MCS group had significantly higher angiopoietin-2 level divided by log10 BNP compared with the HF group (2.80 ± 0.20 vs. 1.88 ± 0.17, p < 0.001). Angiopoetin-2 had a moderate correlation with central venous pressure and C-reactive protein during the MCS support (r = 0.51 and r = 0.45, respectively). Higher angiopoietin-2 level divided by log10 BNP (> 4.3) was significantly associated with the occurrence of GIB with a hazard ratio of 296 (95% confidence interval 2.24-38620, p = 0.0224). Angiopoietin-2 was already elevated in the HF cohort and more elevated following MCS initiation. Among the MCS cohort, angiopoietin-2 was particularly elevated in patients with systemic congestion and inflammation and was associated with higher incidence of GIB.

C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis.

ABSTRACT: In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.

Combining antiplatelet and anticoagulant therapy in cardiovascular disease.

Up to 10% of the >3 million Americans with atrial fibrillation will experience an acute coronary syndrome or undergo percutaneous coronary intervention. Therefore, concurrent indications for multiple antithrombotic agents is a common clinical scenario. Although each helps reduce thrombotic risk, their combined use significantly increases the risk of major bleeding events, which can be life threatening. In the past 5 years, a number of randomized clinical trials have explored different combinations of anticoagulation plus antiplatelet agents aimed at minimizing bleeding risk while preserving low thrombotic event rates. In general, shorter courses with fewer antithrombotic agents have been found to be effective, particularly when direct oral anticoagulants are combined with clopidogrel. Combined use of very low-dose rivaroxaban plus aspirin has also demonstrated benefit in atherosclerotic diseases, including coronary and peripheral artery disease. Use of proton pump inhibitor therapy while patients are taking multiple antithrombotic agents has the potential to further reduce upper gastrointestinal bleeding risk in select populations. Applying this evidence to patients with multiple thrombotic conditions will help to avoid costly and life-threatening adverse medication events.

Procalcitonin and C-reactive Protein Levels as Biomarkers to Determine Gastrointestinal Involvement in Adult Henoch-Schönlein Purpura Patients.

OBJECTIVE: To investigate the association of procalcitonin (PCT) and C-reactive protein (CRP) levels with gastrointestinal (GI) involvement in adult HSP patients. METHOD: A retrospective study using clinical data and serum PCT and CRP levels from 121 adult HSP patients was performed. RESULTS: The proportion of male HSP patients with GI involvement was significantly higher compared to patients without GI involvement. PCT and CRP levels in adult HSP patients with GI involvement were higher compared to patients without GI involvement (P < 0.05); Among the patients with GI involvement, those with GI hemorrhage had significant higher PCT and CRP levels (P < 0.05); the median PCT value was lower compared to the threshold value for systemic infection. There was a positive correlation between PCT and CRP levels in HSP patients with GI involvement and GI bleeding (P < 0.05). ROC curve analysis demonstrated that the PCT and CRP cutoff levels of 0.07 ng/ml and 29.35 mg/L respectively had optimal diagnostic efficacy for GI bleeding in adult HSP patients. CONCLUSION: Elevated serum PCT and CRP levels were significantly associated with GI involvement in adult HSP patients, especially for GI bleeding. PCT levels correlated well with CRP levels.

Diagnostic Values of Blood Count Values and Ratios in Distinguishing between Peptic Ulcer Bleeding and Esophagogastric Variceal Bleeding.

BACKGROUND: To investigate the diagnostic values of blood count values and ratios in distinguishing between peptic ulcer bleeding (PUB) and esophagogastric variceal bleeding (EGVB). METHODS: Due to acute hematemesis and or melaena, 57 patients diagnosed with PUB (PUB group) and 33 cases with EGVB (EGVB group) were enrolled in this retrospective study. The levels of peripheral blood leukocyte counts (leukocyte), neutrophil counts (neutrophil), lymphocyte counts (lymphocyte), platelet counts (platelet), neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) were recorded and compared between the two groups. Student's t-test of independent samples was adopted for comparing the mean between the two groups. Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Comparison of AUC was performed using the Z-test. RESULTS: The levels of leukocyte, neutrophil, lymphocyte, platelet, and PLR were significantly increased in PUB group compared with EGVB group (all p < 0.05), while there was no significant statistical difference of NLR (p > 0.05); moreover, AUCs in distinguishing PUB from EGVB were 0.859, 0.811, 0.760, 0.952, and 0.687 for leukocyte, neutrophil, lymphocyte, platelet, and PLR, respectively, and significant differences were observed between platelet and any parameter of the rest (all p < 0.05); finally, the cutoff values were 8 x 109/L in distinguishing between PUB and EGVB (specificity 78.95%, sensitivity 87.88%, and Youden index 0.668) for leukocyte, 5.3 x 109/L (specificity 70.18%, sensitivity 81.82%, and Youden index 0.520) for neutrophil, 1.2 x 109/L (specificity 84.21%, sensitivity 60.61%, and Youden index 0.448) for lymphocyte, 131 x 109/L (specificity 92.98%, sensitivity 90.91%, and Youden index 0.839) for platelet, and 88 (specificity 70.18%, sensitivity 63.64%, and Youden index 0.338) for PLR. CONCLUSIONS: Leukocyte, neutrophil, lymphocyte, platelet and PLR are useful and potential biomarkers in distinguishing between PUB and EGVB; moreover, platelet can demonstrate more accurate and reliable diagnostic value.

A study on two kinds of scoring models in predicting the degree of esophageal varices and bleeding.

OBJECTIVE: This study aims to investigate the value and determine the accuracy of two kinds of scoring models in predicting the degree of esophageal varices (EV) and esophageal variceal bleeding (EVB) in patients with liver cirrhosis (LC). PATIENTS AND METHODS: A total of 189 patients with LC, who underwent esophagogastroduodenoscopy (EGD), color Doppler ultrasound (CDU), and computed tomography (CT), were retrospectively analyzed. Then, the routine blood examination, liver function test, M-index of the spleen in CT, EGD, and CDU results were recorded. According to the EGD result, these patients were divided into five groups: varicose bleeding group, severe varices group, moderate varices group, mild varices group, and no varices group. Then, the receiver operating characteristic curves of all predicting parameters studied were respectively drawn, the area under the receiver operating characteristic curves were calculated, and the predictive value of EV and EVB was evaluated. RESULTS: The area under the receiver operating characteristic curve of the VAP score model and Plt/S-D score model was 0.901 and 0.835, respectively. The VAP score model cut-off value of 461.5 for predicting moderate esophageal varices (MoEV), severe esophageal varices (SEV), and EVB has a specificity and sensitivity of 100% and 68.7%, respectively, while the Plt/S-D score model cut-off value of 835.5 for predicting MoEV, SEV, and EVB has a specificity and sensitivity of 95.1% and 58.2%, respectively. CONCLUSIONS: These two kinds of scoring models can predict the degree of esophageal varices and bleeding in liver cirrhosis patients and has good predictive accuracy.

A case of unexplained duodenal ulcer and massive gastrointestinal bleed.

A 73-year-old man was displaying symptoms of massive gastrointestinal (GI) bleed. Surgical actions were performed to control the bleed caused by an erosive duodenal ulcer with duodenal perforation. When investigating the culprit of this case, the pain medications prescribed two weeks prior by a traditional Chinese medicine doctor raised attention. The patient's admission serum sample and the pain medications from unknown sources were analyzed using a clinically validated liquid chromatography-high-resolution mass spectrometry (LC-HRMS) method. The NSAIDs diclofenac, piroxicam, and indomethacin were identified, as well as some other synthetic drugs and natural products. The patient's concurrent exposure to multiple NSAIDs significantly increased the risk of upper GI complications. It is reasonable to argue that the high-dose use of the NSAIDs was a major cause of the duodenal ulcer and GI bleed. In addition, the identified natural products such as atropine and ephedrine have well-documented toxicities. It is important to increase the visibility of unregulated medications, and the capability to perform untargeted mass spectrometry analysis provides a unique diagnostic advantage in cases where exposure to toxic substances is possible.

The diagnostic value of a change in bowel habit for colorectal cancer within different age groups.

BACKGROUND: Change in bowel habit as a sole alarm symptom for colorectal cancer is disputed. OBJECTIVE: We investigated the diagnostic value of change in bowel habit for colorectal cancer, particularly as a single symptom and within different age groups. METHODS: This retrospective cohort study examined colorectal cancer fast track referrals and outcomes across four Swedish hospitals (April 2016-May 2017). Entry criteria constituted one or more of three alarm features: anaemia, visible rectal bleeding, or change in bowel habit for more than 4 weeks in patients over 40 years of age. Patients were grouped as having only change in bowel habit, change in bowel habit plus anaemia/bleeding or anaemia/bleeding only. RESULTS: Of 628 patients, 22% were diagnosed with colorectal cancer. There were no cases of colorectal cancer in the only change in bowel habit group under 55 years, while this was 6% for 55-64 years, 8% for 65-74 years and 14% for 75 years and older. Among subjects under 55 years, 2% with anaemia/bleeding had colorectal cancer, this increased to 34% for 55 years and older (P < 0.0001). Change in bowel habit plus anaemia/bleeding gave a colorectal cancer prevalence of 16% in under 55 years and increased to 30% for 55 years and older (P = 0.07). CONCLUSION: Change in bowel habit as the only alarm feature has a low diagnostic yield for colorectal cancer in patients under 55 years.