I found the paragraph about ulcerative colitis in your practice pearls by Dr Mitchell (BCMJ 2006;48[2]:84-85) [9] very confusing. Chronic ulcerative colitis, especially pancolitis, is associated with an increased cancer risk after several years. After 10 years of disease, alternate year surveillance colonoscopy with biopsies to detect dysplasia is appropriate, and if dysplasia is found colectomy is indicated to prevent cancer. Barium enema is not an acceptable test since it will not detect dysplasia in the absence of a mass lesion. In general, a good quality barium study read by an experienced radiologist is useful, but remember that it does not evaluate the rectum. A lesser study, particularly if the preparation is poor, should be interpreted with caution, as it may miss polyps and cancer. I assume that the “detection rates” comment referred to cancer, in which case I would point out that your “preferred test” (barium enema) missed 14% (nearly 1 in 5) cancers, dooming these unfortunate people. A potentially lethal diagnosis surely deserves the best test. The diagnosis of a colon cancer represents failure, a failure of screening or surveillance, as this is a preventable disease.

If I could add a gastroenterology pearl, it would be a plea for digital rectal exams. Patients with rectal bleeding demand a rectal exam, and annual rectal exams for your asymptomatic over-fifties will save lives.

—David Pearson, MD
Victoria

At this time, a province-wide screening program for colorectal carcinoma in asymptomatic individuals that involves screening colonoscopy does not exist. Patients with no known risk factors are recommended to undergo annual digital rectal examination (DRE) and fecal occult blood screening, with an optional flexible sigmiodoscopy every 5 years, age 50 to 75. Don’t forget to do a DRE before inserting the endoscope, as lesions in the rectum may not be visualized. See “Detection of Colorectal Neoplasms in Asymptomatic Patients” at www.healthservices.gov.bc.ca/msp/protoguides/index.html [10]. —ED