Colonoscopy Not the cure for Acute Lower GI Bleeding Liz O’Gorman Surgical Intern Cork University...

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Colonoscopy Not the cure for Acute Lower GI Bleeding Liz O’Gorman Surgical Intern Cork University Hospital

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  • 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