Outcomes of Early versus Late Colonoscopy in Acute Lower Gastrointestinal Bleeding: A Single Center Experience

Douaihy, Youssef El; Nassani, Najib; Moussawi, Hassan Al; Polavarapu, Abhishek; Imad, Talal El; Haddad, Fady G.; Mridha, Banshari; Barakat, Iskandar; Deeb, Liliane

doi:10.14309/00000434-201710001-02712

Cited by 2 publications

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“…Available evidence comparing early vs. elective colonoscopy in the management of patients with acute LGIB consists of seven systematic reviews with meta-analyses [55][56][57][58][59][60][61], four RCTs [51,[62][63][64], and 16 observational studies [65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80] (Table 7 s). Patients with "minor" LGIB managed as outpatients and patients with an UGIB source were excluded from the RCTs [51,[62][63][64] and most of the observational studies [66,67,69,[71][72][73][74][75][76][77][78]. Early or urgent colonoscopy was defined as a colonoscopy performed within 24 hours of presentation in most studies [62][63][64][65]…”

Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

“…We considered the certainty of evidence to be low, despite the significant number of studies evaluating the appropriate timing of colonoscopy. All but one [80] of the observational studies were retrospective [65][66][67][68][69][70][71][72][73][74][75][76][77][78][79], and the definitions and selection criteria were heterogeneous. All RCTs were nonblinded, with some concerns regarding bias (Tables 7 s and 8 s), and two trials were terminated before reaching the pre-planned sample size [51,63].…”

Section: Recommendationmentioning

confidence: 99%

“…Patients with "minor" LGIB managed as outpatients and patients with an UGIB source were excluded from the RCTs [51,[62][63][64] and most of the observational studies [66,67,69,[71][72][73][74][75][76][77][78]. Early or urgent colonoscopy was defined as a colonoscopy performed within 24 hours of presentation in most studies [62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78]. In RCTs, delayed or elective colonoscopy was defined as that performed between 24 hours and 96 hours from the time of hospital admission [51,[62][63][64].…”

Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

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Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2021

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Main Recommendations 1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable.Strong recommendation, low quality evidence. 4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

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Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

Section: Recommendationmentioning

confidence: 99%

Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

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Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2021

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“…Four RCTs 7,10,21,22 (n = 266) compared early colonoscopy done within 8 10 to 12 7 hours of presentation or within 24 hours 21,22 to standard of care or elective colonoscopy. Among observational studies (n = 1 061 281), early colonoscopy (≤24hours) was compared to elective or delayed colonoscopy (>24 hours) in 13 studies (1 prospective 36 and 12 retrospective 8,9,13,23,24,37–43 ).…”

Section: Resultsmentioning

confidence: 99%

Systematic review with meta‐analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding

Kherad

Restellini

Almadi

et al. 2020

Aliment Pharmacol Ther

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Background:The optimal timing of colonoscopy in acute lower gastrointestinal bleeding (LGIB) remains controversial.Aim: To characterise the utility of early colonoscopy (within 24 hours) in managing acute LGIB. Methods:A systematic literature search to October 2019 identified fully published articles and abstracts of randomised controlled trials (RCTs) and observational studies with control groups assessing early colonoscopy in acute LGIB. The primary outcome was rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events. Odds ratios (ORs) and mean differences (MD) were calculated.Results: Of 1116 citations, 4 RCTs (466 patients) and 13 observational studies with elective colonoscopy (>24 hours) as control group (1 061 281 patients) were included.No differences in rebleeding were noted between early and elective colonoscopy groups among RCTs alone (OR = 1.70; 0.79; 3.64), or observational studies alone (OR = 1.20; 0.69; 2.09). No other significant between-group differences in outcomes were found when restricting the analysis to RCTs. Among observational studies only, early colonoscopy was associated with lower rates of all-cause mortality (OR = 0.86; 0.75; 0.98), surgery (OR = 0.52; 0.42; 0.64), blood transfusion (OR = 0.81; 0.75; 0.87), units of blood transfusion (MD = −4.30; −6.24; −2.36) and shorter LOS (MD = −1.70; −1.70; −1.70 days). Conclusion:In contradistinction to observational studies, data from RCTs do not support a role for early colonoscopy in the routine management of acute LGIB with regards to the most important clinical outcomes. Further research is needed to better identify patients with high-risk LGIB who may benefit from early colonoscopy.

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Outcomes of Early versus Late Colonoscopy in Acute Lower Gastrointestinal Bleeding: A Single Center Experience

Cited by 2 publications

References 0 publications

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Systematic review with meta‐analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding

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