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CC BY-NC-ND 4.0 · Endosc Int Open 2017; 05(10): E959-E973
DOI: 10.1055/s-0043-117958
Review
Eigentümer und Copyright ©Georg Thieme Verlag KG 2017

Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review

Kathryn Oakland
1   NHS Blood and Transplant, Oxford, United Kingdom
,
Jennifer Isherwood
2   Department of General Surgery, Milton Keynes Hospital, Milton Keynes, United Kingdom
,
Conor Lahiff
3   Translational Gastroenterology Unit, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
,
Petra Goldsmith
4   Department of Transplantation, Royal Liverpool Hospital, Liverpool, United Kingdom
,
Michael Desborough
1   NHS Blood and Transplant, Oxford, United Kingdom
,
Katherine S. Colman
1   NHS Blood and Transplant, Oxford, United Kingdom
,
Richard Guy
5   Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
,
Raman Uberoi
6   Department of Interventional Radiology, Oxford University Hospitals, Oxford, United Kingdom
,
Michael F. Murphy
1   NHS Blood and Transplant, Oxford, United Kingdom
,
James E. East
3   Translational Gastroenterology Unit, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
,
Sally Hopewell
7   Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United Kingdom
,
Vipul Jairath
8   Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
9   Department of Medicine, Division of Gastroenterology, University Hospital, London, Ontario, Canada
› Author Affiliations
Further Information

Publication History

submitted 02 May 2017

accepted after revision 10 July 2017

Publication Date:
29 September 2017 (online)

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Abstract

Background and study aims Investigations for lower gastrointestinal bleeding (LGIB) include flexible sigmoidoscopy, colonoscopy, computed tomographic angiography (CTA), and angiography. All may be used to direct endoscopic, radiological or surgical treatment, although their optimal use is unknown. The aims of this study were to determine the diagnostic and therapeutic yields of endoscopy, CTA, and angiography for managing LGIB, and their influence on rebleeding, transfusion, and hospital stay.

Patients and methods A systematic search of MEDLINE, PubMed, EMBASE, and CENTRAL was undertaken to identify randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) published between 2000 and 12 November 2015 in patients hospitalized with LGIB. Separate meta-analyses were conducted, presented as pooled odds (ORs) or risk ratios (RR) with 95 % confidence intervals (CIs).

Results Two RCTs and 13 NRSIs were included, none of which examined flexible sigmoidoscopy, or compared endotherapy with embolization, or investigated the timing of CTA or angiography. Two NRSIs (57 – 223 participants) comparing colonoscopy and CTA were of insufficient quality for synthesis but showed no difference in diagnostic yields between the two interventions. One RCT and 4 NRSIs (779 participants) compared early colonoscopy (< 24 hours) with colonoscopy performed later; meta-analysis of the NRSIs demonstrated higher diagnostic and therapeutic yields with early colonoscopy (OR 1.86, 95 %CI 1.12 to 2.86, P = 0.004 and OR 3.08, 95 %CI 1.93 to 4.90, P < 0.001, respectively) and reduced length of stay (mean difference 2.64 days, 95 %CI 1.54 to 3.73), but no difference in transfusion or rebleeding.

Conclusions In LGIB there is a paucity of high-quality evidence, although the limited studies on the timing of colonoscopy suggest increased rates of diagnosis and therapy with early colonoscopy.

 

  • References

  • 1 Lanas A, Garcia-Rodriguez LA, Polo-Tomas M. et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009; 104: 1633-1641
    CrossrefPubMedSearch in Google Scholar
  • 2 Scheffel H, Pfammatter T, Wildi S. et al. Acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row CT. Eur Radiol 2007; 17: 1555-1565
    CrossrefPubMedSearch in Google Scholar
  • 3 Cardin F, Andreotti A, Martella B. et al. Current practice in colonoscopy in the elderly. Aging Clin Exp Res 2012; 24: 9-13
    PubMedSearch in Google Scholar
  • 4 Green BT, Rockey DC, Portwood G. et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100: 2395-2402
    CrossrefPubMedSearch in Google Scholar
  • 5 Strate LL, Gralnek IM. ACG Clinical Guideline: Management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111: 459-474 Erratum in Am J Gastroenterol 2016; 111: 755
    CrossrefPubMedSearch in Google Scholar
  • 6 Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010; 8: 333-343
    CrossrefPubMedSearch in Google Scholar
  • 7 Koh FH, Soong J, Lieske B. et al. Does the timing of an invasive mesenteric angiography following a positive CT mesenteric angiography make a difference?. Int J Colorectal Dis 2015; 30: 57-61
    CrossrefPubMedSearch in Google Scholar
  • 8 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264-269, w264
    CrossrefPubMedSearch in Google Scholar
  • 9 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
    CrossrefPubMedSearch in Google Scholar
  • 10 Dekkers OM, Egger M, Altman DG. et al. Distinguishing case series from cohort studies. Ann Intern Med 2012; 156: 37-40
    CrossrefPubMedSearch in Google Scholar
  • 11 Gralnek IM, Neeman Z, Strate LL. Acute lower gastrointestinal bleeding. NEJM 2017; 376: 1054-1063
    CrossrefPubMedSearch in Google Scholar
  • 12 Raju GS, Gerson L, Das A. et al. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133: 1697-1717
    CrossrefPubMedSearch in Google Scholar
  • 13 Higgins JGS. Cochrane handbook for systematic reviews of interventions. Cochrane Book Series 2008; 392-432
    PubMedSearch in Google Scholar
  • 14 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603-605
    CrossrefPubMedSearch in Google Scholar
  • 15 Sengupta N, Tapper EB, Feuerstein JD. Early versus delayed colonoscopy in hospitalized patients with lower gastrointestinal bleeding: a meta-analysis. Clin J Gastroenterol 2017; 51: 352-359
    CrossrefPubMedSearch in Google Scholar
  • 16 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
    CrossrefPubMedSearch in Google Scholar
  • 17 Ishii N, Fujita Y. Endoscopic treatment for colonic diverticular hemorrhage: from endoscopic clipping to endoscopic band ligation. Gastrointest Endosc 2011; 73: AB292
    PubMedSearch in Google Scholar
  • 18 Ketwaroo GA, Tewani SK, Kheraj R. et al. Mesenteric CT angiography in the evaluation and management of acute lower GI bleeding. Gastroenterology 2012; 142: S581
    PubMedSearch in Google Scholar
  • 19 Rodriguez-Moranta F, Berrozpe A, Botargues JM. et al. Colonoscopy delay in lower gastrointestinal bleeding: influence on diagnostic accuracy, endoscopic therapy and hospital stay. Gastrointest Endosc 2007; 65: AB261
    CrossrefPubMedSearch in Google Scholar
  • 20 Sun J, Khandelwal N, Wong R. CT angiography is superior to tagged red blood cell scanning for localizing GI bleeding and for guiding management. Am J Gastroenterol 2011; 106: S82
    PubMedSearch in Google Scholar
  • 21 Yabutani A, Tomisato K, Teramoto A. et al. Possible utility of contract enhanced computed tomography for detecting colonic diverticular bleeding by emergent colonoscopy. J Gastroenterol Hepatol 2014; 29 (Suppl. 03) 307-308
    PubMedSearch in Google Scholar
  • 22 Nakano K, Ishii N, Fujita Y. Long-term outcomes of endoscopic band ligation versus endoscopic clipping for treatment of colonic diverticular hemorrhage. Gastrointest Endosc 2015; 81: AB370
    PubMedSearch in Google Scholar
  • 23 Yamaguchi T, Manabe N, Hata J. et al. The usefulness of transabdominal ultrasound for the diagnosis of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2006; 23: 1267-1272
    CrossrefPubMedSearch in Google Scholar
  • 24 Albeldawi M, Ha D, Mehta P. et al. Utility of urgent colonoscopy in acute lower gastro-intestinal bleeding: a single-center experience. Gastroenterol Rep 2014; 2: 300-305
    CrossrefPubMedSearch in Google Scholar
  • 25 Jacovides CL, Nadolski G, Allen SR. et al. Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA Surgery 2015; 150: 650-656
    CrossrefPubMedSearch in Google Scholar
  • 26 Nagata N, Niikura R, Aoki T. et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy. J Gastroenterol 2015; 50: 1162-1172
    CrossrefPubMedSearch in Google Scholar
  • 27 Nagata N, Niikura R, Sakurai T. et al. Safety and effectiveness of early colonoscopy in management of acute lower gastrointestinal bleeding on the basis of propensity score matching analysis. Clin Gastroenterol Hepatol 2016; 14: 558-564
    CrossrefPubMedSearch in Google Scholar
  • 28 Strate LL, Syngal S. Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleeding. Am J Gastroenterol 2003; 98: 317-322
    PubMedSearch in Google Scholar
  • 29 Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105: 2636-2641
    CrossrefPubMedSearch in Google Scholar
  • 30 Jensen DM, Machicado GA, Jutabha R. et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. NEJM 2000; 342: 78-82
    CrossrefPubMedSearch in Google Scholar
  • 31 Kouanda AM, Somsouk M, Sewell JL. et al. Urgent colonoscopy in patients with lower gastrointestinal bleeding: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 107-117 e1
    CrossrefPubMedSearch in Google Scholar
  • 32 Seth A, Khan MA, Nollan R. et al. Does urgent colonoscopy improve outcomes in the management of lower gastrointestinal bleeding?. Am J Med Sci 2017; 353: 298-306
    CrossrefPubMedSearch in Google Scholar
  • 33 Oakland K, Guy R, Uberoi R. et al. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit. Gut 2017;
    CrossrefPubMedSearch in Google Scholar
  • 34 Campbell HE, Stokes EA, Bargo D. et al. Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial. BMJ Open 2015; 5: e007230
    CrossrefPubMedSearch in Google Scholar
  • 35 Cirocchi R, Grassi V, Cavaliere D. et al. New trends in acute management of colonic diverticular bleeding: a systematic review. Medicine 2015; 94: e1710
    CrossrefPubMedSearch in Google Scholar
  • 36 Strate LL, Ayanian JZ, Kotler G. et al. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol 2008; 6: 1004-1010
    CrossrefPubMedSearch in Google Scholar
  • 37 Oakland K, Jairath V, Uberoi R. et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol 2017;
    CrossrefPubMedSearch in Google Scholar
  • 38 Clerc D, Grass F, Schafer M. et al. Lower gastrointestinal bleeding – computed tomographic angiography, colonoscopy or both?. World J Emerg Surg 2017; 12: 1
    CrossrefPubMedSearch in Google Scholar