While generally recommended for diagnosis and treatment of severe bleeding, early colonoscopy did not improve stigmata identification or reduce rebleeding rates in patients admitted for acute lower gastrointestinal bleeding in a relatively large, multicenter randomized trial, investigators report.
The proportion of patients with identified stigmata of recent hemorrhage (SRH) was not statistically significantly different between groups of patients who had early colonoscopy versus those who had a procedure 24 hours or more after admission, according to results of the 170-patient randomized study.
Although rebleeding rate was only a secondary endpoint, a larger study would be “unlikely to show a benefit” of the urgent approach, said investigators led by Ryota Niikura, MD, PhD, of the department of gastroenterology in the graduate school of medicine at the University of Tokyo.
“Our results for rebleeding suggested that early colonoscopy does not improve rebleeding outcomes, even if we chose rebleeding as the primary outcome,” Dr. Niikura and colleagues said in a discussion of the results, which appear in.
Leading up to this trial, there was “controversy” over whether early colonoscopy could improve significant clinical outcomes such as rebleeding, transfusion need, and mortality, according to the authors, who said this is the largest of four randomized, controlled trials reported on the subject to date, and the first multicenter trial among that group.
One of those randomized studies, reported by Green and colleagues in the American Journal of Gastroenterology in 2005, found no differences in mortality, hospital stay, intensive care unit stay, transfusion requirements, rebleeding, or surgery for urgent colonoscopy versus care provided according to a standard algorithm.
Similarly, Laine and Shah said urgent colonoscopy had no edge over routine elective colonoscopy in terms of clinical outcomes or lowering costs, in a randomized study reported in 2010, also in the.
In September 2019, van Rongen and colleagues reported results of the BLEED study of early versus standard colonoscopy. Length of hospital stay was significantly shorter among patients randomized to the urgent approach; however, the rate of recurrent bleeding and hospital readmission was significantly higher in that group, according to results published in the.
Two out of three of the previous randomized trials also showed no improvement in diagnostic yield with early colonoscopy, though “some meta-analyses” do suggest such a benefit, Dr. Niikura and coauthors said.
The latest reported randomized trial by Dr. Niikura and coinvestigators included patients 20 years of age or older who had moderate to severe hematochezia or melena within 24 hours of admission. A total of 162 adult patients at 15 hospitals in Japan were randomized to undergo early colonoscopy within 24 hours, or elective colonoscopy between 24 and 72 hours.
The primary outcome, identification of SRH, was not significantly different for the early versus later colonoscopy. Investigators said SRH was observed in 17 of 79 patients undergoing early colonoscopy or 21.5%, and in 17 of 80 patients in the elective colonoscopy group, or 21.3% (P = .967).
Similar rates of SRH between early and elective colonoscopy is a finding “in line” with the two of three previous randomized trials that found no increase in diagnostic yield, Dr. Niikura and coinvestigators noted in their report.
Rebleeding within 30 days, the “key secondary outcome” of the study according to investigators, was seen in 11 of 72 patients in the early colonoscopy group, or 15.3%, and in 5 of 75 patients in the elective colonoscopy group, or 6.7%, for a difference of 8.6 percentage points (95% confidence interval, –1.4 to 18.7).
Taken together, these findings suggest that early colonoscopy did not improve the SRH identification rate and that the 30-day rebleeding rate was not different, the authors said in a discussion of the results.
“Guidelines and prior studies often recommend that early colonoscopy be performed within 8-24 hours of admission to increase diagnostic yield and the likelihood of a therapeutic intervention,” they added in their discussion.
Dr. Niikura and coauthors acknowledged receiving grant funding from the Japanese Gastroenterological Association. Study coauthor Mitsuhiro Fujishiro, MD, PhD, reported disclosures related to Takeda, AstraZeneca, Zeria, Daiichi-Sankyo, and EA Pharma. The remaining authors did not declare competing interests.
SOURCE: Niikura R et al. Gastroenterology. 2019. .