Colonoscopy Not the cure for Acute Lower GI Bleeding

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ColonoscopyNot the cure for Acute Lower GI
Bleeding

• Liz OGorman
• Surgical Intern
• Cork University Hospital

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• 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

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Why not perform Colonoscopy?
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• Long standing debate
• Numerous studies tried to address this question
• No gold standard test for acute LGIB

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AIM treat and diagnose bleeding source

• 1 need to identify source
• 2 facilities to implement treatment

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Limitations of Colonoscopy
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1. Bowel Preparation

• Unique 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

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• 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

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2. Stigmata of Haemorrhage

• Diagnostic 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

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3. Your Environment

• Not 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 LGIB
• managed with urgent colonoscopy

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Risks
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1. Perforation

• Low 0.3-1.3
• Catastrophic with high mortality
• patient already compromised

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2. Volume Shifts

• Rapid bowel preps
• Haemodynamically compromised patients
• Renal compromise and electrolyte imbalances
  Goldman et al,1982
• Left ventricular dysfunction
• - exacerbation of symptoms and ECF volume
  overload

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Alternatives
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Angiography

• Diagnostic and therapeutic
• Superselective embolisation
• Meta-analysis J GI Surg 2005 Khanna A et al
• - Diverticular Bleed 85 success
• if fails lt 2 days
• - Non-diverticular Bleed 50 success
• if fails lt 2 days

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CT Angiography

• Triage prior to angiography (avoid risks
  associated with intervention)
• ALL patients with a suspected, known or
  previously treated AAA
• - ? Aortoenteric fistula
• Bleeding of 2cc/sec

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Radionucleotide Scintigraphy

• Radiolabelled RBCs (99mTc)
• Identifies LGIB site in up to 78
• of cases
• Bleeding of 0.2 cc/sec
• No intervention risks

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Summary

• Colonoscopy
• - 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

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BOTTOM LINE

• Colonoscopy diagnostically poor in acute LGIB
• You can not treat something you can not diagnose
• Acute lower GI bleeding usually stops without
  intervention

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Thank You