Fecal Occult Blood Test-Positive Stools in a Nonanemic Patient
How far should one investigate fecal occult blood test-positive stools in a nonanemic patient with no gastrointestinal symptoms and a negative colonoscopy? Is upper endoscopy the standard of care?

The question posed is an interesting one, and is commonly encountered in clinical practice. The issue revolves around a number of factors, and some clinical data are needed that are not presented. One can easily argue that the conditions regarding the performance of the guaiac testing are of paramount importance. The currently established screening practices are based on the correct selection of patients for the guaiac-based testing -- that is, dietary issues, age, number of stools, and avoidance of rehydration; all need to be established for the optimal performance of guaiac-based screening. For example, one can argue that a stool sample obtained from a 38-year-old male during a rectal exam in the office is not an appropriate use of the guaiac-based test for screening. Having said that, one can also argue that the role of guaiac-based testing is markedly reduced in the present era and one can easily justify the primary use of colonoscopy.

For the present case, we will assume that the patient is over 50 years of age, had the samples collected as an outpatient under correct conditions, and that the slides were not rehydrated. It is also assumed that there was occurrence of a single occult-positive test, and that subsequent appropriately performed tests were negative. Scant data exist; the only recent study that examines only occult-positive patients without anemia is the investigation by Rockey and colleagues, in which some upper gastrointestinal lesions were found. In the present case, colonoscopy was correctly recommended and performed as per the published recommendations. In an otherwise asymptomatic patient, the performance of an upper endoscopy is not required as standard of care, although it may be prudent. The performance of additional investigations can be tailored to the individual patient if the patient is not anemic or symptomatic, and has subsequent negative fecal occult blood tests. If the patient has recurrent positive tests, then he falls into the category of obscure gastrointestinal bleeding and requires further investigation, which should be tailored to the clinical circumstances.