Colonoscopy Not the cure for Acute Lower GI Bleeding Liz O’Gorman Surgical Intern Cork University Hospital

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

Why not perform Colonoscopy?

Long standing debate Numerous studies tried to address this question No gold standard test for acute LGIB

AIM = treat and diagnose bleeding source 1 – need to identify source 2 – facilities to implement treatment

Limitations of Colonoscopy

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

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

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

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

Risks

1. Perforation Low: 0.3-1.3% Catastrophic with high mortality – patient already compromised

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

Alternatives

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

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

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

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

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

Thank You