Role of screening colonoscopy in elective liver transplantation evaluation

OPTIMAL selection of appropriate candidates for orthotopic liver transplantation (OLT) depends on effective preoperative assessment. The goals of this preoperative evaluation include: establishing the long-term prognosis of individual patients, identifying concurrent medical conditions, and excluding those patients in whom the risk of postoperative morbidity and mortality outweighs the potential benefit of OLT. 1–7 As this preoperative assessment is labor-intensive and costly, it is critical that it be selective, while comprehensive. At our institution, as in many others, established OLT evaluation protocols have provided for colonoscopy to be performed in all patients greater than age 45. The rationale for this procedure is to detect malignancies that would alter the life expectancy of transplant recipients. If a colon cancer were detected, curative treatment of the cancer would need to be carried out before considering OLT. If the cancer was metastatic or unresectable, the patient would no longer be considered a candidate for OLT. Although colonoscopy is usually well tolerated in patients with cirrhosis, it is not without risk. Beyond the normal concerns of procedure-induced bleeding or perforation, colonoscopy in the patient population with cirrhosis presents certain additional risks. These risks include increased bleeding risk secondary to underlying coagulopathy and thrombocytopenia, excessive sedation due to prolonged half-life of sedative/hypnotics, and, in patients with ascites, an increased risk of peritonitis. 8 Although the role of colonoscopy as a screening tool for colorectal malignancies is controversial, full colonoscopy is the definitive examination to detect such lesions in the pretransplant population. Colonoscopy, as opposed to flexible sigmoidoscopy, can detect right-sided lesions despite normal findings in more distal aspects of the colon. 9–11 There is no evidence to support an increased incidence of colon cancer in patients with primary liver diseases. 12 In an effort to determine whether colonoscopy should be an integral component of the elective OLT evaluation, this retrospective study had several aims, including: to assess the prevalence of colon polyps and cancer in patients evaluated for elective OLT, to identify the prevalence of colon polyps and cancer beyond the reach of the flexible sigmoidoscope and to evaluate possible predictors for the presence of polyps or cancer on colonoscopy in patients with advanced cirrhosis.