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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 136-140

Colonoscopy appropriateness in a libyan hospital: The experience with a modified open-access system

Department of Medicine, Benghazi Medical Centre, Benghazi, Libya

Date of Submission28-Sep-2019
Date of Acceptance04-Dec-2019
Date of Web Publication26-Dec-2019

Correspondence Address:
Dr. Abdelhakim M Elbarsha
Department of Medicine, Benghazi Medical Centre, Second Ring Road, Benghazi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_53_19

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Background and Aim: In the absence of guidelines for referring patients for colonoscopy in the Benghazi Medical Center, the use of a modified open-access system of referral may decrease the rate of inappropriate colonoscopies. This study aimed to assess the impact of modified open-access system of referral on colonoscopy appropriateness using the American Society of Gastrointestinal Endoscopy guidelines as a reference. Subjects and Methods: In this observational, cross-sectional, and retrospective study, all colonoscopies performed in the Benghazi Medical Center during the period from January 1, 2015, to December 31, 2016, were retrospectively studied. Colonoscopy reports were retrieved from the paper-based hospital medical archives. Results: After exclusion of colonoscopy records with inadequate data, only 344 colonoscopies were included in the study. Three hundred and nine (89.8%) colonoscopies were found to be appropriate and 35 (10.2%) were inappropriate. The most common appropriate indication was rectal bleeding (61, 19.7%). Examination results were negative in 135 (39.2%) and positive in 209 (60.75%) colonoscopies. Among colonoscopies with positive findings, the number of colonoscopies with positive relevant findings was 126 (60.3%). Of these, the indication was appropriate in 122 (96.8%) and inappropriate in 4 (3.2%) colonoscopies. Appropriate colonoscopies were significantly more likely to be associated with positive relevant findings (P = 0.0029). Conclusion: Modified open-access system of colonoscopy referral increases the rate of appropriate colonoscopies, even if no definite guidelines for colonoscopy appropriateness are followed, neither by referring physicians nor endoscopists.

Keywords: Appropriateness, colonoscopy, modified open access system

How to cite this article:
Elbarsha AM, Ghoul YA, Ali MF. Colonoscopy appropriateness in a libyan hospital: The experience with a modified open-access system. Libyan J Med Sci 2019;3:136-40

How to cite this URL:
Elbarsha AM, Ghoul YA, Ali MF. Colonoscopy appropriateness in a libyan hospital: The experience with a modified open-access system. Libyan J Med Sci [serial online] 2019 [cited 2023 Mar 30];3:136-40. Available from: https://www.ljmsonline.com/text.asp?2019/3/4/136/274102

  Introduction Top

Colonoscopy was long considered superior to less invasive procedures in the diagnosis of colonic diseases.[1] In the United States alone, about 15 million colposcopies were performed in the year 2012.[2],[3] Colonoscopy is also considered as the gold standard method for colorectal cancer screening.[4] The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for defining colonoscopy appropriateness and inappropriateness are globally accepted.[5] Most of the published studies involved centers with open-access system for colonoscopy referrals.[6] The aim of this study was to retrospectively estimate the rate of colonoscopy appropriateness in a modified open-access system of referring.

  Subjects and Methods Top

Setting and study design

The study design is observational, cross-sectional, and retrospective. Colonoscopy referral letters and the results of all procedures done from January 1, 2015, to December 31, 2016, were collected from the paper-based medical record archive of the endoscopy department in Benghazi Medical Center. The following data were extracted from the records: age, sex, indication of the procedure, either in- or outpatient, and the examination findings.

Inclusion criteria

All procedure records with complete data, complete examination, and adequate colonic preparation were included in the study.


According to the information obtained from the referral letters, colonoscopies were classified as appropriate or inappropriate. The ASGE guidelines were used as a reference for deciding for the procedure appropriateness. The colonoscopy results were classified as positive relevant findings (abnormal findings that either explained patients' symptoms or had impact on therapy or prognosis), positive irrelevant findings (abnormal findings which did not explain patients' symptoms and may or may had not impact on therapy or prognosis), and negative (normal) findings.

Statistical analysis

Statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS), version 18.0 (IBM Corp., Armonk, NY, USA). Data were analyzed by the calculation of odds ratio and related 95% confidence intervals. The results were considered statistically significant at P < 0.05.

Compliance with ethical principles

Approval for the study was granted by the Endoscopy Department, Benghazi Medical Center, Benghazi, Libya. The study was conducted with no direct or indirect involvement of patients.

  Results Top

A total of 344 procedures were included in the study according to the inclusion criteria. The total number of male patients was 155 (45.1%) and the number of female patients was 189 (54.9%). The age range was 15–85 years, with a mean of 50.7 years. The number of female patients referred for colonoscopy was higher (54. 9%) than males. Most of the patients were older than 45 years (61%), with a mean age of 50.7 years. Positive colonoscopy findings were reported in 60.75% of colonoscopies, with hemorrhoids being the most common finding (49.7%), followed by colonic polyps (17.2%) [Table 1]. Positive relevant and irrelevant findings were not different in patients older than 45 years and in those who were 45 years or younger.
Table 1: Positive colonoscopy findings

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Of the 344 procedures included, 309 (89.8%) were found to be appropriate and 35 (10.2%) were inappropriate. The most common appropriate indications include rectal bleeding (61, 19.7%), diarrhea of unexplained origin (36, 11.6%), unexplained iron deficiency anemia (24, 7.7%), significant abnormality on imaging study (22, 7.1%), assessment of Crohn's disease (22, 7.1%), and abdominal pain (21, 6.8%) [Table 2]. Of the total 344 colonoscopies, 135 (39.2%) examination results were negative, while in 209 (60.75%) colonoscopies, the results were positive.
Table 2: Appropriate colonoscopy indications and positive findings

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The number of appropriate colonoscopies in male and female patients was 137 (88.4%) and 172 (91%), respectively. There was no significant difference in colonoscopy appropriateness between the two genders (P = 0.4253). The number of appropriate colonoscopies with positive relevant and irrelevant findings was 122 and 187, respectively. While only four inappropriate colonoscopies detected relevant positive findings (i.e., influencing management), the majority (31 inappropriate colonoscopies) showed no relevant findings [Table 3]. Appropriate colonoscopies were significantly more likely to reveal positive relevant findings (P = 0.0029).
Table 3: Colonoscopy indications and appropriateness versus relevance of findings

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Among patients aged 45 years and younger who underwent colonoscopy, positive relevant findings were detected in 50 of 131 patients (38.1%). In the 213 patients who were older than 45 years, positive relevant findings were found in only 76 patients (35.7%). There was no difference in the rate of positive relevant findings between the two age categories (≤45 and >45 years) (P = 0.64). By comparing the patients' gender and colonoscopy findings, the number of male and female patients with positive relevant findings was 58 (46.03%) and 68 (54%), respectively, with no significant difference between males and females (P = 0.7826).

  Discussion Top

In this study, we assessed the impact of a modified open access system of colonoscopy referrals on colonoscopy appropriateness compared it with open-access system figures worldwide. The number of appropriate colonoscopies in this study was high, compared with that observed in an open-access system, in which colonoscopy referrals were not subjected to the revision by endoscopists. The rate of colonoscopy appropriateness in our study group (89.8%) was higher than most of open-access system figures reported worldwide. The age of our patients also did not affect the appropriateness of colonoscopy, an observation that was similar to previous findings.[7] There was no difference in the rate of appropriate colonoscopies and positive relevant and irrelevant findings among male and female patients. In a Portuguese observation, the rate of inappropriate colonoscopies was higher among females.[7] In one study from Italy, the rate of appropriate colonoscopies was 71% where referrals were subjected to the revision by endoscopists and on referring to the guidelines. This rate was comparable to that we observed in our modified open access system.[8]

Inappropriate procedures, despite the presence of guidelines, are still performed. It was estimated that 18%–42% of colonoscopies were inappropriate in different centers with open-access system.[9],[10],[11],[12],[13],[14],[15] While appropriate colonoscopy indications in many studies are defined according to the ASGE guidelines, there are indications that are not listed in the guidelines and therefore are not classified to neither appropriate nor inappropriate. These unclassified indications were as high as 25.4% of colonoscopies performed, in a Malaysian observation.[16] In a study from the United States, the percentage of appropriate colonoscopies in open-access system was high (81%) when the referring physicians were instructed regarding the appropriate indications.[17]

The variations in the rate of appropriate and inappropriate colonoscopies, in different observations, may depend on the strength of adherence to guidelines by referring doctors in open-access systems.

In a nonopen access system where gastroenterologist consultation is required before deciding for the colonoscopy, the majority of colonoscopies were appropriate according to the ASGE guidelines. The percentage of positive findings in a nonopen access system is variable but is generally high, with a significant association between colonoscopy appropriateness and positive findings.[18]

Inappropriate colonoscopies are associated with a higher percentage of negative findings compared with appropriate colonoscopies. In this study, appropriate colonoscopies were significantly more likely to detect positive relevant findings. Relevant positive findings in one study were reported in 21.1% of colonoscopies, and the diagnostic yield was significantly higher for appropriate than for inappropriate colonoscopies.[7],[10] In an African study, colonoscopy indications were appropriate in 73.3%, with a diagnostic yield of 58.8%.[19] This is in comparison with what we observed in our modified open-access system where positive relevant findings were present in 122 appropriate colonoscopies, with a diagnostic yield of 35.46%, while in inappropriate colonoscopies, the diagnostic yield was 1.16%.

Since this study was retrospective, the limitation was the lack of adequate information in most colonoscopies performed during the defined time period owing to the low quality of the medical record archive system and resulted in the exclusion of a large number of colonoscopies.

  Conclusion Top

Appropriate colonoscopy indications were linked to higher diagnostic yield compared to inappropriate procedures, and the adherence to appropriate indications (according to the ASGE guidelines), by referring doctors in the open access system, will maintain a high diagnostic yield. Alternatively, revising colonoscopy referrals by endoscopists to ensure appropriateness, as in the case of a modified open-access system, will further increase the diagnostic yield, by minimizing the number of inappropriate colonoscopies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Bersani G, Rossi A, Ricci G, Pollino V, Defabritiis G, Suzzi A, et al. Do ASGE guidelines for the appropriate use of colonoscopy enhance the probability of finding relevant pathologies in an open access service? Dig Liver Dis 2005;37:609-14.  Back to cited text no. 10
Froehlich F, Burnand B, Pache I, Vader JP, Fried M, Schneider C, et al. Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: A prospective study in primary care. Gastrointest Endosc 1997;45:13-9.  Back to cited text no. 11
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Froehlich F, Pache I, Burnand B, Vader JP, Fried M, Beglinger C, et al. Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: A prospective study. Gastrointest Endosc 1998;48:128-36.  Back to cited text no. 14
Siddique I, Mohan K, Hasan F, Memon A, Patty I, Al-Nakib B. Appropriateness of indication and diagnostic yield of colonoscopy:First report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy. World J Gastroenterol 2005;11:7007-13.  Back to cited text no. 15
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Mahajan RJ, Barthel JS, Marshall JB. Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do? Arch Intern Med 1996;156:2065-9.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3]

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