1. COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH PATIENTS EVALUATION AND DIAGNOSIS: COLONSCOPY Stefania Caronna MD Dept. of Gastroenterology Molinette Hospital-Turin

2. COLORECTAL BLEEDING Incidence: 20-30 episodes/100.000 persons annually Mortality rate: 5% (increases with age and in patients with associated comorbidities like hepatic disfunction, heart disease and malignancies)

3. TYPE OF BLEEDING AND DIAGNOSTIC PROCEDURE 1.Minor bleeding that resolves with conservative therapy (75-90% ) 2.Chronic intermittent bleeding colonscopy 3.Severe life-threatening bleeding urgent colonscopy (diagnostic and therapeutic role) or RBC Tc-labeled scintigraphy 4.Continual active bleeding angiography or surgery

4. ACUTE MASSIVE RECTAL BLEEDING Frequently arises from an upper gastrointestinal source expecially in case of massive bleeding Nasogastric aspiration can identify an upper GI bleeding site If no blood is returned and bile is identified an upper GI source cannot be entirely excluded but becomes less likely Definitive test is EGDscopy

5. CAUSES OF RECTAL BLEEDING LARGE BOWEL Diverticular disease

6. CAUSES OF RECTAL BLEEDING LARGE BOWEL Diverticular disease Arteriovenous malformations (angiodysplasia, varices)

7. CAUSES OF RECTAL BLEEDING LARGE BOWEL Diverticular disease Arteriovenous malformations (angiodysplasia, varices) Colitis (ischemic, Crohn, ulcerative, radiation, infectious) Neoplasm Post polipectomy bleeding

8. CAUSES OF ACUTE MASSIVE RECTAL BLEEDING LARGE BOWEL Diverticular disease Arteriovenous malformations (angiodysplasia, varices) Colitis (ischemic, Crohn, ulcerative, radiation, infectious) Neoplasm Post polipectomy bleeding Anorectal causes

9. CAUSES OF RECTAL BLEEDING SMALL BOWEL Angiodysplasia Jejunoileal diverticula Meckel’s diverticulum Neoplasm/limphoma Enteritis/Crohn Aortoenteric fistula

10. CAUSES OF RECTAL BLEEDING PATIENTS < 50 YEARS 1.Anorectal causes 2.Colitis PATIENTS > 50 YEARS 1.Diverticular disease 2.Arteriovenous malformations 3.Neoplasm

11. COLORECTAL BLEEDING: A MULTIDISCIPLINARY APPROACH In patients < 50 years with low risk simptoms visualization of left colon may be adequate because: - rectal bleeding has positive predictive value of 34% for left sided neoplasm and 0,9% for right sided neoplasm - 2/3 of colorectal tumors occur in the rectum and sigmoid colon In the elderly patients colonscopy is the diagnostic tool of choice

12. Lower endoscopic study is the diagnostic procedure of choice in the setting of acute lower GI hemorrhage If sigmoidoscopy is the initial endoscopic approach, the procedure should only be considered diagnostic if actively bleeding lesion is visualized Anal or rectal lesion may not exclude a more proximal bleeding lesion Many endoscopists prefer to perform colonscopy as initial evaluation

13. COLONSCOPY Direct visualization Access for tissue biopsy Highly effective to evaluate sub massive lower GI bleeding Lower complication rate than arteriography In massive hemmorrhage poor visibility (arteriography must be considered)

14. COLONSCOPY Defines accurately bleeding source (diagnostic accuracy 72-86%) Provides effective therapy whenever possible Guides surgical approach

15. COLONSCOPY URGENT within 8 hours of presentation ELECTIVE after cessation of bleeding

16. URGENT COLONSCOPY REQUIRES: Rapid bowel preparation with a polyethylene glycol based solution administered orally in 3-4 h Availability of endoscopists

17. URGENT COLONSCOPY Identified a definitive source of lower GI bleeding more often than in standard care group (42% versus 22%) There was no differences in important outcomes Mortality Hospital stay Tranfusions requirements Early rebleeding Surgery Late rebleeding (follow up 60 months) Green T et al, American Journal of Gastroenterolgy 2005

18. CONCLUSIONS I Colonscopy is the procedure of choice both for its accuracy in localization of the bleeding site and its therapeutic capability When a bleeding site is identified (active bleeding or visible vessel) endoscopic therapy appears to have excellent efficacy and low morbidity

19. CONCLUSIONS II About timing there is an open question Some authors reccomanded beginning preparation as soon as possible and if effluent clears consider urgent colonscopy In case of aggressive bleeding consider arteriography If bleeding ceases elective colonscopy could also be considered The choice of this two approaches should be based on local expertise and available resources

20. ACUTE SEVERE HAEMATOCHEZIA History, phisical examination and resuscitation Upper GI source No Yes colonscopy EGD treatment source identified source not identified source not identified adequate exam inadequate exam treatment active bleeding yes no angiography treatment enteroscopy +/- treatment +/- surgery videocapsule endoscopy Farrel and Friedman, Aliment Pharmacol Ther 2005 - + +