2. Introduction Fresh bleeding per rectum (FBPR) may suggest possible organic pathology in the colon FBPR is common 20% of young adults had a history of visible rectal blood FBPR is underreported The commonest causes of recurrent FBPR are haemorrhoids and anal fissure FBPR may be one of the presentations of colorectal cancer (CRC) Presence of benign anorectal lesions in patients with FBPR does not exclude serious colonic lesions

3. Introduction Up to 16% of patients have been found to have colorectal neoplasms concurrent with an ano-rectal source CRC is uncommon in the younger age Well accepted that full colonoscopicexamination should be performed in patients with FBPR in >50 years To weigh the risks and costs of an extensive approach of colonoscopy with a low expected yield against missing a cancer

4. Introduction Colonoscopy offers complete visualization more discomfort increased financial cost more risk of complications Sigmoidoscopy convenient cost-effective May miss a potentially treatable sinister pathology in the proximal colon

5. Introduction Most data on FBPR in young is from west In west, the incidence of CRC is very low < 50 years In South Asia, CRC is diagnosed at a younger age Imperative that for the South Asian population the utility of full colonoscopic examination is defined for young patients with FBPR Aim: to determine the frequency and location of endoscopic lesions in young patients with FBPR and to ascertain whether full colonoscopicexamination is necessary in these patients

6. Patients and methods Cross-sectional study , on consecutive patients, Conducted between May 2007 and October 2009 at Aga Khan University Hospital Inclusion Scheduled to undergo colonoscopy following complaint of FBPR, referred from the outpatient clinic Informed consent had been obtained Aged between 18 and 50 years FBPR in the previous 6 months

7. Patients and methods Excluded History of known IBD History of colorectal surgery Family history of CRC Bleeding diathesis Iron deficiency anaemia Anticoagulant therapy Significant bleeding per rectum requiring blood transfusions and/or emergency room visit

8. Patients and methods FBPR Passing of fresh blood per rectum Noticing red blood in faeces, on toilet paper, or in toilet bowl Colonoscopy Under conscious sedation using combination of midazolam and pethidine or fentanyl Left lateral position to prevent aspiration Blood pressure, heart rate, and oxygen saturation were monitored every 5 minutes during procedure & then every 15 minutes for 2 hours post-procedure Details of bowel-cleansing preparation, completion of procedure, and intubation of terminal ileum were also recorded

9. Patients and Methods Lesions found on colonoscopy were recorded on the basis of location and type Location of the lesion was defined as distal if it was present in the rectum, sigmoid colon or descending colon (and hence likely within reach of a flexible sigmoidoscope), and proximal if it was located between the cecum and splenic flexure All lesions were biopsied for histopathological diagnosis except for hemorrhoids, anal fissure, diverticulosis, and arteriovenous malformation Polyps found during colonoscopy were removed and sent for histopathological analysis.

10. Statistical Analysis Data entry and analysis using the SPSS 15 Descriptive statistics were calculated for continuous variables such as age and haemoglobin. Mean ± SD were computed For categorical variables such as sex and type of lesion, the frequencies and percentages were calculated The chi-squared test, odds ratio (OR), and 95% confidence interval (CI) were calculated to evaluate the association of adenomatous polyps and CRC with respect to age and sex.

11. Results

12. Results No polyp/malignant lesion in those who had incomplete colonoscopy 379 patients were analyzed 257 men (67.8 %) and 122 women (32.2 %) 131 patients (34.6 %) in the 40–50 yrs& 248 (65.4 %) < 40 years Mean age at presentation was 36 ± 9 years Mean hemoglobin was 12.93 ± 1.78 g/dL No perforation and hemorrhage were noted in any patient Three patients became drowsy under the effect of sedatives drugs, were treated with intravenous flumazenil and recovered 12 patients experienced moderate pain post-procedure

13. Results 73 patients (19.3 %) had no lesion 306 patients (80.7 %) endoscopic lesions were found Hemorrhoids in 219 patients (57.8 %), hemorrhoids alone in 198 patients, in 21 patients hemorrhoids coexisted with other lesions Malignant lesions in nine patients with mean age of 41 years (range 33–48 years) Polyps in 30 patients Solitary rectal ulcers in 16 patients Ulcerative colitis in 29 patients (7.7 %), 20 left-sided colitis & 9 had pancolitis

14. Results 11 patients mild patchy erythema, non-specific changes in biopsy Anal fissure in 6 Diverticulosis in 4; 3 in rectosigmoid, and one in both distal and proximal colon Arteriovenousmalformations in 3, all in recto-sigmoid

15. Results

16. Malignant lesions All were in distal colon All were adenocarcinomas All patients with CRC underwent surgery, except for one patient who had advanced metastatic disease.

17. Malignant Lesions

18. Polyps Present in 30 patients Eight had adenomatous polyps (3 in < 40 years group and five in the 40–50 years age group) All were found in the distal colon, except for a 5-mm polyp in the transverse colon Four polyps were less than 1 cm and the rest were 1 cm or more in diameter None revealed a villous morphology or high grade dysplasia on histopathology

19. Polyps Juvenile polyps were also found in 13 patients Hyperplastic polyps in nine These lesions were predominantly in the 30–40 years age group Located in the rectosigmoid region Juvenile polyposis was found in one patient who underwent total colectomy

20. Results On univariate analysis, malignant and adenomatous lesions were significant in the 40–50 years age group (P = 0.031; OR 2.84; 95% CI 1.05–7.65)

21. Results

22. Discussion FBPR is common in the general population The incidence of CRC among patients with BPR varies from 4% to 19% Serious colonic pathology is rare in the young Approach to FBPR in young patients is not very clear and is still evolving. It is generally accepted that patients > 50 years with FBPR should undergo full colonoscopicexamination The cut-off of 50 years is chosen because the incidence of CRC begins to rise in the sixth decade of life in the Western population

23. Discussion In South Asia the exact incidence of CRC in patients with bleeding per rectum is not known CRC is diagnosed at a younger age in South Asian individuals than in their Caucasian counterparts In the present study CRC was found in nine patients (2.4 %) adenomatous polyps in eight (2.1 %)

24. Discussion These figures are greater than in the West In an Italian study of young patients with rectal bleeding without other alarm features, only 0.6% had CRC and all of them were in the distal colon A US study found only 1 and 11 patients out of 570 to have CRC and advanced adenoma, and all of in the distal colon Another American study of 223 young patients with rectal bleeding found CRC in 1.8% and all lesionswere distal

25. Discussion (Present study) Nine cases of CRC in the 33–49 years age group, a much younger age compared with the Western population; South Asian ethnicity may be a risk factor for early development of CRC All CRC patients had left-sided lesions No gender difference was found in the detection of adenomatous polyps and CRC

26. Discussion (Present study) Isolated proximal lesions are rare in patients with FBPR One patient with an adenomatous polyp in the transverse colon but he also had congested hemorrhoids If only proctoscopy is performed, potentially sinister pathology may be missed in the sigmoid and descending colon Authors recommend that young patients undergo sigmoidoscopyfor their evaluation A significantly increased number of CRC and adenomatous polyps in patients over 40 years old compared with patients younger than 40 year Flexible sigmoidoscopy seems to be a reasonable evaluation tool in young patients with no other alarm symptoms or no family history of CRC

27. Comments Provides data from South Asia where CRC occurs at an earlier age but no screening programmes exist Single-center study Setting: tertiary-care hospital; referral