Endoscopic management of acute lower gastrointestinal bleeding

External Validation of the Oakland Score for Acute Lower Gastrointestinal Bleeding

Introduction Acute lower gastrointestinal bleeding (LGIB) presents challenges in emergency settings, with incidence influenced by demographic shifts and anticoagulant usage. The Oakland score aids in risk stratification for safe discharge based on clinical and laboratory parameters. However, external validation remains limited. Methods This study validated the Oakland score in a French cohort of patients with acute LGIB and assessed the discriminatory value of the score using the area under the curve (AUC) and then its sensitivity and specificity. Results A retrospective examination of 343 patient records that satisfied the inclusion criteria showed a median score of 14 points and good discriminatory capacity (area under the receiver operating characteristic (AUROC) curve: 0.83). There was low sensitivity (20.9%) for safe discharge but good specificity (98.5%) when using an 8-point threshold. With a 9-point threshold, the sensitivity was increased to 36.5%, while the specificity remained at 95%. Conclusion Identifying low-risk LGIB patients is accomplished without sacrificing sensitivity by increasing the Oakland score threshold to 9 points. This modification improves patient safety and resource allocation in the emergency room and has been verified by other large series. For wider implementation, additional validation and long-term outcome evaluations are required.

A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study

BACKGROUND

Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD.

METHODS

We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips.

RESULTS

82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture.

CONCLUSION

The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize “when” to safely perform a colonoscopy in the different DD settings and “why”.

Lower Gastrointestinal Bleeding

Lower gastrointestinal (LGI) bleeding indicates bleeding from colon or anorectum. Typically, patients with LGI bleeding present with bright red blood per rectum or hematochezia, although rarely they can present with melena as well. Alternatively, LGI bleeding is also defined as bleeding from a source within potential reach of a colonoscope, that is, colon and terminal ileum. LGI bleedings have more favorable outcomes than upper GI (UGI) bleeding and less common than UGI bleeding. Any patient presenting with GI bleeding should undergo a detailed history and physical examination for clues that may suggest source and possible etiology. Colonoscopy remains the most widely used and preferred instrument of choice for both diagnosis and therapy. This review will discuss in brief the causes, triaging, and role of colonoscopy in the management of LGI bleeding.

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Early Versus Standard Colonoscopy: A Randomized Controlled Trial in Patients With Acute Lower Gastrointestinal Bleeding: Results of the BLEED Study

GOALS

The aim of our study was to examine differences in length of hospital stay (LOHS) between patients with lower gastrointestinal bleeding who received either an early colonoscopy (within 24 h of presentation) or a standard colonoscopy (within 1 to 3 d).

BACKGROUND

Diagnostic management of lower gastrointestinal bleeding has been extensively debated in recent literature, especially whether colonoscopy within 24 hours of presentation is feasible and safe.

STUDY

In this single center, nonblinded, randomized controlled trial, patients presenting at the emergency department with acute hematochezia were eligible if they required hospital admission. A total of 132 patients were included. Primary outcome was LOHS. Secondary outcomes included yield of colonoscopy, blood transfusion requirements, recurrent bleedings, complications, interventions related to complications, and 30-day mortality. The follow-up period was 1 month.

RESULTS

In total, 63 patients were randomized for <24 hours colonoscopy and 69 for standard colonoscopy. In the intention to treat analysis, LOHS was significantly lower in patients that underwent an early colonoscopy, compared with the standard group: median 2.0 days (inter quartile range, 2.0 to 4.0) versus median 3.0 days (inter quartile range, 2.0 to 4.0) (P=0.009). Recurrent bleedings and hospital readmissions were significantly more frequent in the <24-hour group: 13% versus 3% (P=0.04) and 11% versus 2% (P=0.02), respectively. No difference was observed regarding the number of patients diagnosed with a confirmed or presumptive bleeding source. In both groups, blood transfusion rate was similar and 30-day mortality was 0.

CONCLUSIONS

Early colonoscopy reduces LOHS, but also results in lower clinical efficacy compared with standard colonoscopy.

Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review

Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.

Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation

Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.

Acute lower gastrointestinal bleeding in Sudanese patients: a study on 301 patients in a specialized centre

BACKGROUND AND STUDY AIMS

Lower gastrointestinal bleeding originates from a site distal to the ligament of Treitz. It can present as an acute life-threatening or chronicbleeding. It is common among older patients and those with comorbidity. The common causes are diverticular disease, angiodysplasias, neoplasms, colitis, ischaemia and anorectal disorders. The aim of this study is to determine the prevalence and causes of acute lower gastrointestinal bleeding among Sudanese patients.

PATIENTS AND METHODS

In a period of 2 years we studied 301 patients with fresh rectal bleeding out of 5625 patients with gastrointestinal bleeding in Ibn Sina Specialized Hospital, Khartoum, Sudan, This is a cross sectional observational hospital based study. All patients with fresh rectal bleeding within 24 h were included and consented.

RESULT

Lower gastrointestinal bleeding constituted 5.37% of total cases of gastrointestinal bleeding. The mean age of patients was 55.43 ± 17.779, male: female ratio was 2:1. The most common cause (if upper gastrointestinal bleeding is excluded) was diverticular disease 39.6% (n = 61) followed by piles 24.1% (n = 35), colonic tumours 12.34% (n = 19), ulcerative colitis 5.19% (n = 8), Crohn's 5.19% (n = 8), colonic polyps 3,89% (n = 6), angiodysplesia 4.5% (n = 7), colonic ulcer 2.59% (n = 4), ischaemic colitis 1.3%, nonspecific colitis 1.3% (n = 2), and small bowel source in 1.3% (n = 2). The majority of those patients with diverticular disease were male and with first presentation. The commonest cause in those patients younger than 20 years was polyps, and in those between 21 and 40 was piles followed by inflammatory bowel disease, and in those between 41 and 60 years old was piles followed by diverticular disease and tumours, and in those above 60 years was diverticular disease followed by piles and tumours. The correlation between positive colonoscopy finding and diabetes and the use of nonsteroidal anti-inflammatory drugs were statistically significant. The one-month mortality rate was 2.3% CONCLUSION: Acute lower gastrointestinal bleeding is common among elderly patients and the commonest cause is diverticular disease. Colonoscopy plays an important role in the diagnosis. Most patients respond to conservative therapy.

Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology

Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Lower Gastrointestinal Bleeding in Children

This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.

Endoscopic management of colonic diverticular bleeding

Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Colonoscopy can be used for both diagnosis and treatment of colonic diverticular bleeding. Identification of the stigmata of recent hemorrhage allows for various endoscopic hemostasis methods. Clipping, endoscopic band ligation, injection therapy, and thermal contact are available methods for endoscopic hemostasis. However, the optimal technique remains to be determined. Herein, we review the techniques and clinical outcomes of endoscopic hemostasis for colonic diverticular bleeding.

Achieving hemostasis and the risks associated with therapy

Acute gastrointestinal bleeding is a common cause for hospitalization. Endoscopic hemostasis plays a central role in the management of lesions with active bleeding or high-risk stigmata for rebleeding. The efficacy and safety of endoscopic hemostasis rely on the identification of lesions suitable for endoscopic therapy, selection of the appropriate hemostatic devices, attention to technique, and prompt recognition and management of procedure-related adverse events. In this article, practical applications of hemostatic devices and pitfalls related to endoscopic hemostasis are discussed.

Massive right-sided colon diverticular bleeding complicated by the transfusion related acute lung injury (TRALI)

Colonic diverticulosis is a condition which causes extensive bleeding of the lower gastrointestine in 40–50% of cases. In particular, right-sided diverticulosis, although uncommon requires lifesaving colectomy. Transfusion related acute lung injury (TRALI) is a transfusion reaction, which can occur after administration of various blood products. Although life threatening, it can be completely reversed usually within 72 to 96 hours. Here, we report a case of a young Caucasian male hospitalized due to severe anemia, hematochezia and extensive blood loss, all due to lower gastrointestinal hemorrhage from right-sided diverticulosis. These conditions were overlooked endoscopically and diagnosed then treated surgically with the right-sided hemicolectomy. During postoperative course, four hours after the last transfusion, patient developed fever, hypoxia and noncardiogenic pulmonary oedema, but made complete recovery through aggressive oxygen support within 96 hours. The aim of this case was to review current literature, to draw attention to a serious and under-diagnosed transfusion reaction, as well as discuss possible explanations for the diagnostic difficulties that occurred in this case.

Management by the intensivist of gastrointestinal bleeding in adults and children

Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.

Epidemiology of lower gastrointestinal bleeding in China: single-center series and systematic analysis of Chinese literature with 53,951 patients

OBJECTIVES

The epidemiology of lower gastrointestinal bleeding (LGIB) in Western populations has been reported; however, there are scant Asian reports. The aim of the present study was to determine the etiology of LGIB in a Chinese population by reporting a retrospective case series and a systematic analysis of Chinese literature.

METHODS

A large colonoscopy database in a tertiary endoscopic center was searched to identify all patients with the indication of LGIB. The data, including patients' sex, age, endoscopic and pathological findings, were collected and analyzed. A comprehensive database search of the Chinese literature was carried out to obtain all relevant studies.

RESULTS

In our series, a total of 720 patients with LGIB were included. There were 425 males and 295 females with a median age of 50 years, the most common etiologies of LGIB were inflammatory bowel disease (IBD; 30.2%), polyps (23.4%) and cancer (10.7%). In 30.2% of all the patients, no obvious causes were identified. A systematic analysis of Chinese literature found an additional 160 studies providing relevant data in 53,951 patients. Overall, colorectal cancer (24.4%), colorectal polyps (24.1%), colitis (16.8%), anorectal disease (9.8%) and IBD (9.5%) were the most common etiologies of LGIB. The main etiologies were different between adults, the elderly and children.

CONCLUSION

The study shows colorectal cancer, colorectal polyps, colitis, anorectal disease and IBD were the most common etiologies of LGIB in the Chinese adult and elderly population, whereas colorectal polyps, chronic colitis and intussusception were the main causes of LGIB in Chinese children. Whereas diverticulum, the most common cause of LGIB in Western populations, is uncommon in China.

The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding

There are multiple strategies for evaluating and treating lower intestinal bleeding (LIB). Colonoscopy has become the preferred initial test for most patients with LIB because of its diagnostic and therapeutic capabilities and its safety. However, few studies have directly compared colonoscopy with other techniques and there are controversies regarding the optimal timing of colonoscopy, the importance of colon preparation, the prevalence of stigmata of hemorrhage, and the efficacy of endoscopic hemostasis. Angiography, radionuclide scintigraphy, and multidetector computed tomography scanning are complementary modalities, but the requirement of active bleeding at the time of the examination limits their routine use. In addition, angiography can result in serious complications. This review summarizes the available evidence regarding colonoscopy and radiographic studies in the management of acute LIB.

Diagnosis and management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) can present as an acute and life-threatening event or as chronic bleeding, which might manifest as iron-deficiency anemia, fecal occult blood or intermittent scant hematochezia. Bleeding from the small bowel has been shown to be a distinct entity, and LGIB is defined as bleeding from a colonic source. Acute bleeding from the colon is usually less dramatic than upper gastrointestinal hemorrhage and is self-limiting in most cases. Several factors might contribute to increased mortality, a severe course of bleeding and recurrent bleeding, including advanced age, comorbidity, intestinal ischemia, bleeding as a result of a separate process, and hemodynamic instability. Diverticula, angiodysplasias, neoplasms, colitis, ischemia, anorectal disorders and postpolypectomy bleeding are the most common causes of LGIB. Volume resuscitation should take place concurrently upon initial patient assessment. Colonoscopy is the diagnostic and therapeutic procedure of choice, for acute and chronic bleeding. Angiography is used if colonoscopy fails or cannot be performed. The use of radioisotope scans is reserved for cases of unexplained intermittent bleeding, when other methods have failed to detect the source. Embolization or modern endoscopy techniques, such as injection therapy, thermocoagulation and mechanical devices, effectively promote hemostasis. Surgery is the final approach for severe bleeding.