Colonoscopy as a primary diagnostic procedure in chronic gastrointestinal tract bleeding

We compared the use of barium enema (BE) and colonoscopy in evaluating patients with chronic gastrointestinal tract bleeding by dividing into three groups 329 consecutive colonoscopies and 207 consecutive BE examinations done with chronic gastrointestinal tract bleeding as an indication. In the first group, of 96 patients with negative results of BE studies, subsequent colonoscopy showed carcinoma of the colon in 16%, polyps larger than 1 cm in 21%, and other causes in 20%. In 43% the colonoscopy gave negative results or was incomplete. In the other two groups we directly compared findings of the 207 BE and the 233 remaining colonoscopies when each was used as a primary diagnostic test. Colonoscopy was found to have fewer negative results (74% vs 43%), fewer inconclusive examinations requiring repeat (19% vs 3%), and more positive correct findings to explain the cause of bleeding (54% vs 5%).     

Vascular ectasia. Diagnosis and treatment by colonoscopy

Vascular ectasia is an increasingly recognized cause of gastrointestinal tract bleeding in the elderly. Colonoscopy is assuming an important role in diagnosis and treatment of these lesions. The records of 30 patients who had a diagnosis of vascular ectasia made by colonoscopy have been retrospectively reviewed. The 30 patients included 14 men and 16 women whose median age was 70 years (range, 54 to 89 years). All patients had vascular ectasia of the cecum or ascending colon or both, five patients (16.7%) had multiple lesions, and 18 patients (60%) had associated cardiac, vascular, pulmonary, or renal disease. Of the 27 patients who presented with gastrointestinal tract bleeding, 13 (48.1%) underwent endoscopic fulguration, nine (33.3%) underwent resection, and seven (25.9%) were treated conservatively. Endoscopic fulguration was definitive treatment in 11 of the 27 patients (40.7%). A positive histologic diagnosis of vascular ectasia was made in nine of 15 patients (60%) in whom endoscopic biopsy was performed. In the hands of an experienced endoscopist, colonoscopy is a safe and effective way of diagnosing vascular ectasia and is potentially therapeutic. Endoscopic coagulation should be attempted before operation in patients with chronic anemia, limited bleeding, or concomitant severe medical disease.     

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目的 探讨应用软结肠镜(内镜)对常见下消化道外科疾病的诊治，以提高利用内镜进行诊治的安全性及疗效。方法 回顾1984～2001年37939例行内镜诊治的病人，其中行内镜治疗9039例，包括低位肠梗阻64例、乙状结肠扭转11例、假性结肠梗阻6例、下消化道出血56例、良性肠狭窄23例及肠道息肉8879例。总结操作体会，分析疗效及并发症的原因。结果 低位肠梗阻明确梗阻原因、部位者35例(54．7％，35／64)；乙状结肠扭转复位成功11例(100％，11／11)；假性结肠梗阻经内镜减压，治愈者5例(83．3％，5／6)，急性下消化道出血明确出血原因及部位者37例(66．1％，37／56)，37例中立即经内镜止血成功者36例(97．3％，36／37)；结、直肠吻合口经内镜下扩张均成功(100％，23／23)；内镜下行大肠息肉摘除术8864例，共10105枚，术后出血4例，迟发性穿孔2例；术中经内镜行小肠息肉摘除术15例，共412枚，术后无并发症。结论 内镜提高了下消化道外科疾病的诊治水平，但应严格把握适应证。     

Clinical features and treatment of lower intestinal hemorrhage

We have experienced 471 patients with anal bleeding during the past seven years. The Results are as follows: 1. As for the types of disease, incidence of hemorrhoid, colorectal cancer and ulcerative colitis (UC) was high, while that of small intestinal problems was low. 2. In the cases of remarkable bleeding from the lower intestinal tract, massive or acute progressive bleeding was less frequent than expected. 3. Inflammatory diseases were the main causes of massive bleeding. Bleeding by UC was the major indication for urgent operation. In the cases with acute massive hemorrhage, basic complications were often found and the possibility of the diseases of small intestine and blood vessel disorders also should be considered. 4. At the examination of bleeding patients, it is efficient to explore the lower colon and rectum first by colonoscopy or sigmoidoscopy, for most of the bleeding lesions are found in these portions. 5. As for surgical treatment, most of colorectal cancer patients with hemorrhage are able to be operated with wait- and -see management. For UC patients, complete cure operation is possible even if they have high-dose steroid medication.     

腹腔镜联合影像学检查在治疗小肠出血中的临床应用价值

目的 探讨在小肠出血患者中应用影像学检查准确定位指导腹腔镜精确手术治疗的应用价值.方法 回顾性分析2011年1月-2015年12月间收治的19例小肠出血病例的临床资料.患者入院后均先行胃镜或结肠镜排除上消化道出血和结直肠出血,明确为小肠出血.根据出血量分为急性大量出血、慢性显性出血和慢性隐性出血,分别或联合进行MSCT平扫及CTA、全消化道钡餐造影、胶囊内镜、DSA等检查.依据病因给予急诊或择期腹腔镜手术治疗.结果 19例患者均经手术治疗痊愈,其中择期手术16例(84.2％)、急诊手术3例(15.8％);单纯腹腔镜手术7例(36.8％)、导管注入垂体后叶素+腹腔镜手术8例(42.1％)、选择性插管栓塞+腹腔镜手术4例(21.1％).结论 腹腔镜联合影像学检查在精准治疗小肠出血具有诊断明确、定位准确、疗效确切、创伤微化等优点,具有临床应用价值,值得推广.     

腹腔镜、结肠镜联合治疗结肠息肉8例报告

目的：探讨腹腔镜、结肠镜联合治疗结肠息肉的可行性和安全性。方法：8例结肠镜无法切除的结肠息肉或结肠镜术中出现并发症的病例联合应用腹腔镜、结肠镜,其中1例穿孔者行腹腔镜修补术;1例术后大出血者在结肠镜指引下,用腹腔镜对病灶进行缝扎止血;1例乙状结肠广基息肉在结肠镜切除病灶后,用腹腔镜缝合修补肠管;5例切除病变肠段。结果：8例患者均顺利完成手术,无中转开腹,术后无并发症发生。结论：应用腹腔镜、结肠镜联合手术完成结肠镜无法治疗的结肠息肉,提高了手术的安全性和彻底性。     

Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995?

Bleeding non-neoplastic lesions of the upper gastrointestinal tract, not due to portal hypertension, are a frequent cause of emergency admission. In the present paper we report our retrospective experience in hemostatic injection treatment of these lesions. From May 1990 to May 1994, 164 patients were admitted to our institution for a bleeding gastrointestinal lesion. In 124 cases an ulcer classified according Forrest's criteria was detected. Four patients underwent immediate surgery. The second group of 86 patients (FIIa/FIIb/FIII) were treated conservatively. The third group of 34 patients (FIa/FIb/FIIa) underwent perilesional injection of adrenaline 1:10,000 and polidocanol 1% saline solution during endoscopic examination; 29% (25 pts) of the second group re-bled during the first 72 h vs 8.8% (3 pts) of the third group. The postoperative morbidity in the rebleeding patients was higher in the second group: 38.4% vs 0%. The importance of immediate, inexpensive, and simple hemostatic treatment extended to Forrest IIa lesions is emphasized.     

Surgical Treatment Concepts for Acute Lower Gastrointestinal Bleeding

Background and purpose  To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years. Methods  Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases. Results  Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%. Conclusions  Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.     

Role of colonoscopy in emergency surgery of the colon

The article analyses the results of using colonoscopy as a method for emergency identification of the causes of acute colonic obstruction and intestinal hemorrhage. The diagnostic informativeness of emergency colonoscopy was 98.7% in colonic obstruction and 97.2% in intestinal hemorrhage. With the use of the results of emergency endoscopy in the choice of the therapeutic tactic for patients with acute colonic obstruction and intestinal bleeding, the percentage of fatal outcomes in the group of patients who underwent operation reduced significantly: to 18.8% in operations for acute colonic obstruction and to 14.8% in operations for intestinal hemorrhage.     

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy.

OBJECTIVE. There is disagreement over the reliability of technetium Tc 99m (99mTc)-labeled erythrocyte scintigraphy in the localization of active lower gastrointestinal hemorrhage. A previous study at The New York Hospital-Cornell Medical Center that showed a superior sensitivity for localization of scintigraphy versus angiography in surgical patients led the authors to emphasize scintigraphy as the diagnostic test of first choice in the clinical diagnostic algorithm. The authors hypothesized that tagged erythrocyte scintigraphy can be used accurately as the primary diagnostic modality in localizing acute bleeding and guiding surgical intervention. METHODS. The authors conducted a 5-year, retrospective analysis of 224 inpatients who underwent scintigraphic imaging for diagnosis and localization of active lower gastrointestinal bleeding. Using scintigraphy as the primary diagnostic test, with colonoscopy, upper endoscopy, and angiography as adjunctive studies, 99mTc-labeled erythrocyte scans were performed at the clinician's discretion and were reviewed again for study purposes by two nuclear radiologists who were blinded to clinical outcome. Adjunctive diagnostic tests also were ordered for clinical indications. RESULTS. Using delayed periodic scintigraphic imaging, results of 115 scans (51.3%) demonstrated bleeding, with 96 scans (42.9%) localizing to a specific anatomic site. Patients with positive scans were five times more likely to require surgery (p < 0.005) than patients with negative scans, and surgical patients were twice as likely to localize by scintigraphy (p < 0.0001). Fifty patients (22.3%) required surgical intervention to control hemorrhage and had a bleeding site confirmed by both clinical and pathologic examinations. Forty-eight of those patients (96%) had a bleeding site determined preoperatively. For 37 patients with bleeding sites localized preoperatively by scintigraphy, 36 (97.3%) had correct localization based on surgical pathology. Only one patient required a subtotal colectomy solely because of nonlocalized bleeding. No patient bled postoperatively, and there was no mortality in either operated or nonoperated patients. The mean volume of transfused erythrocytes was similar in both scan-localized and nonlocalized surgical patients. CONCLUSION. When performed correctly and interpreted conservatively, scintigraphy is a useful and safe means of guiding segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding.     

Acute colonic hemorrhage. Importance of a preoperative localization of the origin of bleeding in patients requiring emergency surgery

Conservative management of distal gastro-intestinal bleeding is successful in most cases; 10% of patients hospitalised with this diagnosis will however undergo emergency surgery. Preoperative localisation of the bleeding site allows to perform a limited, segmental colectomy even in emergency. This has been shown to be associated with a lower operative mortality and morbidity when compared with subtotal colectomy. In this retrospective study we reviewed the notes of 134 patients admitted with lower gastro-intestinal bleeding. 22 of these required more than 4 units of blood transfusion and 12 underwent emergency surgery. Preoperative localisation of the source of bleeding was possible in 7 cases (58%); the remaining 5 underwent a subtotal colectomy. The operative mortality was 8%. The Authors emphasise the importance of an aggressive diagnostic work up in all cases of massive bleeding (i.e. more than 4 units of blood requirement in the first 24 hours following hospitalisation) in order to minimise the number of emergency subtotal colectomy.     

Enteroscopy as a tool for diagnosing gastrointestinal bleeding requiring blood transfusion

Iron-deficiency anemia secondary to gastrointestinal blood loss is a common cause of hospitalization. In many cases, the bleeding site cannot be defined despite thorough routine examination of the gastrointestinal tract. The aim of this study was to evaluate push enteroscopy as a diagnostic tool in patients with severe anemia, secondary to recurrent gastrointestinal bleeding, that required management by transfusion. Thirty-five consecutive push enteroscopy investigations were performed in 1998 and 1999 on 25 patients (15 men, 10 women). Mean age was 57 +/- 16 years (range, 33-83). All patients had received blood transfusions because of pronounced anemia secondary to gastrointestinal bleeding. Before push enteroscopy, all patients had been investigated with esophagogastroduodenoscopy, colonoscopy, and small-bowel radiography using the double contrast technique; no bleeding site was found. In addition, 10 of 25 patients had been investigated beforehand with 99mTc-labelled red blood cell scintigraphy, and 5 of 25 with scintigraphy for Meckel diverticulum. Two patients were also investigated with angiography before the push enteroscopy, and in six patients an additional total intraoperative enteroscopy was performed, preceded by a new colonoscopy, esophagogastroduodenoscopy, and push enteroscopy. A bleeding site was disclosed in 15 of 25 (60%) patients. In 7 of 25 patients (28%) the bleeding site was found in the stomach or esophagus. even though the patients had undergone one or two esophagogastroduodenoscopies earlier with normal findings. Total intraoperative enteroscopy identified a bleeding site in four of six (67%) patients studied. Two patients had bleeding hemangiomas that were resected surgically. Two patients had small intestinal adenomas, one with adenocarcinoma in situ. Push enteroscopy performed with an overtube inserted under fluoroscopic guidance is an important diagnostic tool in patients in whom conventional examinations do not disclose bleeding sites. Interestingly, 28% of patients had bleeding within reach of the gastroscope, indicating that a new upper endoscopy should be recommended before push enteroscopy is performed. When no positive findings are seen on push enteroscopy and the patient is affected by severe, recurrent iron-deficiency anemia, total intraoperative enteroscopy should be considered.     

Diagnostic yield of colonoscopy for constipation as the sole indication

Aim There is controversy over whether constipation as the only symptom should be an indication for routine diagnostic colonoscopy. The study was carried out to assess the prevalence of abnormal pathology on colonoscopy and to assess the risk factors for colonic neoplasia in patients with constipation but without ‘high risk symptoms’. Method A cross‐sectional, single‐centre study was conducted on individuals who underwent colonoscopy for constipation as the sole indication between 2005 and 2008. Standardized endoscopic and pathology reports were reviewed. Univariable and multivariable analyses were performed. Results A total of 786 patients (595 women, 75.7%; mean age, 57.4 ± 13.5 years) underwent diagnostic colonoscopy for constipation. Forty‐three (5.5%) had polyps, of whom 19 (2.4%) had hyperplastic polyps and 19 (2.4%) adenomas. No cancers were found. In patients with adenoma, the detection rate was 2.9% for patients below age 40 years and 1.7% for patients below age 50 years. Older age was associated with a polyp in both univariate and multivariate analysis. Gender, ethnicity and smoking were not associated with polyp or adenoma. Conclusion Colonoscopy for patients with constipation as the sole indication had a lower yield of neoplastic lesions than that for patients undergoing routine screening colonoscopy. Colonoscopy in constipation may only be warranted in patients who are over 50 years of age.     

Investigative modalities for massive lower gastrointestinal bleeding

The objective of this study was to evaluate the efficacy of various diagnostic modalities in the assessment of patients with massive lower gastrointestinal bleeding. The charts of all patients admitted to a McGill University affiliated teaching hospital with the diagnosis of lower gastrointestinal bleeding over a 25-year period were reviewed. There were 136 patients who underwent 202 admissions. The information documented included demographics on age, gender, co-morbid disease, prescribed medications, requirements for blood transfusions, orthostatic change in blood pressure, acute drop in hematocrit (to <30%), and exclusion of upper gastrointestinal bleeding. Among the 202 admitted patients there were 116 men and 86 women), with an average age of 70 years (range 16-95 years). At least one significant medical disease was found in 93% of these patients; and 20% were on aspirin and 5% on anticoagulants at the time of diagnosis. Rigid or flexible sigmoidoscopy was performed in 68 and 18 patients, respectively, with a definitive diagnosis made in 2.9% and 11.0%, respectively. Colonoscopy was performed in 152 cases, 20 of which were incomplete; a specific diagnosis was made for 59 admissions (45%). A red blood cell or colloid scan was performed on 53 patients, with extravasation noted in 13 (24.5%); a localized site of bleeding was identified in 9 cases (17%). Angiography was performed on 31 patients with bleeding sites localized in 6 (19%). Barium enemas were completed in 85 of 92 patients, and the presumptive cause of bleeding was identified in 72% of those with a complete examination. The most common causes identified were diverticulosis in 52 patients and angiodysplasia in 14. The cause of bleeding was not detected in 48 (35%). Bleeding stopped in most patients spontaneously, with only 7 requiring operation. The average number of units transfused was 3 (range 0-26). Scintigraphy and angiography were less efficacious than colonoscopy for localizing the site and etiology of the bleeding. Despite the combination of investigative modalities, a definitive diagnosis was not made in 35% of the admitted patients. The need for operative intervention in our study was lower than in most previous reports.     

Colonoscopy in lower gastro-intestinal haemorrhage.

The value of colonoscopy in the diagnosis and management of lower gastro-intestinal haemorrhage was assessed in 107 patients who were examined during a 2-year period. The main indications were to define uncertain radiological findings, to further investigate the cause of bleeding in patients with normal barium studies and to carry out polypectomy. Radiological lesions were confirmed in 27, defined in 12, and refuted in 14 patients. Twenty-eight lesions were demonstrated on colonoscopy which were not diagnosed by barium enema or sigmoidoscopy. A diagnosis was made by colonoscopy in more than two-thirds of the patients with frank blood loss and normal radiographs. In cases of occult bleeding it was farless helpful. Colonoscopy significantly improved diagnosis and management of gastro-intestinal bleeding when the cause was in doubt after standard investigations. In addition, 37 polyps were removed through the colonoscope from 30 patients.     

Colonoscopy in the very elderly: a review of 157 cases

Background Colonoscopy is currently the best diagnostic modality for evaluating colonic diseases but studies of its use in the very elderly are limited. Methods A single-institution review of all patients aged 85 years or older who underwent colonoscopy from June 2003 to June 2005 was performed. Parameters evaluated included indications for colonoscopy, findings, ability to perform a complete colonoscopy, and immediate and delayed (≤21 days) complications. Results A total of 157 patients aged 85 years or older (median = 87, range = 85–99) underwent colonoscopy during the two-year period. The cecal intubation rate was 90%. Number of cancers detected/indications for colonoscopy include gross or occult bleeding per rectum, 3/51 (5.9%); abnormal physical exam, 1/2 (50%); abnormal abdominal computed tomography, 3/5 (60%); anemia, 1/25 (4.0%); screening, 0/14; previous history of colonic malignancy, 0/10; previous history of polyps, 0/21; change in bowel habits, 0/5; family history of colonic malignancy, 0/6; abdominal pain, 0/4; diarrhea, 0/6; fecal impaction, 0/2; unknown, 0/6. Immediate complications included hemorrhage at a polypectomy site in one patient that was controlled endoscopically, one episode of bradycardia, and one incident of atrial fibrillation. There were no delayed complications resulting from colonoscopy. Conclusions Our data suggest that colonoscopy can be safely and successfully performed in the very elderly. In patients with symptoms or suggestive radiographic findings, cancer was detected in 4.0%–60% of cases. No cases of cancer were discovered in those patients who were asymptomatic.     

放射性核素显像在小儿下消化道出血诊断中的应用

应用99mTcO及99mTc-RBC动态显像诊断消化道出血20例，结果阳性18例（美克尔憩室11例，肠重复畸形5例，克隆氏病1例，溃疡性回肠炎1例均被手术证实），阴性2例（肠息肉2例，内窥镜证实）。认为此种检查操作简单，损伤小，安全，灵敏度高，可提示出血部位及原因，对诊断及治疗有极大帮助。     

Lower gastrointestinal bleeding with negative or inconclusive radiographic studies: the role of colonoscopy.

The records of more than 1,000 patients who underwent colonoscopy were reviewed. The study group consisted of 55 of these 1,000 patients who had persistent unexplained bleeding per rectum and negative radiographic examinations. Colonoscopy was helpful in defining the site of bleeding in approximately 50 per cent of the patients studied.     

Colonoscopic enema as rescue for inadequate bowel preparation before colonoscopy: a prospective,observational study

Aim Colonoscopy may need to be rescheduled because of inadequate bowel preparation. We evaluated the effectiveness of colonoscopic enema as rescue for an inadequate 1‐day bowel preparation before colonoscopy. Method Patients referred for afternoon colonoscopy were prospectively enrolled in the study during a 1‐year period. Patients took bowel preparation (polyethylene glycol) solution on the morning of the endoscopy. If during colonoscopy the bowel preparation was poor, an enema of polyethylene glycol solution (500 ml) was instilled into the colon at the level of the hepatic flexure via the biopsy channel of the colonoscope which was then removed. The patient was allowed to recover from the propofol sedation and used the bathroom to evacuate the enema. The colonoscope was then introduced and the examination continued. Results Of 504 patients undergoing colonoscopy, 26 (4.9%) received an enema. The median age was 59 (29–79) years and 19 (73%) were female. A subsequent successful colonoscopy was achieved in 25/26 (96%). There were no complications. The mean time spent for the entire colonoscopy from the initial preparation to the end of the examination including the enema was 7.6 ± 1.1 h (5.4 h preparation, 0.2 h first colonoscopy + enema, 0.66 h waiting in the lavatory, 0.33 h second colonoscopy and 1 h for recovery). Conclusion Colonoscopic enema was highly successful as rescue for patients with inadequate bowel preparation and avoided postponement of the procedure.     

Colonoscopy in the follow-up of patients with colorectal carcinoma

In an effort to determine the value of colonoscopy in the follow-up of patients who have undergone resection for colorectal carcinoma, the authors evaluated prospectively 100 consecutive patients who, during follow-up after resection for colorectal cancer, had normal findings on barium enema examination and also underwent colonoscopy. The follow-up from operation to colonoscopy ranged from 8 months to 15 years (average 2.6 years). Two recurrent and two metachronous carcinomas were detected. In addition, 25 polyps (3 benign) were removed from 22 patients. Twelve of the malignant polyps were less than 1 cm in dimension, the other 10 were larger. Colonoscopy is considered valuable in this setting for earlier detection and removal of recurrent and metachronous carcinomas and potentially premalignant lesions.