Don t Waste Time with No Chance to See Kathy P. Bull-Henry, MD, FACG Dr. Bull-Henry has indicated no relevant financial relationships. Don t Waste Time With No Chance to See Kathy Bull-Henry, MD, FACG Associate Professor of Medicine Division of Gastroenterology MedStar Georgetown University Hospital April 13, 2013 1
No financial disclosures Cons of Urgent Colonoscopy Timing of colonoscopy remains controversial Low prevalence of stigmata of hemorrhage Colon preparation Sedation, experienced staff and procedure facilities Complications Strate L, et al. World J Gastrol 2012; 8:1185 2
Prospective studies supporting urgent colonoscopy are small and nonrandomized Case studies supporting urgent colonoscopy are small Elta G. GIE 2004; 59:402-408 Two RCT showed no difference in rebleeding rates and surgery for urgent colonoscopy Green B, et al. Am J Gastrol 2005;100:2395 Laine L, Shah A. Am J Gastrol 2010;105:2632 Green B, et al. Am J Gastrol 2005;100:2395 100 pts were randomized d Urgent Colonoscopy (n=50) Colo < 8 h of presentation Standard Care (n=50) Colo < 4 days of presentation 3
Green B, et al. Am J Gastrol 2005;100:2395 Yes Ongoing bleeding No RBC Scan Positive Negative Angiography Elective Positive Colonoscopy Negative Angiographic hemostasis Elective Colonoscopy Elective Colonoscopy Elective Colonoscopy Standard Care Algorithm Bleeding Source : Results Urgent Colonoscopy (N=50) Standard care (N=50) Definitive Source Diverticulosis 13 8 Angioectasia 4 0 Ischemic colitis 4 3 Total 21 (42%) 11 (22%) 1.1 6.2 Presumptive Source Diverticulosis 26 20 0.7 3.6 Angioectasia 1 1 Colitis 0 3 Polyp 0 2 Ulcer 0 1 Total 27 (54%) 27 (54%) 0.4 2.2 Unknown 2 12 Green B, et al. Am J Gastrol 2005;100:2395 95% CI 4
: Results Urgent Colonoscopy (N=50) Standard care (N=50) Difference (95% CI) Definitive source of 21 (42%) 11 (22%) 20% (1.1 6.2) bleeding Early Rebleeding 11(22%) 15 (30 %) 8% (0.3-1.6) Late rebleeding 8 (16%) 7 (14%) 2% (-12 16%) Units of units of 4.2 units 5 units blood transfused Length of hospital 58d 5.8 days 66d 6.6 days stay Surgery 7 (14%) 6 (12%) Mortality 1 (2%) 2 (4%) Green B, et al. Am J Gastrol 2005;100:2395 Green B, et al. Am J Gastrol 2005;100:2395 Limitations: Trial terminated early before the pre-specified sample size reached (58 in each group) Thus, not adequately powered to determine statistically significant differences Enrollment was over a 10 year period 5
Green B, et al. Am J Gastrol 2005;100:2395 Conclusion Urgent colonoscopy has a higher diagnostic yield But does not significantly decrease Initial hemostasis rate Early and late rebleeding rate Surgical intervention Transfusion requirement Complication rate Length of stay Mortality Laine L, Shah A. Am J Gastrol 2010;105:2632 85 pts eligible Pts with hematochezia, HR > 100, SBP < 100, Orthostatic changes: HR > 20 or BP > 20, Hgb drop >1.5g/dl EGD < 6h 15% (13) had upper source on EGD No clinical evidence of UGI bleeding 7 duodenal ulcers, 3 gastric ulcers, 2 esophageal varices, 1 gastric varices 6
Laine L, Shah A. Am J Gastrol 2010;105:2632 72 pts without UGI source were randomized Urgent Colonoscopy (n=36) Colo < 12 h of presentation (Median 11 hrs) Elective Colonoscopy (n=36) Colo 36-60 h of presentation (Median 47 hrs) Groups were similar except: Urgent group had lower baseline hemoglobin and received more blood transfusions before randomization : Results Urgent Colonoscopy N=36 Poor Prep 2 (6%) 3 (8%) Diverticula with active bleeding or + stigmata 2 (6%) 0 Diverticula without active 9 (25%) 7 (19%) bleeding nor + stigmata Internal hemorrhoids 8 (22%) 6 (17%) Colon cancer 1 (3%) 5 (14%) Colon ulcers 2 (6%) 2 (6%) Colitis 3 (8%) 1 (3%) Vascular ectasias 2 (6%) 0 Rectal varices 0 1 (3%) Portal hypertensive 0 1 (3%) colopathy Nondiagnostic 8 (22%) 12 (33%) Laine L, Shah A. Am J Gastrol 2010;105:2632 Elective Colonoscopy N=36 7
: Results Urgent Elective Colonoscopy Colonoscopy (N=36) (N=36) Difference (95% CI) Rebleeding 8 (22%) 5 (14%) 8% (-9-26%) Units of units of 1.5 units 0.7 units 0.9 (0.02-1.7) blood transfused Length of hospital 5.2 days 4.8 days 0.4 (-1.8 2.6) stay # of diagnostic or 13 (36%) 12 33% 3% (-19-25%) therapeutic interventions Hospital charges $27,590 $26,633 957 (-12,525-14,440) No further bleeding 28 (77%) 31 (86%) Laine L, Shah A. Am J Gastrol 2010;105:2632 Laine L, Shah A. Am J Gastrol 2010;105:2632 Limitations: Trial terminated early before the pre-specified sample size reached (134 in each group) Thus, not adequately powered to determine statistically significant differences 8
Laine L, Shah A. Am J Gastrol 2010;105:2632 Conclusion: UGI Source found in 15% patients with hematochezia About 80% of patients had no further rebleeding Endoscopic therapy performed in only 6% of patients for non-hemorrhoidal sources Urgent colonoscopy did not improve outcomes in LGI bleeding Colonoscopy Prep Prep should be given until clear 5-6 liters of polyethylene glycol given over 3-4hours (often via NG tube) until clear Colonoscopy should then be performed 1-2 hours after stool clearing Promotility agent may prevent nausea Requires coordination of the medical, nursing, and pharmacy staff Requires cooperation of the patient and family Jensen D. NEJM 2000;342:78-82 9
Colonoscopy Prep Colon prep makes urgent colonoscopy difficult Blood and stool in the colon Increase the risk of perforation Impair identification of stigmata Green s study reported poor to fair prep in 62-64% of patients Laine s study reported 7% of patients needed repeat colonoscopy due to poor prep Green B. Am J Gastro 2005;100:2395-2402 Laine L. Am J Gastro 2010;105:2636-2641 Low Prevalence of Stigmata of Hemorrhage Purpose of urgent colonoscopy Identify and treat active bleeding or stigmata of recent bleeding Difficult to identify stigmata Residual blood and stool Intermittent bleeding Multiple potential bleeding sources Large surface area of the colon Low prevalence of stigmata of hemorrhage Strate L. CGH 2010;8:333-343 10
The Most Common Colonic Sources Amenable to Endoscopic Therapy 486 Colonic Cases Cause % Diverticulosis 31.9% Internal hemorrhoids 12.8% Ischemic Colitis 11.9% Rectal ulcers 7.6% UC, Crohn s, other colitis 7.1% Colon angiomas/xrt 7.0% Other LGI sources 5.6% Post polypectomy ulcer 4.7% Focal stigmata amenable to colonoscopic hemostasis Jenson D. & CURE Hemostasis Group Oct 2009 Bleeding Source Low Prevalence of Stigmata of Hemorrhage Urgent Colonoscopy (N=50) Standard care (N=50) Definitive Source Diverticulosis 13 8 Angioectasia 4 0 Ischemic colitis 4 3 Total 21 (42%) 11 (22%) 1.1 6.2 Presumptive Source Diverticulosis 26 20 0.7 3.6 Angioectasia 1 1 Colitis 0 3 Polyp 0 2 Ulcer 0 1 Total 27 (54%) 27 (54%) 0.4 2.2 Unknown 2 12 Green B, et al. Am J Gastrol 2005;100:2395 95% CI 11
Low Prevalence of Stigmata of Hemorrhage Urgent Colonoscopy (N=36) Poor Prep 2(6%) 3(8%) Diverticula with active bleeding or + stigmata 2(6%) 0 Diverticula without active 9(25%) 7(19%) bleeding nor + stigmata Internal hemorrhoids 8(22%) 6(17%) Colon cancer 1(3%) 5(14%) Colon ulcers 2(6%) 2(6%) Colitis 3(8%) 1(3%) Vascular ectasias 2(6%) 0 Rectal varices 0 1(3%) Portal hypertensive 0 1(3%) colopathy Nondiagnostic 8(22%) 12(33%) Laine L. Am J Gastrol 2010;105:2632 Elective Colonoscopy (N=36) Low Prevalence of Stigmata of Hemorrhage Study Pts n Timing hr Dx n(%) Definitive Dx n(%) Endoscopic Tx n(%) Jensen, 2000 121 <12 121 (100) 107 (88) 10 (37) Antuaco, 2001 39 <24 29 (74) 3 (8) 3 (8) Schulewitz, 2003 415 46 369 (89) -- 42 (10) Smoot, 2003 78 18 78 (100) 38 (49) 7 (9) Strate, 2003 144 25 128 (89) 62 (43) 14 (10) Green, 2005 50 7 48 (96) 21 (42) 17 (34) Total 847 773 (91) 231 (53) 93 (12) Angtuaco T. Am J Med 2001;96:1782-1785 Schmulewitz N. GIE 2003;58:841-846 Smoot R. Am J Gastro 2003;98:1996-1999 Strate L. CGH 2010;8:333-343 Jensen D. NEJM 2000;342:78-82 Strate L. Am J Gastro 2003;98:317-322 Green B. Am J Gastro 2005;100:2395-2402 12
Complications Risk of perforation 6-8 liters large volume bowel prep Volume overload Electrolyte abnormality Risk of aspiration Parikh K. Cleve Clin J Med 2011;78: 157-160 Ayus J. BMJ 2003;326:382-384 Sedation, Staffing, Procedure Facilities Coordination of the medical, nursing, technical support staffing for endoscopy at night and on weekends may be challenging and complex 13
Urgent Colonoscopy in Acute LGI Bleeding Conclusion Enthusiasm and support for urgent colonoscopy is not supported by randomized controlled studies The number of patients in supporting prospective studies and case reports is small Urgent Colonoscopy in Acute LGI Bleeding Conclusion Major limitations to performing colonoscopy urgently Bowel prep Coordinating the procedure after-hours Infrequent identification of stigmata Optimal timing of colonoscopy is not defined 6 h, 8h, 12h, 24h, 48h? Is secondary prevention important? Avoidance of NSAIDs, anticoagulants, popcorn, seeds, and nuts 14
Urgent Colonoscopy in Acute LGI Bleeding Conclusion Need for multicenter randomized controlled studies that: Use risk stratification tool that select patients who would benefit from urgent colonoscopy Define the optimal timing of colonoscopy in LGI bleeding Compare available options including RBC scans, angiography, and dmdct angiography Optimize colon preps Standardize endoscopic therapy Standardize criteria for early discharge Assess secondary prevention Suggested Algorithm Hematochezia with hemodynamic instability Yes EGD + Flexible sigmoidoscopy - Massive Bleeding Yes MDCT angiography, RBC Scan - + No No Colonoscopy + Therapy as indicated Colonoscopy Angiography with embolization + or - 15
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