Prince of Wales Hospital Department of Surgery Journal Club Presentation March 2000

1
Prince of Wales HospitalDepartment of
SurgeryJournal Club PresentationMarch 2000

• Kenny Ho
• General Surgery Registrar
• Colorectal Unit

2
Journal Club

• Urgent Colonoscopy for the Diagnosis and
  Treatment of Severe Diverticular Haemorrhage
• New England Journal of Medicine 342 78-82 2000

3
Journal Club

• Dennis M Jensen, Gustavo A Machicado, Rome
  Jutabha, Thomas Kovacs
• Center for Ulcer Research and Education (CURE)
  haemostasis Research Unit, Digestive Diseae
  Resarch Center, Division of Digestive Diseases,
  University of California at Los Angeles Center
  for the Health Sciences, and the Veterans Affairs
  Greater Los Angeles Healthcare System, LA

4
Overview

• Ascertain the role of endoscopy in the
  management of lower gastrointestinal bleeding
  from diverticulosis

5
Research strategy

• Prospectively studied 121 patients with severe PR
  bleeding and diverticulosis

6
Questions Posed

• Outcome of diverticular haemorrhage treated
  medically and surgically, versus those treated
  medically and by colonoscopy

7
End Points

• Rate of recurrence of diverticular haemorrhage
• Length of stay
• Other complications

8
Medical Management

• Hospitalisation
• Monitoring
• Resuscitation in ICU, telemetry
• Cease NSAIDS, Aspirin
• Transfusion - packed cells, other blood products

9
Urgent Colonoscopy

• Performed within six to twelve hours after
  hospitalisation or diagnosis of PR bleeding
• Within 1 hour clearance of stool, blood, and
  clots, as documented by a physician

10
Bowel preparation

• Sulphate purge
• Golytely
• Colyte
• Orally or via nasogastric tube
• Five to six litres

11
Definition of Diverticular Haemorrhage

• Colonoscopic evidence of
• Active bleeding
• Non bleeding vessel
• Adherent clot

12
Study design

• Prospective
• Non-randomised
• Historical control
• Entry criteria
• PR bleeding
• Colonoscopic evidence of diverticulosis

13
Two Sequential Prospective Studies

• June 1986 to June 1992
• June 1994 to December 1998
• Enrolled patients who presented with PR bleeding
  and diagnosis of diverticulosis on colonoscopy

14
June 1986 to June 1992

• Treated Medically and Surgically
• Enrolled 73 consecutive patients
• After diagnosis, observe, transfuse if continued
  or recurred
• Severe bleeding - if patient received at least
  three units of packed red sells in addition to an
  initial transfusion for resuscitation
• Severe bleeding - emergency hemicolectomy

15
June 1994 to December 1998

• Treated Medically and Colonoscopically
• Enrolled 48 consecutive patients
• Medical treatment as per previous
• Colonoscopic treatment for definite diverticular
  haemorrhage based on colonoscopic evidence

16
Standardized Colonoscopic Treatments

• Active bleeding
• One to two mls (120,000) adrenaline
• Non bleeding vessel
• Bipolar coagulation
• Adherent clot
• One to two mls adrenaline, shave clot down to
  three to four mm above attachment with
  polypectomy snare, then bipolar coagulation

17
Prevalance
18
Incidental diverticulosis

• Other sources of bleeding found

19
Outcome of Treatment
20
Execution

• Sample size
• 1st study 17 out of 73
• 2nd study 10 out of 48
• Confounding variables
• Diagnostic skills between 1986-92, and 1994-98
• Improvement in resuscitation management

21
Assessment of Conclusions

• None of the 10 patients in the second group who
  had diverticular bleeding treated by colonoscopic
  haemostasis had recurrence of bleed

22
Application of Study

• Urgent colonoscopy has a role in diagnosing and
  treating PR bleeding
• 56 out of 73 91st study), 24 out of 48 (2nd
  study) patients had incidental diverticulosis and
  PR bleeding

23
Strength of Study

• Clear guidelines in identifying and treatment of
  bleeding from diverticular disease
• Follow up - 30 to 36 months follow-up

24
Weakness of Study

• Small sample size
• All patients with PR bleeding get admitted for
  investigation
• Practicality of performing urgent colonoscopy

25
Weakness of Study-continue

• Significant of five to six litres of bowel
  preparation in elderly patients after PR bleeding
  that required hospitalisation
• Time of day colonoscopy performed

26
The End