ColonoscopyNot the cure for Acute Lower GI BleedingLiz OGormanSurgical InternCork University Hospital

Acute within 24 hours

LGIB in Irish Healthcare System- Diverticular Bleed- Angiodysplasia- IBD/Colitis- Neoplasia- Rectal Trauma- Iatrogenic

Aim of Colonoscopy is to diagnose and treat bleeding sources

I will discuss:

1. Limitations of colonoscopy

2. Risks of colonoscopy

3. Better alternative options

Why not perform Colonoscopy?

Long standing debate

Numerous studies tried to address this question

No gold standard test for acute LGIB

AIM = treat and diagnose bleeding source1 need to identify source

2 facilities to implement treatment

Limitations of Colonoscopy

1. Bowel PreparationUnique to endoscopic interventions

Cleansing bowel of stool and blood imperative to diagnosis

Unprepped- caecum in 55-70% Chaudry at al- reduced identification of bleeding sites Tada et al- increased risk of perforation Strate et al

Diverticular bleeds- multiple subtle bleeding sites- active bleeding identified 21% Jensen et al, 2000- aggressive bowel prep

Green at al, 2005- 62-64% endoscopic view rated poor to fair

2. Stigmata of HaemorrhageDiagnostic interventions alone do not alter rebleeding and operative rates

Variable reports of identification- 7.7% 43 % Angtuaco et al, 2001; Schmuelewitz et al, 2003

Bleeding intermittent- difficult to differentiate fresh blood from old blood and stool

20% haematochezia secondary to Upper GI bleed - Jensen et al, 1998; Laine et al 2010

3. Your EnvironmentNot all centres have same access to on call colonoscopy

Trained personel- trained nursing staff- endoscopy suite / OT- anaesthetist if pt unstable

Waiting for prep increases likelihood of out of hours colonoscopy

Strate et al, 2003- median time from admission to colonoscopy 17hours for LGIBmanaged with urgent colonoscopy

Risks

1. Perforation

Low: 0.3-1.3%

Catastrophic with high mortality patient already compromised

2. Volume ShiftsRapid bowel preps

Haemodynamically compromised patients

Renal compromise and electrolyte imbalances Goldman et al,1982

Left ventricular dysfunction- exacerbation of symptoms and ECF volume overload

Alternatives

AngiographyDiagnostic and therapeuticSuperselective embolisation

Meta-analysis J GI Surg 2005 Khanna A et al- Diverticular Bleed 85% success*if fails < 2 days- Non-diverticular Bleed 50% success* if fails < 2 days

CT AngiographyTriage prior to angiography (avoid risks associated with intervention)

ALL patients with a suspected, known or previously treated AAA- ? Aortoenteric fistula

Bleeding of 2cc/sec

Radionucleotide ScintigraphyRadiolabelled RBCs (99mTc)

Identifies LGIB site in up to 78% of cases

Bleeding of 0.2 cc/sec

No intervention risks

SummaryColonoscopy- difficult to reach caecum without aggressive bowel prep- difficult to identify bleeding source even with bowel prep- prep associated electrolyte disturbances and volume shifts- risk of perforation- median time from admission 17hours ? acute

Alternatives- CT / CT Angio / Radionucleotide Scans

BOTTOM LINEColonoscopy diagnostically poor in acute LGIB

You can not treat something you can not diagnose

Acute lower GI bleeding usually stops without intervention

Thank You