Lower gastrointestinal bleeding diagnostic study of choice: Difference between revisions
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== Diagnostic Study of Choice == | == Diagnostic Study of Choice == | ||
*Colonoscopy is recommended as the first-line investigation in patients presenting with LGIB. | *Colonoscopy is recommended as the first-line investigation in patients presenting with LGIB.<ref name="pmid22468081">{{cite journal |vauthors=Lhewa DY, Strate LL |title=Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding |journal=World J. Gastroenterol. |volume=18 |issue=11 |pages=1185–90 |year=2012 |pmid=22468081 |pmc=3309907 |doi=10.3748/wjg.v18.i11.1185 |url=}}</ref><ref name="pmid24143306">{{cite journal |vauthors=Jang BI |title=Lower gastrointestinal bleeding: is urgent colonoscopy necessary for all hematochezia? |journal=Clin Endosc |volume=46 |issue=5 |pages=476–9 |year=2013 |pmid=24143306 |pmc=3797929 |doi=10.5946/ce.2013.46.5.476 |url=}}</ref><ref name="pmid28174123">{{cite journal |vauthors=Kouanda AM, Somsouk M, Sewell JL, Day LW |title=Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis |journal=Gastrointest. Endosc. |volume=86 |issue=1 |pages=107–117.e1 |year=2017 |pmid=28174123 |doi=10.1016/j.gie.2017.01.035 |url=}}</ref><ref name="pmid21131933">{{cite journal |vauthors=Strate LL |title=Editorial: Urgent colonoscopy in lower GI bleeding: not so fast |journal=Am. J. Gastroenterol. |volume=105 |issue=12 |pages=2643–5 |year=2010 |pmid=21131933 |doi=10.1038/ajg.2010.401 |url=}}</ref><ref name="pmid24060518">{{cite journal |vauthors=Navaneethan U, Njei B, Venkatesh PG, Sanaka MR |title=Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study |journal=Gastrointest. Endosc. |volume=79 |issue=2 |pages=297–306.e12 |year=2014 |pmid=24060518 |doi=10.1016/j.gie.2013.08.001 |url=}}</ref><ref name="pmid9697900">{{cite journal |vauthors=Chaudhry V, Hyser MJ, Gracias VH, Gau FC |title=Colonoscopy: the initial test for acute lower gastrointestinal bleeding |journal=Am Surg |volume=64 |issue=8 |pages=723–8 |year=1998 |pmid=9697900 |doi= |url=}}</ref><ref name="pmid19881516">{{cite journal |vauthors=Barnert J, Messmann H |title=Diagnosis and management of lower gastrointestinal bleeding |journal=Nat Rev Gastroenterol Hepatol |volume=6 |issue=11 |pages=637–46 |year=2009 |pmid=19881516 |doi=10.1038/nrgastro.2009.167 |url=}}</ref> | ||
===Advantages=== | ===Advantages=== | ||
The advantages of colonoscopy as an initial investigation include: | The advantages of colonoscopy as an initial investigation include: | ||
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*Despite the disadvantages, complete colonoscopy can be carried out in more than 95% of patients, and a source of bleeding can be identified by colonoscopy in 74% to 82% of patients. | *Despite the disadvantages, complete colonoscopy can be carried out in more than 95% of patients, and a source of bleeding can be identified by colonoscopy in 74% to 82% of patients. | ||
*There is a risk of bowel perforation with colonoscopy, especially in patients with colitis | *There is a risk of bowel perforation with colonoscopy, especially in patients with colitis | ||
==Endoscopy== | ==Endoscopy== | ||
*Endoscopy is the investigation of choice for ischemic colitis; however, it is not recommended to perform endoscopy in a patient with severe abdominal pain or peritonitis. | *Endoscopy is the investigation of choice for ischemic colitis; however, it is not recommended to perform endoscopy in a patient with severe abdominal pain or peritonitis. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Overview
Diagnostic Study of Choice
- Colonoscopy is recommended as the first-line investigation in patients presenting with LGIB.[1][2][3][4][5][6][7]
Advantages
The advantages of colonoscopy as an initial investigation include:
- The ability to accurately locate and visualize the site of the bleeding, and the potential for therapeutic intervention.
Disadvantages
- Disadvantages of colonoscopy include poor visualization in an unprepared colon.
- Risk of fluid overload in the acutely ill patient receiving rapid bowel preparation.
Interpretation
- The sensitivity of colonoscopy in detecting lesions such as angiodysplasia depends on good bowel preparation, and it is estimated to exceed 80%.
- The sensitivity of colonoscopy in detecting bleeding lesions, however, is estimated at 48% to 90%. Therefore, a bleeding site is frequently not identified.
- Despite the disadvantages, complete colonoscopy can be carried out in more than 95% of patients, and a source of bleeding can be identified by colonoscopy in 74% to 82% of patients.
- There is a risk of bowel perforation with colonoscopy, especially in patients with colitis
Endoscopy
- Endoscopy is the investigation of choice for ischemic colitis; however, it is not recommended to perform endoscopy in a patient with severe abdominal pain or peritonitis.
- In cases in which no source of bleeding is seen on colonoscopy, esophagogastroduodenoscopy should be undertaken, as occasionally, brisk UGIB increases transit time and presents as blood per rectum.
- Endoscopic evaluation of the small bowel may include a combination of endoscopic techniques, such as wireless capsule endoscopy and small bowel enteroscopy (double balloon, push or spiral enteroscopy).
- These modalities are often used if colonoscopy and esophagogastroduodenoscopy have failed to identify the source of gastrointestinal blood loss
- Advantages of capsule endoscopy are that it is technically easier to use, is noninvasive, and does not require sedation. However, it lacks endoscopic access for therapeutic intervention.
- Capsule endoscopy has a higher diagnostic yield in bleeding patients than enteroscopy, 56% and 26% respectively, and is, therefore, often performed before enteroscopy. If a bleeding lesion is visualized, then endoscopic intervention can be considered
CTA
- CTA may be a more appropriate first-line investigation in patients with abdominal pain or suspected peritonitis.
References
- ↑ Lhewa DY, Strate LL (2012). "Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding". World J. Gastroenterol. 18 (11): 1185–90. doi:10.3748/wjg.v18.i11.1185. PMC 3309907. PMID 22468081.
- ↑ Jang BI (2013). "Lower gastrointestinal bleeding: is urgent colonoscopy necessary for all hematochezia?". Clin Endosc. 46 (5): 476–9. doi:10.5946/ce.2013.46.5.476. PMC 3797929. PMID 24143306.
- ↑ Kouanda AM, Somsouk M, Sewell JL, Day LW (2017). "Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis". Gastrointest. Endosc. 86 (1): 107–117.e1. doi:10.1016/j.gie.2017.01.035. PMID 28174123.
- ↑ Strate LL (2010). "Editorial: Urgent colonoscopy in lower GI bleeding: not so fast". Am. J. Gastroenterol. 105 (12): 2643–5. doi:10.1038/ajg.2010.401. PMID 21131933.
- ↑ Navaneethan U, Njei B, Venkatesh PG, Sanaka MR (2014). "Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study". Gastrointest. Endosc. 79 (2): 297–306.e12. doi:10.1016/j.gie.2013.08.001. PMID 24060518.
- ↑ Chaudhry V, Hyser MJ, Gracias VH, Gau FC (1998). "Colonoscopy: the initial test for acute lower gastrointestinal bleeding". Am Surg. 64 (8): 723–8. PMID 9697900.
- ↑ Barnert J, Messmann H (2009). "Diagnosis and management of lower gastrointestinal bleeding". Nat Rev Gastroenterol Hepatol. 6 (11): 637–46. doi:10.1038/nrgastro.2009.167. PMID 19881516.