Advantages of colonoscopy in acute lower GI bleeding Charles Sullivan 28/08/13.
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Transcript of Advantages of colonoscopy in acute lower GI bleeding Charles Sullivan 28/08/13.
![Page 1: Advantages of colonoscopy in acute lower GI bleeding Charles Sullivan 28/08/13.](https://reader035.fdocuments.us/reader035/viewer/2022062720/56649ef65503460f94c09a3d/html5/thumbnails/1.jpg)
Advantages of colonoscopy in acute lower GI bleeding
Charles Sullivan28/08/13
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Acute lower GI bleeding
• Rising incidence– Ageing population, NSAIDs, anticoagulants1
• Mortality, cost, and longer hospital stay1
• Need for an accurate initial investigation
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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
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Diagnosis and intervention
• Intermittent bleeding• Slow diffuse mucosal bleeding
• Radiographic alternatives need active bleeding
• Greater diagnostic yield from colonoscopy2-5
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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)
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Studies
• Richter et al.3 – chart review, 107 patients– Colonoscopy diagnostic in 90%– Successful treatment in 9 of 13 patients (69%)– Shortened hospital stay
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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
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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
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Colonoscopy vs. radiology
Favouring early scope (OR)
• Post-polypectomy bleed (6.3)
• Weekday admission (3.0)• Admission late in day (2.7)
Favouring radiographic (OR)
• Tachycardia (5.1)• Syncope (3.8)• Bleeding in first 4 hours
after admission (3.1)
Strate et al.7 – 118 patients with severe bleeding 33 → early colonoscopy (<24h), 85% diagnostic20 → early radiographic procedure, 45% diagnostic
Colonoscopy: shorter hospital stay (p=0.025), increased diagnostic yield (p=0.005), and fewer transfusions (p=0.024)7
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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%
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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
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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)
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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
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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
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References1. Comay D, Marshall JK. Resource utilization for acute lower
gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol 2002; 16: 677-682
2. 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
3. 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
4. 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
5. 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
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References6. 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