Urgent endoscopy in lower gastrointestinal bleeding

Abstract

Background: Little has been published regarding the role of endoscopic therapy in acute lower gastrointestinal bleeding (haematochezia) in contrast with the almost universal adoption of endoscopic methods of achieving haemostasis for upper gastrointestinal bleeding. The authors examined the role of such intervention for acute colonic diverticular haemorrhage. Design: Two prospective studies of patients admitted to two centres with severe haematochezia and diverticulosis, all of whom underwent urgent colonoscopy (within 6-12 hours of admission) after cleansing the bowel. The first study was of 73 patients from 1986-1992 and those who rebled after diagnostic colonoscopy underwent hemicolectomy. The second study included 48 cases, studied from 1994 to 1998, who underwent endoscopic haemostatic interventions if active bleeding from diverticular disease was found. Bowel cleansing was by the oral or nasogastric route, using 5-6 litres of purge over 3-4 hours, followed within an hour by colonoscopy at the bedside under conscious sedation. Cases without evidence of diverticular disease were excluded from the study. Results: Definite signs of acute diverticular haemorrhage were found in 17/73 (23%) of the first study group (diagnostic colonoscopy only), nine rebled, and six underwent hemicolectomy. In contrast with 10/48 of the latter group with definite signs of diverticular haemorrhage, all underwent endoscopic treatment (injection of epinephrine or bipolar coagulation) with no recurrence of bleeding or need for surgery. A definite cause of bleeding was identified in all of the first cohort, most common diagnoses other than diverticular haemorrhage being angioma, cancer, polyps, or ischaemic colitis. In the later cohort, no bleeding lesion was identified in 14/48 cases, other causes of bleeding being similar to the previous study. Patient characteristics, endoscopic stigmata of haemorrhage, and follow up were similar for both groups. Recurrent bleeding after first colonoscopy and median time to discharge was significantly less in the endoscopically treated group. However, numbers were small and great significance cannot be attached to these differences. Conclusions: Urgent endoscopic and treatment of acute diverticular haemorrhage appears to be a practical and simple method of controlling a significant proportion of patients with lower gastrointestinal haemorrhage. It may well avoid the need for surgery in a predominantly elderly patient group. Further larger randomised trials are required to evaluate this treatment option.