Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding
Authors: Kazuhiko Koike
Shu Kiyotoki
Tomohiro Shinozaki
Katsuhiro Mabe
Tatsuya Mikami
Naoki Ishii
Tsutomu Nishida
Ryota Niikura
Tetsuro Honda
Munenori Takata
Atsuo Yamada
Tomoyuki Yada
Tomoki Fujita
Naoyoshi Nagata
Katsumi Yamamoto
Yasutoshi Shiratori
Hisashi Doyama
Mitsuhiro Fujishiro
Kenkei Hasatani
Kazuo Hara
Tetsuya Sumiyoshi
Journal: Gastroenterology (2020)
Discipline: CLINICAL MEDICINE
Keywords: Acute Lower Gastrointestinal Bleeding; Early Colonoscopy; Randomized Controlled Trial; Stigmata of Recent Hemorrhage.
Affiliations: Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan., Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan; Gastroenterological Endoscopy, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan., Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan. Electronic address: ., Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki-shi, Nagasaki, Japan., Department of Gastroenterology, Fukui Prefectural Hospital, Fukui-shi, Fukui, Japan., Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan., Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Ishikawa, Japan., Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka-shi, Osaka, Japan., Department of Gastroenterology, Tonan Hospital, Sapporo-shi, Hokkaido, Japan., Department of Gastroenterology, Otaru Ekisaikai Hospital, Otaru-shi, Hokkaido, Japan; Department of Gastroenterology, Sapporo Century Hospital, Sapporo-shi, Hokkaido, Japan., Department of Gastroenterology, Shuto General Hospital, Yanai-shi, Yamaguchi, Japan., Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine Kohnodai Hospital, Ichikawa-shi, Chiba, Japan., Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka-shi, Osaka, Japan., Department of Biostatistics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Shinjuku-ku, Tokyo, Japan., Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan., Division of Endoscopy, Hirosaki University Hospital, Hirosaki-shi, Aomori, Japan., Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate-shi, Hokkaido, Japan., Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya-shi, Aichi, Japan., Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Abstract:  Background &amp; aims: We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). Methods: We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. Results: SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. Conclusions: In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173. 

Retracted: No

PubPeer comments:
 **Acute lower GI bleeding: Early colonoscopy not superior to elective colonoscopy in clinical outcome** In a Japanese multicenter, randomized controlled trial, patients with acute lower gastrointestinal bleeding (LGIB) underwent either early ( 24 hours) or elective colonoscopy (within 24-96 hours) in order to determine the optimal time for endoscopic examination in cases of LGIB. Investigated were 159 outpatients aged u226520 years who presented with moderate to severe hematochezia or melena within 24 hours after presentation. Among the most important inclusion criteria were u22653 episodes of hematochezia within 8 hours and hemorrhagic shock or need for transfusion. Endoscopic identification of (acute) bleeding stigmata ( stigmata of recent hemorrhage , SRH) was the primary endpoint. The most important secondary endpoint was a rebleeding within 30 days. SRH were identified in 21.5% of patients in the early colonoscopy group and in 21.3% in the elective colonoscopy group (difference 0.3; 95% CI, -12.5-13.0; p = 0.967) and were rarely found after more than 36 hours. In both groups endoscopic hemostasis was performed in 15 patients each (u223c19%). Both the success of the endoscopic therapy and the necessity of additional endoscopic examinations, a radiological intervention or an operation were similar in both study arms, as was the length of hospital stay. Renewed bleeding within 30 days was observed in 15.3% of patients after early colonoscopy and 6.7% after elective colonoscopy (difference 8.6; 95% AI, -1.4-18.7). After successful endoscopic therapy these occurred in 14.3% (2 14) in the early group and in 16.7% (2 12) in the elective group. The incidence of colonoscopy-associated adverse events was generally low, with the exception of increased bleeding during colonoscopy preparation in 39.2% of patients in the early group vs. 27.5% in the elective group. The authors postulate that early colonoscopy in patients with acute LGIB does not improve the rate of SRH identification compared to elective colonoscopy. Furthermore, the 30-day re-bleeding rate did not differ between the two groups. The authors thus question the recommendation in guidelines and previous studies to perform early colonoscopy to improve diagnostic accuracy. However, it should be noted that patients with acute LGIB and hemorrhagic shock were underrepresented in the study or were excluded from the study if they did not respond to blood transfusions. In addition, the German S2k guideline recommends gastroscopy for haematochecia (and or peranal discharge of blood clots) with haemorrhagic shock, as these patients may also have an upper gastrointestinal haemorrhage. ,