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.