Original article
Clinical endoscopy
Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis

https://doi.org/10.1016/j.gie.2011.06.023Get rights and content

Background

Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes.

Objective

To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups.

Setting and Patients

Elderly patients undergoing colonoscopy.

Design

Systematic review and meta-analysis.

Main Outcome Measurements

Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality.

Results

Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0-27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9-1.5) for perforation, 6.3 (95% CI, 5.7-7.0) for GI bleeding, 19.1 (95% CI, 18.0-20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7-2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9-38.0), perforation rate of 1.5 (95% CI, 1.1-1.9), GI bleeding rate of 2.4 (95% CI, 1.1-4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2-31.8), and mortality rate of 0.5 (95% CI, 0.06-1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5-1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2-2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant.

Limitations

Heterogeneity of studies included and not all complications related to colonoscopy were captured.

Conclusions

Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.

Section snippets

Study population

We performed a systematic review of computerized bibliography databases for elderly patients who underwent colonoscopy. We defined elderly using the World Health Organization's definition of a patient 65 years of age and older. Studies were included if data pertaining to patients 65 years of age and older and documented adverse events related to colonoscopy were reported and could be abstracted. Colonoscopies may have been performed in either the outpatient or inpatient setting and could have

Results

Our initial search strategy yielded 3328 articles. After initial title and abstract review, 88 articles remained for full manuscript review. Sixty-eight articles were excluded with the most frequent reason being that both the number of colonoscopies and specific number of adverse events could not be abstracted from the articles and stratified into either 65 years of age and older or 80 years of age and older age groups (Fig. 1). Twenty articles remained for inclusion in the study with 3 studies

Discussion

As individuals live longer, information regarding the differences in the risk of colonoscopy by age becomes increasingly important for patients and providers. In the articles retrieved for our study, the elderly overwhelmingly underwent colonoscopy for diagnostic purposes. Among individuals 65 years of age and older, the cumulative GI adverse event rate (perforation, bleeding, and CV/pulmonary) was 26.0/1000 colonoscopies, whereas in octogenarian patients, the cumulative adverse event rate

References (66)

  • G. Dafnis et al.

    Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden

    Gastrointest Endosc

    (2001)
  • H. Singh et al.

    Colonoscopy and its complications across a Canadian regional health authority

    Gastrointest Endosc

    (2009)
  • R. Zubarik et al.

    Prospective analysis of complications 30 days after outpatient colonoscopy

    Gastrointest Endosc

    (1999)
  • V.K. Sharma et al.

    A national study of cardiopulmonary unplanned events after GI endoscopy

    Gastrointest Endosc

    (2007)
  • S.B. Benjamin

    Complications of conscious sedation

    Gastrointest Endosc Clin N Am

    (1996)
  • J.D. Waye et al.

    Complications of colonoscopy and flexible sigmoidoscopy

    Gastrointest Endosc Clin N Am

    (1996)
  • G.A. Paspatis et al.

    Complications of colonoscopy in a large public county hospital in GreeceA 10-year study

    Dig Liver Dis

    (2008)
  • H. Watabe et al.

    Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors

    Gastrointest Endosc

    (2006)
  • A. Jemal et al.

    Cancer statistics, 2009

    CA Cancer J Clin

    (2009)
  • Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement

    Ann Intern Med

    (2008)
  • E.G. McFarland et al.

    Revised colorectal screening guidelines: joint effort of the American Cancer Society, U.S. Multisociety Task Force on Colorectal Cancer, and American College of Radiology

    Radiology

    (2008)
  • N.N. Baxter et al.

    Association of colonoscopy and death from colorectal cancer

    Ann Intern Med

    (2009)
  • H. Brenner et al.

    Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study

    J Natl Cancer Inst

    (2010)
  • R.L. Barclay et al.

    Colonoscopic withdrawal times and adenoma detection during screening colonoscopy

    N Engl J Med

    (2006)
  • S.D. Saini et al.

    Surveillance colonoscopy is cost-effective for patients with adenomas who are at high risk of colorectal cancer

    Gastroenterology

    (2010)
  • H. Singh et al.

    Time trends in colon cancer incidence and distribution and lower gastrointestinal endoscopy utilization in Manitoba

    Am J Gastroenterol

    (2008)
  • N.M. Gatto et al.

    Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study

    J Natl Cancer Inst

    (2003)
  • J.A. Lagares-Garcia et al.

    Colonoscopy in octogenarians and older patients

    Surg Endosc

    (2001)
  • T.C. Sardinha et al.

    Colonoscopy in octogenarians: a review of 428 cases

    Int J Colorectal Dis

    (1999)
  • J.L. Warren et al.

    Adverse events after outpatient colonoscopy in the Medicare population

    Ann Intern Med

    (2009)
  • W.B. Perry et al.

    Geriatric colonoscopy

    Perspect Colon Rectal Surg

    (2000)
  • L. Bat et al.

    Colonoscopy in patients aged 80 years or older and its contribution to the evaluation of rectal bleeding

    Postgrad Med J

    (1992)
  • P. Chatrenet et al.

    Colonoscopy in the elderly: a study of 200 cases

    Eur J Med

    (1993)
  • Cited by (0)

    DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. This work was funded in part by grants from the Mount Zion Health Fund and American Society for Gastrointestinal Endoscopy Cook Career Development Award (M.S.) and from the National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK080941) (J.M.I.). Dr. Walter is supported by a VA Health Services Research and Development grant IIR-04-427 and by grant 1R01CA134425 from the National Cancer Institute.

    If you would like to chat with an author of this article, you may contact Dr. Day at [email protected].

    View full text