From the AGA Journals

Early colonoscopy for acute lower GI bleeding fails to improve diagnostic yield or reduce rebleeding rate

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No real time or value difference between early and elective colonoscopy

When to perform colonoscopy for the evaluation of acute lower gastrointestinal bleeding (LGIB) is controversial. Multiple observational studies, three small, single center randomized controlled trials, and several meta-analyses have produced mixed results. Therefore, a large, multicenter trial is of high priority.

Dr. Lisa L. Strate, professor of medicine, University of Washington, section chief, gastroenterology, Harborview Medical Center, Seattle

Dr. Lisa L. Strate

This study by Niikura et al. is the largest and first multicenter trial on this topic. The authors found no difference between the early vs. elective colonoscopy arms in the primary outcome, identification of stigmata of recent hemorrhage (SRH). SRH is a surrogate outcome; however, previous studies have found SRH to be predictive of rebleeding, and any decrease in rebleeding would likely be due to endoscopic treatment of these lesions. Furthermore, although the study was not powered to detect differences in clinical outcomes such as rebleeding, the 95% confidence interval suggests at most a 1.4% decrease in rebleeding with early colonoscopy. It is possible that early colonoscopy is beneficial in certain patient populations or in expert hands. However, in subgroup analyses there was no benefit for early colonoscopy in patients with severe bleeding, a diverticular source, or a colonoscopy performed by an expert.

Overall, the results suggest that in most patients presenting with acute LGIB, we do not need to perform colonoscopy within 24 hours of admission. However, the mean time to colonoscopy in the elective group was 41 hours from presentation. Therefore, colonoscopy should be performed on a next available basis. Further delays add unnecessary hospital days and increase cost of care. Future studies are needed to identify alternative ways to improve outcomes in LGIB, define the management of unstable patients with acute LGIB, and perfect the approach to endoscopic hemostasis in the colon.

Lisa L. Strate, MD, is professor of medicine, University of Washington, and section chief, gastroenterology, Harborview Medical Center, Seattle.


 

FROM GASTROENTEROLOGY

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 Gastroenterology.

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 American Journal of Gastroenterology.

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 Journal of Clinical Gastroenterology.

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. doi: 10.1053/j.gastro.2019.09.010.

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