When to Scope in Lower GI Bleeding: It Must Be Done Now Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA Outline Epidemiology Overview of available tests Urgent colonoscopy Endoscopic treatment Risk stratification Take Home Points 1
Lower GI Bleeding (LGIB) Is Common Lanas, et al. Am J Gastroenterol 2009; 104:1633 1641 Laine, et al. Am J Gastroenterol 2012; 107: 1190-5 Lower GI Bleeding Is Resource Intensive Outcome LGIB UGIB Length of Stay (mean) 11.6 days 7.9 days Number of tests (mean) 1.26 0.98 Recurrence 10% 5% Lanas, et al. Am J Gastroenterol 2009; 104:1633 41 2
Colonoscopy Is the Best Test Diagnosis Rx Safety Preparation Colonoscopy + + + - Sigmoidoscopy +/- +/- + + Angiography +/- +/- +/- + Tagged scan +/- - + + CT angiography +/- - + + Radiology: No Therapy vs. Risk of Complications Test Advantages Disadvantages Tagged Scan Sensitive Inaccurate Not widely available Delay in therapy CT Angiography (MDCT) Accurate Anatomic detail Available Not therapeutic Radiation and contrast Angiography Diagnostic and Less sensitive Therapeutic (Super-selective embolization) Serious complications Not immediate Pennoyer et al. Dis Colon Rectum 1997; 40:1014-9 Zink et al. AJR 2008:191:1107 3
Colonoscopy for Most LGIB Low-risk / Inactive High-risk / Massive r/o Upper GI bleeding Stable Unstable Colonoscopy Angiography ± CT angiography Tagged scan Early Endoscopy for Upper GI Bleeding Diagnosis Identifies bleeding source > 95% Prognosis Low risk stigmata discharge High risk stigmata treat Treatment: (20% have high risk stigmata) Controls bleeding 85-95% rebleeding hospital length of stay Sacks JAMA 1990; Hay et al. Am J Med 1996 4
Urgent Colonoscopy Overview Colonoscopy within 12-2424 hours of admission 4-8 liters of PEG solution over 3-4 hours Goals: High Risk Patients - endoscopic therapy of stigmata Low Risk Patients early hospital discharge Conflicting evidence Jensen, et al. Gastroenterol 1988; 95(6):1569-74 Variability in LGIB Literature Patient selection criteria Severe bleeding all admissions Study setting Bleeding team routine care Timing of colonoscopy Immediately after rapid purge no time limit Type and quality of bowel preparation Rapid, large volume purge no preparation Diagnostic criteria Definitive sources only no criteria Few randomized controlled trials 5
Urgent Colonoscopy Improves Outcomes in Severe Diverticular Bleeding Outcome Medical Rx Endoscopic Rx n= 17/73 n=10/48 Recurrent bleeding 88% 0 Surgery 35% 0 Length of stay 5 days 2 day Validity and generalizability of findings: Historical control group Specialized GI bleeding center Only severe diverticular bleeding Jensen, et al NEJM 2000; 342:78-82 Stigmata Predict Natural History Stigmata n Rebleeding Surgery Active bleed 6 67% 50% NBVV 4 50% 25% Adherent clot 7 43% 29% Total 17 53% 35% Jensen, et al NEJM 2000; 342:78-82 Jensen et al. DDW 2012 6
Urgent Colon Improves Diagnostic Yield Urgent Colonoscopy Standard of care n=50 n=50 Definite Source 42% 22% Therapy 34% 20% Recurrent bleeding 22% 30% Surgery 14% 12% Length of stay 5.8 days 6.6 days Complications 2% 0 Validity of findings: Underpowered (needed ~400 patients) Poor colon preps (65% in urgent group) Out-dated angiographic therapy Green, et al. Am J Gastro 2005;100:2395 02 Urgent Colon Not Better Than Delayed Urgent Colonoscopy Delayed Colonoscopy n=36 n=36 Definitive source 6% 0 Recurrent bleeding 22% 14% Blood transfusion 1.5 units 0.7 units Subsequent intervention 36% 33% Complications 0 3% Hospital stay 5.2 days 4.8 days Hospital charges $27,600 $26,600 600 Validity of findings: Underpowered Sicker patients in urgent arm Preparation quality not noted Laine, et al. Am J Gastroenterol 2010; 105: 2636 7
Early Colon Decreases Length of Stay Variable Hazards Ratio (95%CI)* P Value Time to colonoscopy 2.04 (1.6-2.7) <0.0001 Blood transfusions 2 0.41 (0.03-0.57) <0.0001 Recurrent bleeding 0.49 (0.25-0.96) 0.037 Charlson Index > 2 0.75 (0.57-0.99) 0.045 * Low risk patients discharged after colonoscopy * Earlier colonoscopy more therapeutic interventions (p=0.01) Strate, et al. Am J Gastro 2003; 98:317-22 Lower GI Bleeding is Treatable Source Frequency Endoscopic Treatment Diverticulosis 30-50% Yes Ischemic colitis 10-20% No Hemorrhoids 10-15% Yes Neoplasia 5-10% Sometimes Colitis, other 5-10% Sometimes Post-polypectomy 3-10% Yes Angiodysplasia 1-5% Yes Rectal ulcer 0-8% Yes Dieulafoy s Rare Yes Rectal varices Rare Sometimes Total treatable 45-65% Strate, et al Clin Gastroenterol Hepatol 2010; 8:333-43 8
Endoscopic Therapy for Diverticular Bleeding No. Patients Hemostasis Complications Thermal contact 17 88% 0 Epinephrine 20 85% 0 Thermal + injection 25 76% 0 Banding 49 92% 0 Clips 119 87% 0 Total 230 86% 0 Strate, Naumann Clin Gastro Hepatol 2010; 8:333 43 Kaltenbach, et al. Clin Gastro Hepatol 2012;10:131-37 Setoyama, et al. Surg Endosc 2011; 25:3574-8 Ishii, et al. Gastrointest Endosc 2012; 75:382-87 How Urgent: ~12-24hrs Timing Diagnosis Definitive Dx Endo Rx < 12 hrs 79% 43% 29% 12-24 hrs 89% 56% 13% > 24 hrs 47% 17% 4% Stigmata rarely identified on elective exams Preparation may be as important as timing Time relative to active bleeding not admission Strate, et al. Am J Gastro 2003; 98:317-22 Yen EF, et al. Colonoscopic Dig DisSci 2008;53:2480 85. 9
Urgent Colonoscopy: Yes or No Logistical Factors Clinical Indicators Goal: target high risk patients Stable Clinical Spectrum? Urgent Colonoscopy Unstable Colon next available Radiology Risk Stratification Clinical Information Low Risk High Risk General ward Early endo & discharge Outpatient management ICU Aggressive care Emergent intervention Length of stay Costs of care = Clinical outcomes Treat stigmata Rebleeding Surgery Mortality 10
Risk Factors for Poor Outcome Hemodynamic instability Hypotension Tachycardia Syncope Orthostasis Ongoing bleeding Ongoing hematochezia Blood on rectal exam Comorbid illness Age Secondary bleeding Anticoagulation H/o diverticulosis, Angiodysplasia Nontender abdomen Anemia (HCT < 35) Elevated Cr Abnormal WBC Kollef, et al Crit Care Med 1995; 25: 1025-32 Strate, et al Arch Int Med 2003; 163: 838-43 Das, et al Lancet 2003; 362: 1261-6 Velayos, et al Clin Gastroenterol Hepatol 2004; 2:485-90 Risk Score to Facilitate Triage Predictors of severe bleeding Hypotension (<115 mmhg) Tachycardia (>100 bpm) Syncope Nontender abdomen Bleeding w/in 4 hrs of presentation ti ASA use > 2 comorbid conditions Risk group Risk of severe bleeding > 3 risk factors 84% 1-3 risk factors 43% No risk factors 9% Strate, et al. Arch Int Med 2003;163:838-43 Strate, et al. Am J Gastroenterol 2005; 100:1821 27 11
Take Home Points Colonoscopy is the best initial test for most LGIB Radiographic tests t only for unstable patients t Urgent colonoscopy: diagnostic & therapeutic yield hospital stay Safe Urgent colonoscopy appropriate for select patients Risk stratification can aid in triage 12