Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: A randomized controlled trial

Green, Bryan T.; Rockey, Don C.; Portwood, G.; Tarnasky, Paul R.; Guarisco, Steve; Branch, Malcolm S.; Leung, Joseph; Jowell, Paul S.

doi:10.1016/s0016-5085(03)80087-2

Cited by 84 publications

(175 citation statements)

References 21 publications

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“…There is no clear consensus regarding the management of these patients, with debate between the endoscopic and angiographic approach. Following the study of Jensen et al (2) urgent colonoscopy has become an important diagnostic and therapeutic tool in severe lower gastrointestinal bleeding, showing a higher diagnostic rate (2,3) and resulting in shorter time to discharge from hospital if colonoscopy is performed in the first hours (4), although not all of the studies agree on this point (13). Most studies defend purging the colon, which would be the ideal situation, although there is no clear consensus on this point (14).…”

Section: Discussionmentioning

confidence: 99%

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Couto-Worner

González-Conde

Estévez-Prieto

et al. 2013

Rev. esp. enferm. dig.

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Diverticular disease is the most frequent cause of lower gastrointestinal bleeding. Most of the times, bleeding stops without any intervention but in 10-20 % of the cases it is necessary to treat the hemorrhage. Several modalities of endoscopic treatment have been described after purging the colon. We present five cases of severe diverticular bleeding treated with injection of epinephrine and hemoclips. All the colonoscopies were performed without purging of the colon in an emergency setting, with correct visualization of the point of bleeding. Patients recovered well avoiding other aggressive procedures such as angiography or surgery.

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Section: Discussionmentioning

confidence: 99%

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Couto-Worner

González-Conde

Estévez-Prieto

et al. 2013

Rev. esp. enferm. dig.

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“…Notably, the only two stigmata of hemorrhage that were identifi ed were in patients with diverticulosis undergoing urgent colonoscopy. Similarly, in a trial by Green et al ( 2 ), a defi nitive bleeding source was identifi ed signifi cantly more oft en in patients with LGIB undergoing urgent colonoscopy vs. elective colonoscopy (42 vs. 22 % , P = 0.03), and no stigmata of hemorrhage were identifi ed in patients undergoing elective colonoscopy following a positive tagged red blood cell scan (mean time to colonoscopy was 38 h). Other series have found that the yield of colonoscopy is higher when performed in the setting of active bleeding vs. electively ( 10,11 ), suggesting that the timing of colonoscopy relative to bleeding is more important than the interval since admission .…”

mentioning

confidence: 80%

Urgent Colonoscopy in Lower GI Bleeding: Not So Fast

Strate¹

2010

American Journal of Gastroenterology

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LGIB were found to have upper gastrointestinal bleeding, highlighting the importance of excluding a gastroduodenal source in patients with severe hematochezia. The majority of patients with LGIB (72 % ) stopped bleeding spontaneously, and there were no differences in rebleeding, blood transfusions, diagnostic or therapeutic interventions, length of hospital stay, or hospital charges in patients undergoing urgent vs. elective colonoscopy. However, the limited number of patients in this study and the fact that patients in the urgent colonoscopy arm appeared to have more severe bleeding than those undergoing elective examinations make it diffi cult to draw conclusions regarding the utility of urgent vs. elective colonoscopy in LGIB. Am J Gastroenterol 2010; 105:2643 -2645 doi: 10.1038/ajg.2010 Lower gastrointestinal bleeding (LGIB) is a common gastrointestinal emergency. Th e incidence of LGIB is increasing, and, in the elderly, may surpass that of upper gastrointestinal bleeding (UGIB) ( 1 ). However, the literature regarding LGIB lags considerably behind UGIB. Endoscopy is the standard of care in the management of UGIB, and urgent esophagogastroduodenoscopy (EGD) within 12 -24 h of admission has been shown to provide valuable prognostic information, facilitate the treatment of high-risk lesions, and improve patient outcomes and resource utilization.In contrast, the role of urgent colonoscopy in LGIB remains controversial. Historically, colonoscopy in LGIB was performed electively due to the need for colon preparation and concern regarding complications. Over the last two decades, a number of studies have indicated that urgent colonoscopy, defi ned as colonoscopy performed within 12 -24 h of admission following a rapid colon purge, is safe and may facilitate the identifi cation and treatment of bleeding lesions ( 2 -4 ). However, studies comparing this approach to delayed colonoscopy or to other interventions for LGIB are limited. Moreover, urgent colonoscopy is logistically complicated, stigmata of hemorrhage are arguably diffi cult to identify, and there are a number of other potential management options to choose from, including fl exible sigmoidoscopy, angiography, radionuclide scintigraphy, and multidetector computed tomography scanning.In this issue of the American Journal of Gastroenterology , Laine and Shah present a randomized trial of urgent vs. elective colonoscopy in patients with LGIB ( 5 ). Aft er undergoing an EGD to exclude an upper gastrointestinal source, 72 patients with severe LGIB were randomized 1:1 to colonoscopy within 12 h of admission or elective colonoscopy within 36 -60 h. Colonoscopies were performed by the on-call or attending gastroenterologist, and management decisions outside the endoscopic encounter were left to the admitting team. Th e authors found no diff erences in the primary outcome, rebleeding during the hospitalization, or secondary outcomes, including number of units of blood transfused, number of diagnostic or therapeutic interventions, length of hospital stay, or hospit...

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“…Notably, 7% (two in the urgent group and three in the routine group) required repeat colonoscopies secondary to inadequate preparation [164] . In a study by Green et al [165] in 2005, 50 patients that underwent colonoscopy received PEG (a total of 4-6 L, 250 mL every 15 min) orally or by nasogastric tube for patients that could not drink the solution; 3-4 h were necessary to clean the colon. The elective colonoscopy group was prepared with routine 4-6 L of PEG, administered orally beginning the night before the procedure, which was performed within four days of admission.…”

Section: Pediatric Patientsmentioning

confidence: 99%

Achieving the best bowel preparation for colonoscopy

Parra‐Blanco¹,

Ruiz²,

Álvarez-Lobos³

et al. 2014

WJG

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Bowel preparation is a core issue in colonoscopy, as it is closely related to the quality of the procedure. Patients often find that bowel preparation is the most unpleasant part of the examination. It is widely accepted that the quality of cleansing must be excellent to facilitate detecting neoplastic lesions. In spite of its importance and potential implications, until recently, bowel preparation has not been the subject of much study. The most commonly used agents are high-volume polyethylene glycol (PEG) electrolyte solution and sodium phosphate. There has been some confusion, even in published meta-analyses, regarding which of the two agents provides better cleansing. It is clear now that both PEG and sodium phosphate are effective when administered with proper timing. Consequently, the timing of administration is recognized as one of the central factors to the quality of cleansing. The bowel preparation agent should be administered, at least in part, a few hours in advance of the colonoscopy. Several low volume agents are available, and either new or modified schedules with PEG that usually improve tolerance. Certain adjuvants can also be used to reduce the volume of PEG, or to improve the efficacy of other agents. Other factors apart from the choice of agent can improve the quality of bowel cleansing. For instance, the effect of diet before colonoscopy has not been completely clarified, but an exclusively liquid diet is probably not required, and a low-fiber diet may be preferable because it improves patient satisfaction and the quality of the procedure. Some patients, such as diabetics and persons with heart or kidney disease, require modified procedures and certain precautions. Bowel preparation for pediatric patients is also reviewed here. In such cases, PEG remains the most commonly used agent. As detecting neoplasia is not the main objective with these patients, less intensive preparation may suffice. Special considerations must be made for patients with inflammatory bowel disease, including safety and diagnostic issues, so that the most adequate agent is chosen. Identifying neoplasia is one of the main objectives of colonoscopy with these patients, and the target lesions are often almost invisible with white light endoscopy. Therefore excellent quality preparation is required to find these lesions and to apply advanced methods such as chromoendoscopy. Bowel preparation for patients with lower gastrointestinal bleeding represents a challenge, and the strategies available are also reviewed here. Core tip: Bowel preparation for colonoscopy is a central issue related to the quality of the procedure. There are different agents for bowel preparation that can be administered with different schedules. We review the most commonly used agents, as well as new agents and combinations. Moreover, certain considerations should be taken into account for special populations in order to improve safety, efficacy and tolerance. Regimens for bowel preparation in special situations are discussed, such as for pedi...

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Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: A randomized controlled trial

Cited by 84 publications

References 21 publications

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Urgent Colonoscopy in Lower GI Bleeding: Not So Fast

Achieving the best bowel preparation for colonoscopy

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