Do not confuse movement for progress: The saga of urgent colonoscopies in lower gastro-intestinal bleeding

The philosopher Alfred Montapert once said, “Do not confuse motion and progress. A rocking horse keeps moving but does not make any progress”. This quote elegantly summarizes many of the medical interventions that seem on the surface to improve patient outcomes, but, in reality, they provide little benefit to the patient. Furthermore, at times, it is easier to measure a surrogate indicator to infer a positive patient outcome, but this can be misleading. This is the case for urgent colonoscopy (within 24 hours) in the management of acute lower gastro-intestinal bleeding (LGIB), where at first glance, the procedure seems to be a life-saving intervention that needs to be done as soon as possible to localize the bleeding, achieve hemostasis, and subsequently improve important patient outcomes, including decreased re-bleeding, re-admission, need for blood transfusion, urgent surgical or radiological interventions, or even mortality. Yet, the current literature argues otherwise.

Acute LGIB, defined as bleeding originating from the colon or anorectum, is a common emergency that seems to be on the rise globally due to the aging population and increasing use of anti-thrombotics.[1] LGIB is responsible for a significant proportion of emergency room visits and hospital admissions with substantial healthcare resource utilization.[2] Despite the plethora of research from Western and Asian countries, the true impact of LGIB and its clinical outcomes remain lacking in the Gulf region. In this issue, Alhassan et al.[3] provide an important and timely study assessing the outcomes of patients with acute LGIB who received a colonoscopy during their hospital admission. This was a retrospective cohort study that examined the outcomes of 84 patients presenting with acute LGIB at a university hospital, a tertiary-care center in Riyadh, from May 2015 to December 2021. The primary outcome of the study was the 90-day re-bleeding rate, and secondary outcomes included measurement of other important clinical outcomes and predictors of intervention and re-admission. The study found 90-day re-bleeding and re-admission rates of 6% and 19%, respectively. Furthermore, the authors were able to identify the performance of upper endoscopy as a significant predictor of the need for intervention while a personal history of inflammatory bowel disease (IBD) and the performance of sigmoidoscopy as significant predictors of re-admission. The authors concluded correctly that LGIB is an important emergency that requires a multi-disciplinary approach to optimize patient outcomes. However, a detailed dissection of this study provides even more important information that warrants further discussion.

This study provides insight into the epidemiology of LGIB in the region. The most common etiologies of LGIB in this cohort were colorectal cancer and ulcerative colitis, followed by hemorrhoids and angiodysplasia. Diverticular bleeding, the most common etiology of acute LGIB globally, was responsible for only 5.9% of cases. This could be explained by the younger population included in this study (a mean age of 49.6 years) and the nature of the hospital as a tertiary-care referral center. However, it also reflects the true lower prevalence of diverticulosis in the Middle East[4] and how this differs significantly from the Western and Asian populations, where diverticulosis is the most common etiology of LGIB, accounting for up to 65% of cases.[1] The re-bleeding rate (6%) is significantly lower than what has been reported in other studies (13–19%),[5,6] which could reflect the different bleeding etiologies and the shorter follow-up time in the current study.

But probably the more important finding of this study is the role of colonoscopy as a therapeutic intervention to manage acute LGIB and how this intervention influenced patient outcomes. Active bleeding was noted in 17 patients (20%), while endoscopic intervention was required in only 13 (15.5%) patients. When the endoscopic interventions were analyzed even further, the majority (61.5%) of interventions were polypectomy rather than hemostatic interventions. Furthermore, other non-endoscopic interventions, including radiological and surgical interventions, were required in a small minority of patients (6%), while blood transfusion was required in 19%. These observations are consistent with those reported in the literature, where the vast majority of patients presenting with acute LGIB are hemodynamically stable and do not require any urgent invasive intervention.[1] This is further supported by the current study, where a shock index >0.9 (reflecting hemodynamic instability) was observed in only 14 patients (16.7%) at presentation, and only 3 patients required intensive care unit admission due to persistent instability.

One of the controversial areas in LGIB is the timing of colonoscopy, where previous guidelines suggested performing urgent colonoscopy (within 24 hours) in all patients presenting with acute LGIB.[7] However, the available literature has provided mixed results, and the current evidence suggests no improvement in important clinical outcomes with urgent colonoscopy. In fact, the most recent European[8] and North American[9] guidelines recommend performing elective colonoscopy at the next available timeslot rather than urgent colonoscopy for patients with stable LGIB. Japanese guidelines[10] differ from the other guidelines by endorsing urgent colonoscopy (within 24 hours) for all patients presenting with acute LGIB, but this recommendation is probably more suitable for the unique Japanese healthcare system, and this recommendation may not be generalizable to other systems. Although the performance of urgent colonoscopy has been shown to increase the rates of lesion detection and endoscopic interventions, this did not translate into improved clinical outcomes such as decreased re-bleeding, the need for angioembolization or surgery, or a shortened hospital stay.[11] Despite the authors’ suggestion that certain patients may benefit from urgent colonoscopy (within 12 hours), their findings do not support this practice and, in fact, point toward potential harm. Colonoscopy was performed after 24 hours in 60 patients (71.4%), while the rest received a more urgent colonoscopy. The performance of urgent colonoscopy did not improve important patients’ outcomes (e.g., need for blood transfusion), and it also led to the abortion of the procedure in >20% of cases, mostly due to inadequate bowel preparation and, in some cases, concerns about impending bowel perforation. The lack of benefit of urgent colonoscopy in acute LGIB is further supported by the results of a randomized controlled study which found a significantly higher risk of re-bleeding and re-admission among patients who underwent urgent colonoscopy compared to standard colonoscopy (within 1–3 days).[12] Consequently, the study findings, in addition to the published literature, support that urgent colonoscopy should be avoided, and instead, an algorithm to manage acute LGIB should follow those suggested by recent guidelines,[8,9] with a specific focus on adequate resuscitation, including appropriate management of anti-thrombotics and blood transfusion to improve patients’ outcomes,[13] followed by an elective colonoscopy for stable patients or urgent angioembolization for unstable patients.

Finally, the authors tried to explore predictors for endoscopic intervention and were able to identify the performance of upper endoscopy (required in 8.3% of the cohort) as a significant predictor for intervention (OR = 4.118; 1.354–12.5). This finding is likely a reflection of the severity of the bleeding episode, where massive upper gastro-intestinal bleeding needs to be ruled out. A personal history of IBD (OR = 5.009; 1.518–17.12) and the performance of sigmoidoscopy (OR = 5.083; 1.302–19.85) were predictors for 90-day re-admission. Given the high re-admission rate (19%), a clear and expedited treatment plan provided by the treating services should be offered to patients presenting with acute LGIB, especially those with a higher risk of readmission, to reduce this undesirable outcome.

So, what can we conclude from this study? Despite the limitations of the study, including the small sample size, single-center setting, lack of a comparative group, and the inclusion of relatively young patients with low co-morbidity burden who might not be representative of the usual LGIB cohort reported in the literature, the study actually adds some valuable information to the regional literature, where it is becoming clearer that the epidemiology of LGIB is vastly different from those reported elsewhere, with a lower prevalence of diverticular bleeding and a higher burden of other etiologies, especially malignancy in the younger population. Despite these differences, the study indirectly supports the current recommendation that colonoscopy has a major diagnostic but less of a therapeutic role in patients with acute LGIB, and urgent colonoscopy may not confer any benefit to the patient, with the potential for increased harm. Hence, the focus of managing patients with acute LGIB should be directed toward proper triage, resuscitation, and stabilization. Furthermore, managing patients with acute LGIB is a true multi-disciplinary task that requires the input of multiple medical specialities, including gastroenterologists, surgeons, and radiologists, to optimize patients’ outcomes rather than rushing into urgent colonoscopy in sub-optimal settings with unproven clinical benefits that can be potentially harmful to the patient without any added advantages. When all is said and done, we must always remember:

“Just because you are doing a lot more doesn’t mean you are getting a lot done.”

Denzel Washington