March 7th, 2011
Lower gastrointestinal bleeding: Rush in now to scope or wait till morning?
It used to be dogma that the earlier we “scoped” patients with gastrointestinal bleeding the better off they would be in terms of outcomes such as fewer transfusions, less need for surgery, and shorter hospital stays. However, we now have good data that demonstrate for most patients with upper GI bleeding that this is not the case. Instead, patients with upper GI bleeding scoped electively, but within 24 hours, fare as well as those scoped urgently, although there are exceptions one should keep in mind.
Is the same true of lower GI hemorrhage? Well, the lesions are different, as diverticular bleeding, AVMs, hemorrhoids, and neoplasia predominate as causes of lower GI bleeding. Nonetheless, urgent endoscopy after rapid bowel prep was how I was taught to manage these folks, and most of my colleagues seemed to treat them the same way. More recently, though, the benefits of urgent colonoscopy in patients presenting with suspected lower GI bleeding have been called into question.
So I am asking you:
1) When do you think we should scope patients with lower GI bleeding who are otherwise stable: within a few hours, 12 hours, 24 hours, or more?
2) Should we begin the prep right away or wait and do it later?
3) Do you use the prep to get ready for the procedure, to monitor bleeding, or both?
4) What do you do if patients have had a high-quality colonoscopy in the last 3 years with a finding of tics only? Do you still scope them?
5) What other issues do you consider or think are important in managing these patients?