Endoscopic hemostasis is rarely used for hematochezia: a population-based study from the Clinical Outcomes Research Initiative National Endoscopic Database

Abstract

Background Data on use of endoscopic hemostasis performed during colonoscopy for hematochezia are primarily derived from expert opinion and case series from tertiary care settings. Objective To characterize patients with hematochezia who underwent in-patient colonoscopy and compare those who received endoscopic hemostasis with those who did not receive endoscopic hemostasis. Design Retrospective analysis Setting Clinical Outcomes Research Initiative (CORI) National Endoscopic Database 2002 – 2008 Patients Adults with hematochezia Interventions None Main Outcome Measurements Demographics, co-morbidity, practice setting, adverse events, and colonoscopy procedural characteristics and findings. Results We identified 3,151 persons who underwent in-patient colonoscopy for hematochezia. Endoscopic hemostasis was performed in 144 patients (4.6%). Of those who received endoscopic hemostasis, the majority were male (60.3%), White (83.3%), older (mean age 70.9 ± 12.3 years), had a low risk ASA Score (53.9%), and underwent colonoscopy in a community setting (67.4%). The hemostasis-receiving cohort was significantly more likely to be White (83.3% vs. 71.0%, p=0.02), have more co-morbidities (ASA Score III and IV 46.2% vs. 36.0%, p=0.04), and have the cecum reached (95.8% vs. 87.7%, p=0.003). Those receiving hemostasis were significantly more likely to have an endoscopic diagnosis of AVM’s (32.6% vs. 2.6%) p=0.0001or solitary ulcer (8.3% vs. 2.1%), p<0.0001. Limitations Retrospective database analysis. Conclusions Less than five percent of persons presenting with hematochezia and undergoing inpatient colonoscopy received endoscopic hemostasis. These findings differ from published tertiary care setting data. These data provide new insights on in-patient colonoscopy performed primarily in a community practice setting for patients with hematochezia.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

“…Other less common causes include colorectal polyps/neoplasms, Dieulafoy’s lesion, inflammatory bowel disease, and anorectal conditions including solitary rectal ulcer, radiation proctitis, and rectal varices. 56, 57 It is imperative to carefully inspect the colonic mucosa both on insertion and withdrawal since culprit lesions often bleed intermittently and may be missed when not actively bleeding. The endoscopist should intubate the terminal ileum to rule out proximal blood suggestive of a small bowel lesion.…”

Risk factors of interventional radiology/surgery for colonic diverticular bleeding

“…Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (LGIB) 1,2 . LGIB can be serious and potentially lead to death 3–5 .…”

Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding

“…Consistent with other studies, our data demonstrated that in most cases the etiology of LGIB is from benign pathologies such as diverticulosis, hemorrhoids and colonic ulcers. However, studies have demonstrated a 2-15% rate of finding colon neoplasm in patients presenting with lower GIB [ 15 , 16 ]. As a result, it is important to ensure appropriate outpatient evaluation to exclude malignant causes, particularly given the increased incidence of colon cancer in younger age groups, as younger age was shown to be predictive of discharge [ 17 ].…”