Systematic review with meta‐analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding

Kherad, Omar; Restellini, Sophie; Almadi, Majid A; Strate, Lisa L.; Ménard, Charles; Martel, Myriam; Afshar, Ira Roshan; Sadr, Mohamad Seyed; Barkun, Alan N.

doi:10.1111/apt.15925

Cited by 24 publications

(32 citation statements)

References 48 publications

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“…However, a statistical analysis was not performed to specifically evaluate this result. Another recent meta-analysis studied impact of timing on LOS for RCTs and observational studies separately: no difference in LOS was found for RCTs only, but when only observational studies were analyzed, LOS was statistically reduced [34]. In our study, we found that EC was associated with a substantially decreased hospital LOS (by 1.6 days) in comparison to late colonoscopy, consistent with several other studies [15,[20][21][22][23].…”

Section: Discussionsupporting

confidence: 89%

“…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%

“…Similarly, observational studies 20 21 showed that EC provided no mortality benefit. Results from seven meta-analyses 28 29 30 31 32 33 34 have yielded mixed results, with four reporting no difference in diagnostic yield 28 30 32 34 while three report increased diagnostic yield 29 31 33 ; all showed no difference in rebleeding rate; all reported no difference in LOS except one 29 ; no difference in transfusion requirement but one reported increased transfusion for EC 33 ; all showed no difference in mortality rate. All these meta-analyses differed in the number of studies, and study designs included in quantitative synthesis along with their primary aim of study.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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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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“…Recent meta-analyses report that early colonoscopy within 24 hours does not improve clinical outcomes 1 2 . Holzwanger et al suggest a conservative approach for SARS-CoV-2-positive patients with acute LGIB 3 , but no advice is provided on management and outcomes of patients who remain hemodynamically unstable after adequate resuscitation.…”

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confidence: 99%

Updating the recommendations on bowel preparation for acute lower gastro-intestinal bleeding: The time has come!

Soriani

Biancheri

Hassan³

et al. 2021

Endosc Int Open

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Systematic review with meta‐analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding

Cited by 24 publications

References 48 publications

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

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

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

Updating the recommendations on bowel preparation for acute lower gastro-intestinal bleeding: The time has come!

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