jcoloproctol(rioj).2016;36(4):185–188
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Colonoscopy
in
the
diagnosis
of
acute
lower
gastrointestinal
bleeding
Igor
Borba
de
Souza
e
Benevides
a,
Carlos
Henrique
Marques
dos
Santos
a,b,∗aHospitalRegionaldeMatoGrossodoSul,CampoGrande,MS,Brazil bSociedadeBrasileiradeColoproctologia,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received27February2016 Accepted18April2016
Availableonline9September2016
Keywords:
Colonoscopy
Lowergastrointestinalbleeding
a
b
s
t
r
a
c
t
Lowergastrointestinalbleedingisdefinedasableedingoriginatedfromasourcedistalto theTreitzligamentandthecolonoscopyiswellestablishedasthediagnosticprocedureof choice.
Objective:Toevaluatetheresultsofcolonoscopiesperformedtodiagnosethecauseofacute lowergastrointestinalbleedinginageneralhospitalatMatoGrossodoSul.
Materialandmethods:ColonoscopyproceduresperformedintheEndoscopyserviceofthe HospitalRegionaldeMatoGrossodoSulinthosepatientsadmittedduetoanacutelower gastrointestinalbleedingfromJanuary2014toDecember2015wereanalyzedretrospectively. Thestudiedvariableswereage,gender,diagnosisandlocalizationofthelesion.
Results:Themeanagewas66years,andtherewasalittlepredominanceofthemalegender. Diverticulardiseasewasthemaincauseoflowergastrointestinalbleedinginthisstudy, followedbycancer,inflammatorygastrointestinaldisease,polyps,andangiodysplasia.
Conclusion: Thecolonoscopyshowedtobeaneffectivediagnosticmethodinthecaseof acutelowergastrointestinalbleedingandagoodtherapeutictoolinthecaseofdiverticular diseaseandangiodysplasia.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
A
colonoscopia
no
diagnóstico
da
hemorragia
digestiva
baixa
aguda
Palavras-chave:
Colonoscopia
Hemorragiadigestivabaixa
r
e
s
u
m
o
Hemorragiadigestivabaixaédefinidacomosangramentooriginadodeumafontedistal aoligamentodeTreitzeacolonoscopiaestabemestabelecidacomooseuprocedimento diagnósticodeescolha.
∗ Correspondingauthor.
E-mail:chenriquems@yahoo.com.br(C.H.Santos). http://dx.doi.org/10.1016/j.jcol.2016.04.016
186
jcoloproctol(rioj).2016;36(4):185–188Objetivo:Avaliarosresultadosdascolonoscopiasrealizadasparaelucidac¸ãodiagnósticados casosdeHemorragiadigestivabaixaagudaemumHospitalGeraldeMatoGrossodoSul.
Materiaisemétodos: Foramanalisadas,deformaretrospectiva,ascolonoscopiasrealizadas nospacientesinternadosdevidoàhemorragiadigestivabaixaaguda,noperíododejaneiro de2014adezembrode2015,noservic¸odeendoscopiadigestivadoHospitalRegionalde MatoGrossodoSul.Asvariáveisestudadasforamaidade,sexo,diagnósticoelocalizac¸ão dalesão.
Resultados: Amédiadeidadefoide66anos,comumadiscretapredominânciadosexo masculino.Adoenc¸adiverticularfoiaprincipalcausadehemorragiadigestivabaixanesse estudo,seguidodeneoplasias,doenc¸ainflamatóriaintestinal,póliposeangiodisplasia.
Conclusão: Acolonoscopiamostrou-secomométodoefetivonodiagnósticodoscasosde Hemorragiadigestivabaixaagudaecomoumaboaferramentaterapêuticatambémnos casosdeangiodisplasia.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Lowergastrointestinalbleedingisdefinedasableeding orig-inatedfromasourcedistaltotheligamentofTreitz.Despite thespontaneouscessationin80%ofcasesofacutelower gas-trointestinalbleeding,theidentificationofthebleedingsource remainsachallengingtaskandrebleedingcanoccurinupto 25%ofcases.1
Colonoscopy is defined as the diagnostic procedure of choice in the presence of acute lower gastrointestinal bleeding.2,3 Itsdiagnosticaccuracyvariesfrom72%to86%.4
Diverticular disease is the most common cause of lower intestinalbleeding,followedbypolyps,malignancy, inflam-matoryboweldiseaseandangiodysplasia.5
Aproperdiagnosisofaclinicalpictureofacutelower gas-trointestinalbleedingisofparamountimportance,givenits potentialforrebleedingand,inaddition,becausethis condi-tionmaybeamanifestationofmalignancy.
Thisstudyaimedtoevaluatetheresultsofcolonoscopy procedurescarriedoutinordertoobtainalaboratorydiagnosis ofacutelowergastrointestinalbleedinginageneralhospital ofMatoGrossodoSul.
Objective
Toevaluatetheresultsofcolonoscopiesperformedtoobtain alaboratorydiagnosisofcasesofacutelowergastrointestinal bleedinginageneralhospitalofMatoGrossodoSul.
Materials
and
methods
Colonoscopies in patients hospitalized due to acute lower gastrointestinalbleedingwereretrospectivelyevaluatedfrom January2014toDecember2015.Lowergastrointestinal bleed-ing was defined as the presence of intestinal bleeding, hematochezia, or melena when the occurrence of upper gastrointestinal bleeding was excluded by upper diges-tive endoscopy. The examinations were performed in the
Table1–Thegenderdistributionofpatientsundergoing
colonoscopyduetoacutelowergastrointestinal
bleeding.
Gender Numberofpatients %
Male 55 48.5
Female 52 41.5
Total 107 100
EndoscopyService,HospitalRegionaldeMatoGrossodoSul, andthedatawerecollectedfromtheirelectronicrecords.
Thevariablesstudiedwere:
1. Gender. 2. Age.
3. Diagnosisofinjury. 4. Thesiteofthelesion.
Patientswithbleedingfromorificialdiseaseandthose com-ingfromtheoutpatientinvestigationwereexcluded.
Results
One hundred and seven patientswere studiedand witha slight predominance of males (Table 1). The mean age of patientswas66years,rangingfrom16to102years.Ofthetotal numberofexaminationsperformed,21(19.6%)werenormal. Atthetimeoftheexamination,88.7%ofpatientsnolonger sufferedanactivebleeding.
Thecolonic diseasemostoftenfoundinthis study was diverticulardisease,accountingfor54.4%ofcases,followedby neoplasias,inflammatoryboweldisease,polypsand angiodys-plasia(Fig.1).Asforgenderdistribution,weobservedahigher frequencyofinflammatoryboweldiseaseasacauseoflower gastrointestinalbleedinginfemalepatients(Fig.2).
jcoloproctol(rioj).2016;36(4):185–188
187
19.6%
54.4% 10.2%
7.4% 5.6%
2.8%
Normal result
Diverticular disease
Neoplasias
Inflammatory bowel disease
Polyps
Angiodysplasia
Fig.1–Maindiagnosesfoundwithcolonoscopy.
hadrightcolonbleeding,1inthetransversecolon,and3in thesigmoidcolon.
Theneoplasiasmostoftenassociatedwithbleedingwere locatedintherectum,followedbyneoplasms(Fig.4).
Inflammatoryboweldiseasesweremorefrequentlyfound inwomen,especiallydiffusecolitis(71.4%).Amanandtwo womenhadbleedingduetoanunspecificproctitis.
Three patients had gastrointestinal bleeding due to angiodysplasia; two of these cases were located in the ascending colon and the third case was caused by rectal angiodysplasia.
Polypswereassociatedwithsixcasesofbleeding,andthree ofthemwerelocatedintherectum,twointhesigmoidcolon, andoneintheascendingcolon.
Discussion
Acutelowergastrointestinalbleedingisanemergency situ-ationoftenfoundinemergencyrooms. Takeninto account thatthisbleedingaffectsapopulationwithmoreadvanced age,itsconsequencescanbeevenmorecatastrophic.2 With
this in view, the definition of the bleeding site and its specific treatment are of paramount importance.5 Where
available,colonoscopyshould beusedintheseclinical pic-tures,consideringitsdiagnosticaccuracyandthepossibility ofitstherapeuticuseinparticularcircumstances.2,6
67.2%
10.9%
1.8% 3.6% 1.8%
40.3%
9.6% 13.4% 7.7%
3.8%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%
Diverticular disease
Inflammatory disease
Neoplasias Polyps Angiodysplasia
Male Female
Fig.2–Thegenderdistributionofdiseasesrelatedtolower gastrointestinalbleeding.
Diffuse disease 53% Left colon
38%
Right colon 9%
Fig.3–Distributionofsitesofdiverticulardisease.
Thecolonoscopieswereinconclusivein19.6%ofcases,a findingconsistentwiththatfoundintheliterature.4Duetothe
limitationsinherenttothismethod,alargeareaofthesmall intestineisnotcoveredintheexam.Inthesecasesandin caseswhereitwasnotpossibletodefinethepreciselocationof thelesion,onecanmakeuseofproceduressuchas scintigra-phyandarteriography,forthedefinitionofthebleedingsite.6
Scintigraphydetectsactivebleedingwithavolumefrom0.1to 0.5mL/minanditsmaindisadvantageistheinaccurate loca-tionofthefocusofbleeding.Ontheotherhand,arteriography isamoreinvasivemethodandrequiresableedingvolumeof 0.5mL/minforitsdetection.6Arteriographymayalsobeused
asatherapeutictool.Embolizationforhemorrhageduetoa diverticularbleedingcanreachasuccessrateof85%.7Inthe
caseofterminationofthebleeding,enteroscopyandcapsule endoscopycanbeusedtoestablishthediagnosis.6
Inthis study,diverticulardisease presenteditself asthe mostfrequentcauseofacutelowergastrointestinalbleeding.
Rectum 46%
Sigmoid 27% Ascending colon
18%
Descending colon 9%
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jcoloproctol(rioj).2016;36(4):185–188Thisresultisalsosupportedintheliterature.Inaretrospective studybyGayeretal.,inwhich1112patientswithlower gas-trointestinalbleedingwerestudied,diverticulardiseasewas alsopresentedasthemostfrequentcause,followedbycancer, whenanorectaldiseasesareexcluded.8
Inupto17%ofcases,colorectalneoplasmsmaypresentas thecauseofintestinalbleeding.However,itismorecommon thatsuchconditionsarepresentedintheformofoccult bleed-inginstool.9Rectalcancerwasmorerelatedtohemorrhagic
episodes.Inhisstudy,Lopesnotedthatleftcoloncancerhada greaterrelationshipwithapictureofacutelower gastrointesti-nalhemorrhage.Classically,wefoundintheliteraturethat rightcoloncancersaremorecloselyrelatedtooccult bleed-inginstool,whilehematocheziaismorerelatedtoleftcolon tumors,andgenerallythesearechronicandslowly progres-sivebleedings.Bleedingsoflargestvolumesareusuallyrelated tomoreadvancedtumors.10
Inflammatoryboweldiseasewasmorecommoninwomen thaninmen,surpassingevencancerasacauseofbleeding; thesedataaresimilartothoseofBoundsetal.2Allcasesof
bleedingsecondarytoinflammatoryboweldiseasewere clas-sifiedasunspecificcolitisorrectitis.Thisisprobablydueto thedifficultyoftheendoscopistindeterminingtheetiology, withouthavingaccesstomoredetailedinformationonthe patient.11
Inthisstudy,angiodysplasiasandpolypswereinfrequent causesoflowerintestinalbleeding.In22.8%ofcases,Lopes et al. attributed to colon and rectum polyps the cause of intestinalbleeding.Ontheotherhand,theseauthorsfound that no cases ofgastrointestinal bleeding were associated withangiodysplasia.12 Inmoreagedpopulations,
angiodys-plasiasincreaseinfrequency,andtheseconditionsmay be responsibleforupto30%ofcasesofhemorrhagediagnosed byendoscopy.13Thecolonoscopycanalsobeused
therapeu-ticallyincasesofangiodysplasia,through theuseofargon plasma, sclerosingsubstances, or thermal contactprobes.6
inthepresentstudy,allcasesofangiodysplasiaweretreated successfullybyendoscopy,withtheuseofargonplasma.
Conclusion
Colonoscopyhasproventobeaneffectivemethodinthe diag-nosisofcasesofacutelowergastrointestinalbleeding,being alsoagoodtherapeutictoolincasesofdiverticulardisease andangiodysplasia.Diverticulardiseasewasthediseasemost often associatedwith these cases, followed byneoplasms.
Thehighfrequencyofneoplasmsthatmanifestthemselves throughintestinalbleedingdemonstratestheimportanceof colonoscopyinthesecases.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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1.EdelmanDA,SugawaC.Lowergastrointestinalbleeding:a review.SurgEndosc.2007;21:514–20.
2.BoundsBC,KelseyPB.Lowergastrointestinalbleeding. GastrointestEndoscClinNAm.2007;17:273–88. 3.FerreiraRPB,EisigJN.ProjetoDiretrizesHemorragias
digestivas.Federac¸ãoBrasileiradeGastroenterologia;2008. 4.FarrellJJ,FriedmanLS.Reviewarticle:themanagementof
lowergastrointestinalbleeding.AlimentPharmacolTher. 2005;21:1281–98.
5.OrnellasAT,OrnellasLC,SouzaAFM,GaburriPD.Hemorragia DigestivaAgudaAltaeBaixa.In:DaniR,editor.
GastroenterologiaEssencial.2ed.RiodeJaneiro:Editora GuanabaraKooganS.A.;2001.p.3–14.
6.CardosoFilhoCAM,MarquesOWJr,PopoutchiP,AverbachM. ProjetoDiretrizes:Hemorragiadigestivabaixa.SocBras EndoscDig.2010.
7.KhannaA,OqnibeneSJ,KoniarisLG.Embolizationasfirst-line therapyfordiverticulosis-relatedmassivelower
gastrointestinalbleeding:evidencefromameta-analysis.J Gastrointest/Surg.2005;9:343–52.
8.GayerC,ChinoA,LucasC,TokiokaS,YamasakiT,Edelman DA,etal.Acutelowergastrointestinalbleedingin1,112 patientsadmittedtoanurbanemergencymedicalcenter. Surgery.2009;146:600–6.
9.BarnertJ,MessmannH.Diagnosisandmanagementoflower gastrointestinalbleeding.NatRevGastroenterolHepatol. 2009;6:637–46.
10.LongstrethGF.Epidemiologyandoutcomeofpatients hospitalizedwithacutelowergastrointestinalhemorrhage:a population-basedstudy.AmJGastroenterol.1997;92:419–24. 11.DosSantosCHM,CuryMS,SaadFT.Principaisachadosde
colonoscopiasrealizadasemcaráterdeurgênciaeeletivas. RevBrasColoproct.2009;29:83–7.
12.LopesADJr,AhuajiVM,Lourenc¸ãoJL,RodriguesAJJr,Birolini D.Opapeldacolonoscopianahemorragiadigestivabaixa aguda.RevBrasColoproct.1998;18:164–7.
