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

2. 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

3. Why not perform Colonoscopy?

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

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

6. Limitations of Colonoscopy

7. 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

8. Diverticular bleeds
- multiple subtle bleeding sites
- active bleeding identified 21% Jensen et al, 2000
- aggressive bowel prep
Green at al, 2005
% endoscopic view rated poor to fair

9. 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

10. 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

11. Risks

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

13. 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

14. Alternatives

15. 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

16. 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

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

18. 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

19. 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

20. Thank You