Early Colonoscopy Does Not Improve Outcomes of Patients With Lower Gastrointestinal Bleeding: Systematic Review of Randomized Trials

Tsay, Cynthia; Shung, Dennis; Frumento, Katherine Stemmer; Laine, Loren

doi:10.1016/j.cgh.2019.11.061

Cited by 41 publications

(38 citation statements)

References 19 publications

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“…Available evidence comparing early vs. elective colonoscopy in the management of patients with acute LGIB consists of seven systematic reviews with meta-analyses [55][56][57][58][59][60][61], four RCTs [51,[62][63][64], and 16 observational studies [65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80] (Table 7 s). Patients with "minor" LGIB managed as outpatients and patients with an UGIB source were excluded from the RCTs [51,[62][63][64] and most of the observational studies [66,67,69,[71][72][73][74][75][76][77][78].…”

Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

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

et al. 2021

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Main Recommendations 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.

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Section: What Is the Appropriate Timing For Colonoscopy In Patients With Acute Lower Gastrointestinal Bleeding?mentioning

confidence: 99%

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

et al. 2021

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“…The possibility that earlier endoscopic intervention can lead to rapid identification and control of culprit lesion bleeding and consequently could lead to reduced mortality in patients with LGIB makes timing of colonoscopy a critical point and area of interest in management of LGIB. Four RCTs 10 11 13 14 , six observational studies 15 20 21 25 26 27 and seven meta-analyses 28 29 30 31 32 33 34 have been performed to evaluate this issue. One RCT showed that urgent colonoscopy led to identification of a definitive source of bleeding more frequently, but it did not lead to lower mortality 11 .…”

Section: Discussionmentioning

confidence: 99%

Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding

et al. 2021

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Background and study aims Current guidelines conditionally recommend performing early colonoscopy (EC) (< 24 hours) in patients admitted with acute lower gastrointestinal bleeding (LGIB). It remains unclear whether this practice is implemented widely. Therefore, we used the Nationwide Inpatient Sample to investigate trends for timing of colonoscopy in patients admitted with acute LGIB. We also assessed trend of hospitalization and mortality in patients with LGIB. Patients and methods Adult patients with LGIB admitted from 2005 to 2014 were examined. ICD-9-CM codes were used to extract LGIB discharges. Trends were assessed using Cochrane-Armitage test. Factors associated with mortality, cost of hospitalization, and length of stay (LOS) were assessed by multivariable mixed-effects and exact-matched logistic, linear regression, and accelerated-failure time models, respectively. Results A total of 814,647 patients with LGIB were included. The most common etiology of LGIB was diverticular bleeding (49 %) and 45 % of patients underwent EC. Over the study period, there was no change in the trend of colonoscopy timing. Although admission with LGIB increased over the study period, the mortality rate decreased for patients undergoing colonoscopy. Independent predictors of mortality were age, surgery (colostomy/colectomy) during admission, intensive care unit admission, acute kidney injury, and blood transfusion requirement. Timing of colonoscopy was not associated with mortality benefit. However, cost of hospitalization was $ 1,946 lower and LOS was 1.6 days shorter with EC. Conclusion Trends in colonoscopy timing in management of LGIB have not changed over the years. EC is associated with lower LOS and cost of hospitalization but it does not appear to improve inpatient mortality.

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“…Although these strategies were not driven by prepandemic studies regarding the timing of endoscopic intervention, this practice fortuitously has been reflected in emerging literature. 7,8 Returning to basic principles of resuscitation, optimizing medical management, and exhausting alternative diagnostic modalities allows us to focus only on the procedures that are most likely to be therapeutic. COVID-19 infection can mimic or exacerbate the hemodynamic effects of GI bleeding and an effort should be made to discern between the two by administering acetaminophen, intravenous fluid, and blood products as indicated.…”

Section: Gastrointestinal Bleedingmentioning

confidence: 99%

Donning a New Approach to the Practice of Gastroenterology: Perspectives From the COVID-19 Pandemic Epicenter

Sethi

Swaminath

Latorre

et al. 2020

Clinical Gastroenterology and Hepatology

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Early Colonoscopy Does Not Improve Outcomes of Patients With Lower Gastrointestinal Bleeding: Systematic Review of Randomized Trials

Cited by 41 publications

References 19 publications

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

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

Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding

Donning a New Approach to the Practice of Gastroenterology: Perspectives From the COVID-19 Pandemic Epicenter

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