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PubMed1999

Ultrasound, CT and colonoscopy of colonic cancer.

Barium enema and colonoscopy are commonly used for the investigation of suspected colonic cancer. These techniques are relatively invasive and both the investigation and the preceding bowel preparation are demanding, particularly in the elderly. A prospective, blinded trial was conducted to compare ultrasound (US) and CT with colonoscopy. CT and colonoscopy were performed on 50 patients with symptoms suggesting colonic cancer. Both radiological investigations were performed prior to the bowel preparation for colonoscopy. US was performed without any preparation and oral contrast medium was the only preparation used for CT. Colonoscopy detected six cancers, all of which were diagnosed by both US and CT. In addition, US and CT diagnosed a further cancer not seen on colonoscopy due to an incomplete study. US had a sensitivity and specificity of 100% and CT a sensitivity of 100% and a specificity of 84%. US and CT were poor at diagnosing polyps. If the detection of polyps greater than 2 cm is included then US sensitivity falls to 67% and CT sensitivity falls to 89% and specificity rises to 88%. In conclusion, both US and CT are possible alternatives to colonoscopy in the investigation of symptomatic patients with suspected colonic cancer. The use of these techniques could markedly reduce the need for colonoscopy in this patient population with attendant cost savings. Non-invasive imaging has particular advantages in the elderly who cope poorly with both the bowel preparation and the procedure.

Adult↗

PubMed1999

Endoluminal CT colonography after an incomplete endoscopic colonoscopy.

OBJECTIVE: We evaluated the clinical usefulness of endoluminal CT colonography after an incomplete colonoscopy. SUBJECTS AND METHODS: We prospectively studied 40 patients in whom the cecum could not be reached endoscopically despite adequate bowel preparation. Endoluminal CT colonography (120 kVp, 120 mA, 3-mm collimation, pitch of 2, 1.5-mm interval reconstruction) was performed within 2 hr of incomplete colonoscopy. Two-dimensional multiplanar reformatted images and three-dimensional endoluminal images were analyzed. Twenty-six patients (65%) underwent barium enema immediately after endoluminal CT colonography. We analyzed colonic distention; duration of endoluminal CT colonography; patient tolerance; number of colonic segments seen at colonoscopy, endoluminal CT colonography, and barium enema; and reasons for incomplete colonoscopy as well as colonic and extracolonic findings. RESULTS: Duration of endoluminal CT colonography was 14.2 +/- 4.6 min (mean +/- SD). Endoluminal CT colonography was better tolerated than colonoscopy or barium enema (p < .001). Probable causes for incomplete colonoscopy were identified at endoluminal CT colonography in 74% of 40 patients. Baseline colonic distention in the region of the transverse and right colon was considered adequate before additional air insufflation; however, the addition of air significantly enhanced colonic distention throughout the entire colon (p < .001). Endoluminal CT colonography adequately revealed 96% of all colonic segments; in comparison, barium enema adequately revealed 91% of all segments (p < .05). CONCLUSION: In patients with incomplete colonoscopy, endoluminal CT colonography successfully showed the previously unrevealed colon in more than 90% of patients. Endoluminal CT colonography is a rapid, well-tolerated technique that provides clinically useful colonic and extracolonic information and should be considered for all patients who undergo incomplete colonoscopy.

Adult↗

PubMed2006

[Screening colonoscopy among first degree relatives of patients with colorectal carcinoma].

BACKGROUND: First degree relatives of patients with colorectal carcinoma are at a higher risk of having the disease than the general population. Therefore, they should be subjected to screening colonoscopy. AIM: To assess the effectiveness of colonoscopy among first degree relatives of patients with colorectal carcinoma. MATERIAL AND METHODS: A free colonoscopy was offered to first degree relatives of patients operated on for colorectal cancer between 1998 and 2000. As inclusion criteria, subjects had to be asymptomatic, older than 40 years or less than 10 years younger than the index case. Each subject was contacted twice, inviting him/her to have a colonoscopy performed. RESULTS: Two hundred forty three relatives were contacted for the study and in 76, a colonoscopy was performed. Among the latter, a neoplasm was found in 13 (17%): One adenocarcinoma and 12 adenomas. Three of these lesions were located in the right colon. The main reason given by the 176 subjects that did not agree to have a colonoscopy was lack of interest. CONCLUSIONS: Screening colonoscopy is effective to detect adenoma and adenocarcinoma among first degree relatives of patients with colorectal carcinoma, however only 31% of all potential relatives agreed to undergo a colonoscopy.

Adenocarcinoma↗

PubMed2006

Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial.

BACKGROUND: Even when primary care physicians have face-to-face discussions with patients before referring them for screening colonoscopy, patient nonadherence can be substantial. Often, primary care physicians lack sufficient time to educate patients and address their potential misconceptions and fears about this procedure. OBJECTIVE: To test whether an informational brochure sent to patients' home addresses after referral for screening colonoscopy would increase patient completion of the procedure. DESIGN: Randomized, controlled trial. SETTING: 2 general internal medicine practices affiliated with the University of Colorado Health Sciences Center. PATIENTS: 781 consecutive patients 50 years of age or older referred by their primary care physicians for screening colonoscopy. INTERVENTION: Patients were randomly assigned to receive usual care (control group) versus usual care plus an informational brochure (intervention group). The brochure was mailed within 10 days of referral for screening colonoscopy; it mentioned the name of the patient's primary care physician and encouraged patients to schedule a procedure. It also described colorectal cancer and polyps and the similar lifetime risks for colorectal cancer for men and women, colonoscopy and risk for perforation, the nature of bowel preparation for the procedure, and alternative screening tests. MEASUREMENTS: Rates of adherence to screening colonoscopy in the 2 study groups. RESULTS: The overall adherence rate was 11.7 percentage points (95% CI, 5.1 to 18.4 percentage points) greater in the intervention group than in the control group (70.7% vs. 59.0%). Older patients were more adherent than younger patients. Patients with low-income insurance plans, such as Medicaid, were less adherent despite being sent a brochure. LIMITATIONS: The small number of clinical practices and minority patients may limit generalizability. In addition, it was not possible to determine the degree to which adherence was influenced by a reminder to schedule a procedure versus detailed information about colonoscopy. CONCLUSIONS: An inexpensive mailed brochure is an effective way to increase patient adherence to primary care physician referral for screening colonoscopy.

Aged↗

PubMed2000

[Viability of colonoscopy without analgesia and conscious sedation].

AIM: To study the need for analgesia and sedation before colonoscopy. PATIENTS AND STUDY DESIGN: Fifty consecutive outpatients were randomly assigned to receive meperidine (0.7 mg/kg) or midazolam (0-035 mg/kg) intravenously (n = 25) or to receive no medication (n = 25) before colonoscopy. Oxygen saturation (SaO2) and heart rate were monitored. Mean blood pressure (MBP) was recorded before and after endoscopy. Patients in the group receiving no medication who experienced marked abdominal pain received sedation and analgesia similar to the premedicated group. Twenty-four hours after the procedure, the patients evaluated the degree of abdominal pain experienced during colonoscopy on a scale from 0 to 9. RESULTS: Complete colonoscopy was performed in 92% of the patients. No significant changes in heart rate were registered in either group. However, in the premedicated group mean blood pressure fell significantly (97.6 +/- 2.6 vs. 89.5 +/- 2.7 mmHg) before and after colonoscopy, respectively (p < 0.05). Nine patients experienced clinically relevant oxygen desaturation (SaO2 > 90%). Of these, five were from the premedicated group and four were from the group receiving no medication. In two patients, both from the premedicated group, the decrease in SaO2 was severe (SaO2 < 85%). The degree of abdominal pain was similar in both groups: 3.64_0.47 (premedicated) vs. 3.92 +/- 0.5 (non-medicated). In the non-medicated group, two patients required analgesia and sedation to complete the colonoscopy and 20 (80%) preferred not to receive sedation in future colonoscopies. CONCLUSIONS: Colonoscopy may be well tolerated without systematic administration of sedation and analgesia, which could be administered selectively.

Abdominal Pain↗

PubMedDate not supplied

Colorectal polyp detection with virtual colonoscopy (computed tomographic colonography); the reliability of the method.

BACKGROUND/AIMS: The aim of this study was to compare the reliability of virtual colonoscopy with conventional colonoscopy in detection of colorectal polyps. METHODOLOGY: Between November 1997 and February 2000, 23 patients (14 males, 9 females) aged 43-86 years (mean: 63) with colorectal polyps who underwent colonoscopy in our endoscopy unit, were referred for virtual colonoscopy. The colon was distended with an enema tube for rectal insufflation and subsequently was scanned by helical CT (Toshiba X-vision) using the following parameters: KV 120, mAs 200, table feed 5 mm/sec, slice thickness 5 mm and reconstruction intervals 2.5 mm. Using SPARC Station 20, virtual colonoscopy was generated. RESULTS: A total of 30 polyps (19 with diameter 8-15 mm and 11 larger than 15 mm) were detected with conventional colonoscopy. Virtual colonoscopy visualized 27 polyps (17 with diameter 8-15 mm and 10 with diameter > 15 mm). CONCLUSIONS: Virtual colonoscopy is a non-invasive, well-tolerated, safe technique and can be useful for detection of colorectal polyps. Weaknesses of the method are the inability to detect small lesions and to perform biopsies.

Adult↗

PubMed2002

[The appropriateness of the indications and diagnostic efficiency of colonoscopy. Results of a survey conducted in all the hospital centers of the Provence-Alpes-Côte d'Azur area].

OBJECTIVE: To evaluate the appropriateness of indications and the diagnostic efficiency of colonoscopy taking into account available guidelines. METHODS: This was a retrospective study conducted by the Union Régionale des Caisses d'Assurance Maladie de Provence-Alpes-Côte d'Azur (URCAM-Paca) aimed at assessing the appropriateness of the indications and diagnostic efficiency of colonoscopy. Anonymous data concerning near totality of the colonoscopies carried out during one week in all the establishments (public and private) of the area, were collected by consulting the medical records. RESULTS: The indications for colonoscopy were first analyzed with regard to the guidelines for good clinical practices (références médicales opposables and consensus conference) according to two scales of reading (literal interpretation and broad interpretation). We noted that the available guidelines do not cover the totality of the colonoscopies performed, that their formulation does not make them all controllable, and that the colonoscopies, which respect them, range from 27.5% (strict reading) to 74.1% (broad reading). When taking into account not only the quality of the preparation, but also the result of the examination after re-classification into benign, pathological or normal examinations, the differences in efficiency appear only when one retains the broad interpretation of the reference guidelines. The efficiency analysis makes it possible to highlight a defect of predictability of the recommendations with regard to the pathologies considered as serious. It also appears that approximately 10% of the colonoscopies are, at the same time, out of the reference and have a normal result, and thus can be considered as absolutely not justified. CONCLUSION: Better compliance of the practitioners to colonoscopy recommendations would initially be generated by improvement in the predictability and the legibility of the current reference guidelines.

Colonoscopy↗

PubMed2004

Appropriateness of colonoscopy in a university hospital.

An open access endoscopy system allows for the direct scheduling of endoscopies by non-gastroenterologist physicians without prior gastroenterology consultation. The aim of our study was to examine our practice of open access endoscopy by evaluating the appropriateness of referrals for colonoscopy and to determine whether there were differences depending on the specialty of the referring clinician. The indication for colonoscopy was assessed in 499 consecutive outpatients referred for colonoscopy at University Hospital, Kuala Lumpur over a 12-month period. The American Society of Gastrointestinal Endoscopy (ASGE) guidelines were used to determine the appropriateness of referrals. 80.6% of colonoscopies requested by the gastroenterologist were performed for accepted indications compared to 50.6% of referrals by the primary care physician (p<0.001) and 67.0% of referrals by the surgeon (p=0.006). The rate of colonoscopies generally not indicated was 2.1% for the gastroenterologist, 25.0% for the internist (p=0.002) and 7.5% for the surgeon (p=0.04). The rate of indications not listed in the ASGE guidelines was significantly lower for requests made by gastroenterologists (17.3%) than those requested by primary care physicians (44.2%; p<0.001). Patients who have had prior consultation with the gastroenterologist were significantly more likely to undergo colonoscopy for appropriate indications than among patients who were referred through an open access system. The rate of inappropriate indications for colonoscopy was also significantly lower when the gastroenterologist made the referral. A substantial proportion of colonoscopies (25.4%) was performed for indications not listed in the ASGE guidelines.

Colonoscopy↗

PubMed2004

New Mexico's capacity for increasing the prevalence of colorectal cancer screening with screening colonoscopies.

INTRODUCTION: Colorectal cancer screening rates are low throughout the United States. Colonoscopy has been recommended as a cost-effective strategy for colorectal cancer screening and prevention. We evaluated New Mexico's capacity to increase the prevalence of colorectal cancer screening using colonoscopy. METHODS: We identified New Mexican gastroenterologists from state licensing data and from endoscopic manufacturers. We surveyed gastroenterologists on their weekly number of colonoscopies, capacity for additional screening colonoscopies, and barriers to increasing capacity. We used census data, published data on the yield of screening colonoscopy, and professional society guidelines for cancer/polyp surveillance to estimate the additional colonoscopies required to increase the state's prevalence of endoscopic screening. RESULTS: Forty gastroenterologists, representing all 11 group practices in the state, and nine of 12 solo practitioners responded. They estimated that their weekly procedure capacity could be increased by 41%, from 832 to 1174 colonoscopies. We estimated an annual capacity increase of 14,880 procedures, which could increase the prevalence of endoscopic colorectal cancer screening from the current 35% to about 50% over five years. Lack of support staff, space, and physicians were barriers to increasing screening. CONCLUSION: Implementing a screening colonoscopy strategy could achieve the goal of a higher level of colorectal screening. However, achieving more universal screening would require additional testing modalities.

Colonoscopy↗

PubMed2005

Colonoscopy in Romania.

BACKGROUND: To date, colonoscopy is considered the gold standard for the investigation of the colon and also the gold standard method for colorectal cancer screening. AIM of this paper was to assess if and how is Romania prepared to cope with screening of colon cancer by means of colonoscopy. METHOD: We sent a study-type questionnaire addressed to all the centers in Romania known to perform digestive endoscopy and we inquired about the total number of colonoscopies and flexible sigmoidoscopies performed in 2003 (the questionnaire was sent to 43 centers). RESULTS: Thirty-eight centers responded to the question-naire. The total number of colonoscopies performed in Romania in 2003, obtained by collecting the data from the study centers, was 22,324. The number of sigmoidoscopies performed during the same period was 12,349. The ratio between the number of colonoscopies and sigmoidoscopies was 1.8/1. There were 106.3 colonoscopies /100,000 inhabitants. CONCLUSION: Considering the population of Romania (about 21 million inhabitants), the number of colonoscopies performed is insufficient for our country. The number of centers performing colonoscopy in Romania is also insufficient.

Colonic Neoplasms↗

PubMedDate not supplied

Rare complications following colonoscopy: case reports of splenic rupture and appendicitis.

BACKGROUND: Appendicitis and splenic rupture are 2 rare complications of colonoscopy reported in the literature. To our knowledge splenic rupture following colonoscopy has been reported 17 times in the English-language literature and is associated with excess traction on the splenocolic ligament. Appendicitis after colonoscopy has been reported only 9 times and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. METHODS: We present the case reports of 2 patients: a 76-year-old woman who presented in consultation 24 hours after a routine colonoscopy with massive hemoperitoneum secondary to splenic rupture, seen on computed tomographic (CT) scan, who then underwent splenectomy; the second, a 60-year-old male who presented to the emergency room 16 hours after colonoscopy with clinical and computed tomographic scan findings of acute appendicitis who underwent a laparoscopic appendectomy. RESULTS: Treatment of both patients resulted in resolution of their complications, splenic rupture and appendicitis. They both had an uneventful postoperative course and are doing well several months postoperatively. CONCLUSIONS: We report 2 rare complications of colonoscopy, splenic rupture and appendicitis. In the setting of a recent colonoscopy and abdominal pain, a high index of suspicion is needed for their diagnosis.

Aged↗

PubMed2006

[Open access colonoscopy: do primary care physicians use it properly?].

BACKGROUND: Open access endoscopy facilitates the performance of colonoscopy on a physician's request, without a prior consultation with a gastroenterologist. OBJECTIVES: To investigate: (1) the rates of relevant endoscopic findings in patients referred by family physicians compared to other specialists; (2) whether there is overuse of open-access colonoscopy in our country where the examination is free of charge for the patient; (3) whether a high rate of pre-malignant and malignant incidental findings might justify a more liberal approach to the indications of colonoscopy. METHODS: Prospective study including all consecutive ambulatory patients referred for open access colonoscopy. The indication for the examination was tabulated according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were classified into relevant or normal; each relevant finding was correlated with the indication for which the examination was performed. RESULTS: A total of 34.2% of patients had a colonoscopy performed for an inappropriate indication; family physicians had a slightly higher rate of appropriate indications compared with the other specialists. However, a relevant endoscopic finding was diagnosed only in 14.0% of their referred cases, compared with 22.8% of the other specialists (p = 0.032). Polyps larger than 5 mm or a malignant tumor were diagnosed in 20.7% of the colonoscopies; 19 out of the 83 cases (23%) were diagnosed in examinations performed for inappropriate indications. CONCLUSION: It was found that 34% of the colonoscopies were performed for inappropriate indications. A higher proportion of relevant endoscopic findings was diagnosed among patients referred by surgeons, oncologists and internists as compared with those referred by family physicians. Considering that as much as 23% of polyps and malignant tumors were found in cases performed for inappropriate indications, we suggest that a liberal approach to the indications for colonoscopy--probably age over 50 years--may benefit the patients.

Colonic Neoplasms↗

PubMed1988

Is preoperative colonoscopy necessary in carcinoma of the colon and rectum?

The incidence of synchronous polyps of the colon has been shown to be 25 to 40 per cent and the incidence of synchronous carcinomas to be two to eight per cent. Because of this, many surgical groups now advocate routine preoperative colonoscopy on all patients with colon carcinoma. The possibility of spreading and implanting tumor cells with the colonoscope has prompted the authors to purposely avoid preoperative colonoscopy and then clear the colon of any missed lesions with an early postoperative colonoscopy. This study is a retrospective review of 104 patients who have undergone a partial colectomy for colon and rectal carcinoma followed by a postoperative colonoscopy between June 1982 and June 1986. The purpose is to determine the adequacy of intraoperative palpation to detect synchronous neoplasms, and to further define the role of perioperative colonoscopy. The results of 34 per cent synchronous polyps and 5.8 per cent synchronous carcinomas parallels previous studies. The six patients with synchronous carcinomas were discovered by intraoperative palpation and the operation was modified in four of the six patients. Postoperative colonoscopy revealed polyps in 20 per cent of the patients, but all of these were amenable to snare polypectomy or electrocoagulation. No carcinomas were overlooked by palpation. It is our conclusion that intraoperative palpation is adequate for detection of synchronous carcinomas and therefore the risk and expense of preoperative colonoscopy can be avoided. Early postoperative colonoscopy, however, is imperative to clear the colon of small polyps which have the potential to progress to carcinoma.

Adult↗

PubMed1986

[Continuous ECG in colonoscopy].

42 patients aged over fifty years underwent continuous electrocardiographic monitoring before preparation for colonoscopy, after preparation and during and after colonoscopy. After preparation 11 patients, and during colonoscopy 12 patients, showed no electrocardiographic abnormalities. 31 patients developed or had increased electrocardiographic abnormalities after preparation and 30 patients during colonoscopy. There was no difference in the frequency of electrocardiographic abnormalities after preparation for colonoscopy and during colonoscopy. 68% of the 19 patients with previously diagnosed heart diseases had arrhythmias after preparation and 47% during colonoscopy, and they were thus significantly more frequent than in patients without heart diseases. Serious forms of arrhythmias also occurred more often in patients with heart diseases. None of the arrhythmias observed produced clinical symptoms or complications. Electrocardiographic monitoring during the whole length of preparation and during colonoscopy for all patients with heart diseases does not appear technically feasible. We therefore recommend it for patients with very severe heart diseases only.

Aged↗

PubMed1995

[Diagnosis of colitis caused by cytomegalovirus infection in AIDS. Comparative value of total colonoscopy and rectosigmoidoscopy (apropos of 24 cases). AIDS GIT].

OBJECTIVES: To evaluate the respective diagnostic value of flexible rectosigmoidoscopy and colonoscopy in the cytomegalovirus colitis. METHODS: Twenty-four patients with AIDS were studied retrospectively. The entry criteria were: flexible rectosigmoidoscopy or colonoscopy, with 2 rectal and 2 caecal biopsies, presenting cytomegalovirus inclusions bodies linked to an inflammation at least on one colonic biopsy. RESULTS: Twenty-four patients had 29 colonoscopies. In 16 cases colonoscopy was performed to the caecum. The endoscopic findings of the 16 full colonoscopies were: 7 right colitis, 5 diffuse colitis, 2 bisegmentary colitis, 1 proctitis and 1 non endoscopic lesion. The histologic findings of the 16 full colonoscopies were: 5 cytomegalovirus inclusions on rectal biopsies and 16 on caecal biopsies. For the 13 incomplete colonoscopies, 11 had inclusions on rectal biopsies. So the flexible rectosigmoidoscopy was not sufficient to find inclusions 13 times out of 29. CONCLUSION: Our study indicates that in the cytomegalovirus colitis, inclusions predominate in the caecum, isolated right colitis exists and extra-colonic cytomegalovirus disease is not always found. For these reasons full colonoscopy is necessary for diagnosis in patients with normal flexible rectosigmoidoscopy.

AIDS-Related Opportunistic Infections↗

PubMed1996

A prospective study of abdominal computerized tomography and colonoscopy in the diagnosis of colonic disease in an elderly population.

OBJECTIVE: The aim of this prospective study was to compare the accuracy of abdominal computed tomography (CT) and colonoscopy in diagnosing colonic pathology in an elderly population. METHODS: Patients over the age of 70 for whom an outpatient diagnostic colonoscopy had been requested, were invited to attend for a CT scan of the abdomen following oral colonic preparation. CT was carried out within 1 month of the colonoscopy and all images were evaluated by a single consultant radiologist with no prior knowledge of the colonoscopy result. RESULTS: Of 72 patients who fulfilled entry criteria and attended for colonoscopy, 55 (29 female) had abdominal CT of the abdomen (mean age 76.6 years, range 70-92). Colonoscopy was successful in 67% of cases and the following colonoscopic diagnoses were made: diverticular disease (26), normal (14), colonic carcinoma (6), polyps (9) colitis (2) and angiodysplasia (1). There was agreement between colonoscopic and CT diagnoses in 38 patients (69%) including all those with carcinoma of the colon. There was disagreement in 12 patients with diverticular disease, CT missed three polyps in three patients and angiodysplasia in one patient. CT provided additional important information in 9 patients: gastric leiomyosarcoma (1), aortic aneurysm (1), absence of metastases (3), liver metastases (2), cirrhosis and portal hypertension (1) and a large pleural effusion (1). One patient thought to have a carcinoma of the colon by both techniques was subsequently found to have a diverticular mass at laparotomy. Two patients undergoing colonoscopy had colonic perforations and one of these died. CONCLUSION: CT may provide an alternative to colonoscopy in diagnosis of colonic disease in the elderly population.

Aged↗

PubMed1997

Splenic rupture: an unusual complication of colonoscopy.

Splenic rupture is an uncommon complication of colonoscopy. A high index of suspicion is a crucial factor in the prompt diagnosis of this rare but potentially fatal complication. We report a case of splenic rupture diagnosed 3 days after a colonoscopy and requiring splenectomy. We also reviewed 17 reported cases of splenic rupture after colonoscopy, including our case. The presumed mechanisms of splenic rupture during colonoscopy are direct trauma to the spleen, excessive splenocolic ligament traction, and decrease in the relative mobility between the spleen and the colon. Of the 17 cases reviewed, 10 had polypectomy and/or biopsy performed during colonoscopy. Other probable risk factors are identified and tabulated. The hemodynamic status of the patient is the primary factor used to determine the therapeutic option. Computed tomographic (CT) scan of the abdomen reliably demonstrates well-contained splenic laceration and subcapsular hematoma, and differentiates these splenic complications from perisplenic clot and hemoperitoneum. Thus, CT scan may help decide which patients may be managed operatively or nonoperatively. Splenectomy is the operative procedure of choice for splenic rupture after colonoscopy. Conservative management includes broad spectrum antibiotics, intravenous fluids, blood transfusion, and close hemodynamic monitoring. The factors mandating further evaluation of persistent abdominal pain after colonoscopy are hemodynamic instability, clinical features of acute abdomen, leukocytosis, and/or acute anemia. The onset of abdominal pain associated with one or more of these critical factors is usually within 24 h after colonoscopy. An emergent CT scan of the abdomen is the modality of choice to further evaluate these clinical features, but intestinal perforation and external bleeding must first be excluded.

Aged↗

PubMed1998

Colonoscopy: the initial test for acute lower gastrointestinal bleeding.

Despite literature showing safety, accuracy, and therapeutic capability of emergency colonoscopy for acute lower gastrointestinal (LGI) bleeding, surgical literature suggests that this examination is difficult to perform in the acute setting. In contrast to currently accepted protocols, we believe that unprepared colonoscopy within 24 hours of presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of LGI bleeding. We report results over a 7-year period in our institution using early colonoscopy as the primary investigative method for the diagnosis and treatment of LGI bleeding. We analyzed 85 consecutive patients suspected of LGI bleeding referred to the surgical service between 1989 and 1996. LGI bleeding was defined as the passage of blood per rectum, distal to the ligament if Trietz. We excluded patients who were only hemoccult positive or had an upper gastrointestinal source by nasogastric aspirate or upper gastrointestinal endoscopy. All patients underwent urgent unprepped colonoscopy by surgical endoscopists relying on the cathartic effect of blood and liberal suction/irrigation to cleanse the colon. Therapeutic maneuvers included Nd:YAG laser or BICAP coagulation. Studies in which active bleeding was found or lesions with endoscopic evidence of recent hemorrhage were considered positive. A total of 126 colonoscopies were performed in 85 patients, 44 males and 41 females, with a median age of 75 years (range, 12-91 years). Fifty-three patients (62%) had hematocrit drops of greater than 5 per cent. Thirty-four patients were transfused an average of 4.5 units of blood per patient. The source of bleeding was correctly identified in 82 of 85 (97%) patients. Ninety-one per cent of sources were colonic, and 9 per cent were small bowel. Fecal residue prevented initial adequate examination in only two patients. Diverticulosis (20%), ischemic colitis (18%), hemorrhoids (14%), and arteriovenous malformations (11%) were the predominant sources of bleeding. Spontaneous cessation of bleeding occurred in 58 (68%) patients. Control of active hemorrhage was achieved endoscopically in 17 of 27 acutely bleeding patients. Significant therapeutic interventions were performed in 26 additional patients, including fulgration, polypectomy, relief of obstruction, and removal of foreign body. One patient with asymptomatic free air was observed nonoperatively, for a complication rate of 0.8 per cent. In-hospital mortality was 3.5 per cent (three patients), all secondary to multisystem organ failure and underlying disease. In-hospital rebleeding rate was 3.5 per cent (three). We conclude that, using colonoscopy, it is possible to identify the source of acute LGI bleeding in more than 95 per cent of cases. Diagnostic and therapeutic capability with colonoscopic intervention to control active hemorrhage is especially appealing. Additionally, the pattern, amount, and location of blood in the unprepared colon all give clues as to source and rate of bleeding. In experienced hands, morbidity and mortality of emergent colonoscopy is very low. High accuracy, safety, and therapeutic capability makes colonoscopy the initial diagnostic test of choice for acute LGI hemorrhage.

Acute Disease↗