Advantages of colonoscopy in
acute lower GI bleeding
Charles Sullivan
28/08/13
Acute lower GI bleeding
• Rising incidence
– Ageing population, NSAIDs, anticoagulants1
• Mortality, cost, and longer hospital stay1
• Need for an accurate initial investigation
Management options
• Endoscopic vs. radiographic
• Advantages of colonoscopy:
– Identify bleeding source regardless of rate or of
active bleeding
– Therapeutic possibilities
– Efficiency (diagnostic and therapeutic potential)
– Often needed for definitive diagnosis
– Safety
Diagnosis and intervention
• Intermittent bleeding
• Slow diffuse mucosal bleeding
• Radiographic alternatives need active bleeding
• Greater diagnostic yield from colonoscopy2-5
Studies
• Green et al.2 - RCT, 50 urgent colonoscopies,
50 angiography + delayed colonoscopy
– Bleeding sources more often identified with
urgent scope than with angio + delayed scope
– No significant difference regarding outcomes
(mortality, LOS, ICU stay, transfusion, surgery,
rebleeding)
Studies
• Richter et al.3 – chart review, 107 patients
– Colonoscopy diagnostic in 90%
– Successful treatment in 9 of 13 patients (69%)
– Shortened hospital stay
Studies
• Angtuaco et al.4 – 90 patients
– 39 of 90 with acute PR bleed scoped
– Definite source in 3, probable source in 26, no
source in 10
– Therapeutic intervention successful in 3 of 4 with
definite or probable bleeding
• Jensen et al.5 – 10 patients, all treated fully
with endoscopy, no recurrent bleeding
Colonoscopy vs. radiology
• Jensen et al.6 – 22 patients, 17 with lower GI
bleeding sources:
– Urgent colonoscopy, OGD and angiography
– Diagnostic yield of 82% for colonoscopy
vs. 12% for angiography
Colonoscopy vs. radiology
Strate et al.7 – 118 patients with severe bleeding
33 → early colonoscopy (<24h), 85% diagnostic
20 → early radiographic procedure, 45% diagnostic
Favouring early scope (OR)
Favouring radiographic (OR)
• Post-polypectomy bleed
(6.3)
• Weekday admission (3.0)
• Admission late in day (2.7)
• Tachycardia (5.1)
• Syncope (3.8)
• Bleeding in first 4 hours
after admission (3.1)
Colonoscopy: shorter hospital stay (p=0.025), increased diagnostic
yield (p=0.005), and fewer transfusions (p=0.024)7
Timing of colonoscopy
• Green et al.2
– 50 colonoscopies after bowel prep within 12h:
• Bleeding source seen in 42%
– 50 elective colonoscopies after 72h:
• Bleeding source seen in 22%
Therapeutic possibilities
•
•
•
•
•
Adrenaline or saline injection
Thermal contact
Argon plasma coagulation
Clipping
Band ligation
• Strate et al.8 – review of 71 diverticular bleeds:
100% success rate of haemoclip treatment, with
no complications
Improved outcomes
• Observational studies: urgent scope reduces LOS
• Strate et al.9 – 252 patients with lower GI bleed
– Colonoscopy in <24h associated with shorter LOS (HR
2.02, CI 1.5-2.6, p<0.0001)
• Schmulewitz et al.10 – 415 colonoscopies
– Colonoscopy associated with reduced LOS (HR 1.54, CI
1.2-1.8)
– Mean LOS shorter with colonoscopy in <24h than
>24h (5.4d vs. 7.2d, p<0.008)
Safety
• Review of 4 studies (664 patients)8:
– 2 perforations
– 0.3% complication rate for colonoscopy
– 0.6% complication rate for urgent colonoscopy
• CCF
• Electrolyte abnormalities
• Aspiration pneumonia
Conclusions
• High diagnostic yield
• Therapeutic: use of endoscopic haemostasis
• Needed to confirm radiographic findings and
exclude serious diagnoses
• Limitations: need for bowel prep, logistics after
hours
• Small studies, retrospective data
• Further prospective randomised studies needed
to define timing and role relative to radiographic
modalities
References
1.
2.
3.
4.
5.
Comay D, Marshall JK. Resource utilization for acute lower
gastrointestinal hemorrhage: the Ontario GI bleed study. Can J
Gastroenterol 2002; 16: 677-682
Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS,
Leung J, Jowell P. Urgent colonoscopy for evaluation and management of
acute lower gastrointestinal hemorrhage: a randomized controlled trial.
Am J Gastroenterol 2005; 100: 2395-2402
Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of
current technology in the diagnosis and management of lower
gastrointestinal hemorrhage. Gastrointest Endosc 1995; 41: 93-98
Angtuaco TL, Reddy SK, Drapkin S, Harrell LE, Howden CW. The utility of
urgent colonoscopy in the evaluation of acute lower gastrointestinal
tract bleeding: a 2-year experience from a single center. Am J
Gastroenterol 2001; 96: 1782-1785
Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy
for the diagnosis and treatment of severe diverticular hemorrhage. N
Engl J Med 2000; 342: 78-82
References
6.
Jensen DM, Machicado GA. Diagnosis and treatment of severe
hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology 1988; 95: 1569-1574
7. Strate LL, Syngal S. Predictors of utilization of early colonoscopy vs.
radiography for severe lower intestinal bleeding. Gastrointest Endosc
2005; 61: 46-52
8. Strate LL, Naumann CR. The role of colonoscopy and radiological
procedures in the management of acute lower intestinal bleeding. Clin
Gastroenterol Hepatol 2010; 8: 333-343; quiz e344
9. Strate LL, Syngal S. Timing of colonoscopy: impact on length of hospital
stay in patients with acute lower intestinal bleeding. Am J Gastroenterol
2003; 98: 317-322
10. Schmulewitz N, Fisher DA, Rockey DC. Early colonoscopy for acute lower
GI bleeding predicts shorter hospital stay: a retrospective study of
experience in a single center. Gastrointest Endosc 2003; 58: 841-846