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Journal of General Internal Medicine

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Rectum -- Diseases -- Treatment


Colon cancer is the third leading cause of cancer-related death in this country.5 The majority of medical societies recommend some form of colon cancer screening for asymptomatic adult patients over age 50. The evaluation of rectal bleeding is different from screening because the risk of serious disease is higher and it is unclear whether early diagnosis and treatment of serious disease results in improved mortality once gross bleeding has occurred. The optimal evaluation strategy for rectal bleeding is unknown. Neither historical information nor the presence or absence of hemorrhoids has been shown to reliably differentiate benign from serious disease.6–11 Fecal hemoccult testing is not a viable evaluation option for these patients as by definition they have observed blood in or on their stools. Potential strategies for investigation include watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema, or colonoscopy. Each of these strategies carries with it cost, discomfort, risk for complication, and a chance for false positive and negative results. Ultimately the choice of strategy depends on whether or not making an accurate diagnosis of serious disease will prolong life at an acceptable cost. Little is known about the relative cost implications of the evaluation strategies for patients over the age of 40 with rectal bleeding. Our objective was to compare the cost-effectiveness of four commonly employed diagnostic strategies for the evaluation of rectal bleeding


© 2020 by the authors. Licensee: Springer. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (

*At the time of publication, C. Nicolaidis was affiliated with OHSU.



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