SCIENTIFIC PAPERS
Lower Gastrointestinal Bleeding With Negative or Inconclusive Radiographic Studies: the Role of Colonoscopy
George J. Todd, MD, New York, New York Kenneth A. Forde, MD, New York, New York
The clinician is often faced with the problem of acute or chronic lower gastrointestinal bleeding, and frequently radiographic studies (mesenteric angiography and barium enema) fail to localize the bleeding site. In these instances fiberoptic colonoscopy may be of particular assistance in defining the colonic pathology. We analyzed our experience with a group of patients in whom colonoscopy was performed because radiographic studies were either inconclusive or failed to define the lesion responsible for lower gastrointestinal bleeding. Material
The records of more than 1,000 patients who underwent colonoscopy during the period 1973 to 1977 were reviewed. The study was designed to identify those patients in whom rectal bleeding persisted (either chronically or acutely) from a source that could not be determined by mesenteric angiography or barium enema. Results
Fifty-five patients with negative or inconclusive radiographic studies underwent colonoscopy because of persistent bleeding. Twenty-one patients underwent emergency colonoscopy for active acute bleeding, and 34 patients were examined because of chronic bleeding through the rectum. Radiographic
studies were negative in 80 per cent of the patients (44 of 55), inconclusive in 5.5 per cent (3 of 55), and demonstrated diverticulosis only without localization of the bleeding site in 14.5 per cent (8 of 55). Colonoscopy was of value in 43 per cent (9 of 21) of the patients with active acute lower gastrointestinal bleeding. The following lesions were disclosed by colonoscopy to be the cause of bleeding: arteriovenous malformation (two patients), polyps (three patients), Crohn’s colitis (one patient), hemorrhoids (one patient), cecal carcinoma (one patient), and bleeding diverticulum (one patient). In 12 of these 21 patients (57 per cent), colonoscopic findings agreed with radiographic findings. Of 34 patients undergoing colonoscopic examination for chronic bleeding, new lesions (not necessarily identifiable as the source of chronic blood loss) were disclosed in 53 per cent (18) of the patients. The following lesions were disclosed: polyps (eight patients), cecal carcinoma (three patients), inflammatory bowel disease (two patients), proctosigmoiditis (two patients), villous adenoma (one patient), bleeding appendiceal stump (one patient), and coionic endometriosis (one patient). In 16 (47 per cent) of the 34 patients evaluated for chronic bleeding, colonoscopic findings agreed with radiographic findings. Comments
From the Department of Surgery, Columbia-Presbyterian Medical Center, 622 West 168 Street, New York, New York. Requests for reprints should be addressed to Kenneth A. Forde, MD, Department of Surgery. Presbyterian Hospital, 622 West 168th Street, New York, New York 10032.
Volume 138, November 1979
Previous reports have indicated the value of colonoscopy in defining otherwise obscure causes of colonic bleeding in approximately 50 per cent of cases
627
Todd and Forde
[l-3]. Our results agree with these reports. Deyhle et al [4] reported that the source of active hemorrhage was either accurately located or excluded in 17 of 18 cases. Radiographic studies were not performed before endoscopy in their series, however, and it is likely that mesenteric angiography would have localized the bleeding site in many of the patients. We view colonoscopy as an adjunct to the radiographic evaluation of the lower gastrointestinal tract. It is not intended to replace radiographic studies. In cases of chronic blood loss through the rectum, the barium enema remains the mainstay of the diagnostic evaluation; in active acute bleeding, mesenteric angiography should be obtained to attempt localization of the bleeding site, This review indicates that colo-
628
noscopy can be of assistance in defining the source of gastrointestinal bleeding in a significant percentage of cases in which radiographic studies are either negative or inconclusive.
References 1. Britton DC, Tregoning 0, Bone G, McKelvey STD: Colonoscopy in surgical practice. BrMedJ 1: 149, 1977. 2. Waye JD: Colonoscopy in rectal bleeding. S Afr JSurg 14: 143, 1976. 3. Teague RH, Thornton JR, Manning AP, Salmon PR. Read AE: Colonoscopy for investigation of unexplained rectal bleeding. Lancet 1: 1350, 1978. 4. Deyhle P, Blum AL, Nuesch HJ, Jenny S: Emergency colonoscopy in the management of the acute peranal hemorrhage. Endoscopy 6: 229, 1974.
The American Journal of Surgery
Lower Gastrointestinal Bleeding With Negative or Inconclusive Radiographic Studies: the Role of Colonoscopy
George J. Todd, MD, New York, New York Kenneth A. Forde, MD, New York, New York
The clinician is often faced with the problem of acute or chronic lower gastrointestinal bleeding, and frequently radiographic studies (mesenteric angiography and barium enema) fail to localize the bleeding site. In these instances fiberoptic colonoscopy may be of particular assistance in defining the colonic pathology. We analyzed our experience with a group of patients in whom colonoscopy was performed because radiographic studies were either inconclusive or failed to define the lesion responsible for lower gastrointestinal bleeding. Material
The records of more than 1,000 patients who underwent colonoscopy during the period 1973 to 1977 were reviewed. The study was designed to identify those patients in whom rectal bleeding persisted (either chronically or acutely) from a source that could not be determined by mesenteric angiography or barium enema. Results
Fifty-five patients with negative or inconclusive radiographic studies underwent colonoscopy because of persistent bleeding. Twenty-one patients underwent emergency colonoscopy for active acute bleeding, and 34 patients were examined because of chronic bleeding through the rectum. Radiographic
studies were negative in 80 per cent of the patients (44 of 55), inconclusive in 5.5 per cent (3 of 55), and demonstrated diverticulosis only without localization of the bleeding site in 14.5 per cent (8 of 55). Colonoscopy was of value in 43 per cent (9 of 21) of the patients with active acute lower gastrointestinal bleeding. The following lesions were disclosed by colonoscopy to be the cause of bleeding: arteriovenous malformation (two patients), polyps (three patients), Crohn’s colitis (one patient), hemorrhoids (one patient), cecal carcinoma (one patient), and bleeding diverticulum (one patient). In 12 of these 21 patients (57 per cent), colonoscopic findings agreed with radiographic findings. Of 34 patients undergoing colonoscopic examination for chronic bleeding, new lesions (not necessarily identifiable as the source of chronic blood loss) were disclosed in 53 per cent (18) of the patients. The following lesions were disclosed: polyps (eight patients), cecal carcinoma (three patients), inflammatory bowel disease (two patients), proctosigmoiditis (two patients), villous adenoma (one patient), bleeding appendiceal stump (one patient), and coionic endometriosis (one patient). In 16 (47 per cent) of the 34 patients evaluated for chronic bleeding, colonoscopic findings agreed with radiographic findings. Comments
From the Department of Surgery, Columbia-Presbyterian Medical Center, 622 West 168 Street, New York, New York. Requests for reprints should be addressed to Kenneth A. Forde, MD, Department of Surgery. Presbyterian Hospital, 622 West 168th Street, New York, New York 10032.
Volume 138, November 1979
Previous reports have indicated the value of colonoscopy in defining otherwise obscure causes of colonic bleeding in approximately 50 per cent of cases
627
Todd and Forde
[l-3]. Our results agree with these reports. Deyhle et al [4] reported that the source of active hemorrhage was either accurately located or excluded in 17 of 18 cases. Radiographic studies were not performed before endoscopy in their series, however, and it is likely that mesenteric angiography would have localized the bleeding site in many of the patients. We view colonoscopy as an adjunct to the radiographic evaluation of the lower gastrointestinal tract. It is not intended to replace radiographic studies. In cases of chronic blood loss through the rectum, the barium enema remains the mainstay of the diagnostic evaluation; in active acute bleeding, mesenteric angiography should be obtained to attempt localization of the bleeding site, This review indicates that colo-
628
noscopy can be of assistance in defining the source of gastrointestinal bleeding in a significant percentage of cases in which radiographic studies are either negative or inconclusive.
References 1. Britton DC, Tregoning 0, Bone G, McKelvey STD: Colonoscopy in surgical practice. BrMedJ 1: 149, 1977. 2. Waye JD: Colonoscopy in rectal bleeding. S Afr JSurg 14: 143, 1976. 3. Teague RH, Thornton JR, Manning AP, Salmon PR. Read AE: Colonoscopy for investigation of unexplained rectal bleeding. Lancet 1: 1350, 1978. 4. Deyhle P, Blum AL, Nuesch HJ, Jenny S: Emergency colonoscopy in the management of the acute peranal hemorrhage. Endoscopy 6: 229, 1974.
The American Journal of Surgery
