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Am Fam Physician. 2020;102(11):692

Clinical Question

Is fecal occult blood testing (FOBT) reliable as part of evaluating patients with clinical indications?

Bottom Line

In this well-conducted systematic review, FOBT, although useful in screening for colorectal cancer, is not highly accurate in evaluating patients with clinical indications. (Level of Evidence = 2a)


The authors searched Medline and Embase for full publications of any research design, except case reports, that evaluated the use of FOBT, either via guaiac test or fecal immunochemical test (FIT), in the evaluation of adults with clinical indications such as diarrhea, iron deficiency anemia, and so forth. The studies also had to include a reference standard, such as endoscopy. Two authors independently assessed the eligibility of studies for selection, as well as the risk of bias of each included trial. The senior author settled any disagreements. The authors included 22 studies that each enrolled between 26 and 1,132 patients. Twelve of the studies evaluated patients with iron deficiency anemia without overt signs of bleeding, eight included patients with ulcerative colitis, and two included patients with diarrhea. Only two of the studies were at low risk of bias. Nine studies evaluated guaiac tests and 13 evaluated FITs. Compared with upper or lower endoscopy, FOBT was 58% sensitive (95% CI, 53% to 63%) and 84% specific (95% CI, 75% to 89%) for diagnosing any gastrointestinal abnormality in patients with iron deficiency anemia, with no meaningful difference between guaiac testing or FIT. FOBT was 83% sensitive (95% CI, 72% to 90%) and 79% specific (95% CI, 68% to 86%) for diagnosing colorectal cancer in patients with iron deficiency anemia. In the studies of patients with ulcerative colitis, FOBT (all of the studies used FIT) was 72% sensitive (95% CI, 57% to 84%) and 80% specific (95% CI, 67% to 89%) for active disease. For patients with diarrhea, the sensitivities of FOBT (both studies used guaiac testing) were widely divergent (38% and 87%) as were the specificities (58% and 85%).

Study design: Meta-analysis (other)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Reference: Lee MW, Pourmorady JS, Laine L. Use of fecal occult blood testing as a diagnostic tool for clinical indications: a systematic review and meta-analysis. Am J Gastroenterol. 2020;115(5):662–670.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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