June 4th, 2013
Suspected Lower GI Bleeding: When do you do an Upper Scope?
Most gastroenterologists I know seem pretty confident that they can differentiate bright red blood from a lower GI (e.g., colonic) source and massive upper GI bleeding presenting as bright red blood in the lower GI tract. The location of bleeding is critical from a treatment and prognosis perspective. Lower GI bleeding usually ceases spontaneously, requires no pharmacological intervention and rarely requires an endoscopic intervention, whereas with upper GI bleeding, PPI infusion and endoscopic therapy offer improvement in outcomes.
Because the distinction is important, some authorities suggest consideration of an urgent EGD in this situation and an elective colonoscopy (if at all). My observation is that most endoscopists do not follow this management approach: They forego the EGD and do an urgent colonoscopy.
So, let’s discuss a hypothetical case.
A patient has an apparent lower GI bleed and is hemodynamically stable upon resuscitation. Which would you do?
1. An urgent colonoscopy
2. An urgent colonoscopy, followed by an EGD if nothing is found
3. An urgent EGD and elective colonoscopy
4. Another approach
Please share your approach and the thinking behind your management strategy. I look forward to a dialogue.
10 Responses to “Suspected Lower GI Bleeding: When do you do an Upper Scope?”
M. Brian Fennerty, MD
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NEJM Journal Watch Gastroenterology
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I would ask for an urgent gastroscopy and afterwards if necesaary an urgent colonoscopy.
I am an internist.
From the choices I would choose urgent egd followed by elective colonoscopy. However, I would evaluate for vital signs with orthosratics, check BUN/Scr ratio and ask the patient if they had clots in the stool. If the Bun/Scr ratio is < 30, orthostatics are normal, and clots in the stool that makes my choice more of an elective colonoscopy after I have performed an anoscopic examination to check for hemorrhoid a common cause for lower GI bleed.
If the urea/creatinine ratio is normal and the patient remains “stable” after “resusc” I’ll investigate the colon electively later. If the urea is disproportionately elevated or the patient has another “big bleed” I’ll do a quick EGD.
In the absence of chronic liver disease I’ll begin with an EGD in two situations. 1) Hemodynamic instability or 2) A positive NG lavage which if you get bile has a strong negative predictive value.
It is my practice to consent the patient for the possibility of both procedures and perform a colonoscopy within 12-24 hours, and if negative, do an EGD immediately after. If both are completely negative for any possible sources, a video capsule is then deployed while the patient is still prepped.
Most likely this patient will settle without further active intervention. Monitor BP, Hb, Urine output, Vital signs, O2 Sats etc, If significant co- morbidity move to ICU. Warmed lactate Ringers, IV fluid replacement. If blood replacement required use fresh packed cells. Check INR, platelets, PTT. Is patient on anti-coagulant/antiplatelet therapy?
On going bleed – pass NGT. If blood +ve do urgent OGD. If -ve do urgent Colonscopy. -if source identified treat. If not identified and not bleeding do small bowel studies. If still bleeding/rebleed do Tc99m scan +/- angiography (urgent embolization or surgery may be needed). If colon origin and gastro-duodenal origin not confirmed – do small bowel studies.
My answer is
arrange an urgent colonscopy + insert Nasogastric tube for irrigation to exclude gastric bleeding source
prefer to start urgent EGD if normal elective colonoscopy.
why? shortly,lower GI bleeding usually not massive and prefer to do after proper preparation
Urgent EGD and then elective colonoscopy
Urgent EGD first
Elective Coloscopy to follow if upper GIT bleeding could be ruled out