Advantages of colonoscopy in acute lower GI bleeding Charles Sullivan 28/08/13

Acute lower GI bleeding Rising incidence – Ageing population, NSAIDs, anticoagulants 1 Mortality, cost, and longer hospital stay 1 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 colonoscopy 2-5

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 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% diagnostic 20 → 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

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 , p<0.0001) Schmulewitz et al. 10 – 415 colonoscopies – Colonoscopy associated with reduced LOS (HR 1.54, CI ) – Mean LOS shorter with colonoscopy in 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.Comay D, Marshall JK. Resource utilization for acute lower gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol 2002; 16: 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: 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: 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: 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: Strate LL, Syngal S. Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding. Gastrointest Endosc 2005; 61: Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010; 8: ; 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: 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: