Fjc

b a the ability to identify patients with longstanding bleeding or with a risk of rebleeding—similar to patients with bleeding ulcers. Jensen et al. (30) and Grisolano et al. (24) have shown that, similar to acute upper gastrointestinal bleeding, evidence of active bleeding (Figs. 13.2-13.4), visible vessels (Figs. 13.5-13.8), and adherent clots (Figs. 13.9-13.11) are associated with severe course or high rate of rebleeding.

According to the literature, colonoscopy is usually performed within 12-24 hours after hospitalization (63). However, it has also been shown that earlier colonoscopy, i.e., within 12 hours after hospitalization, produces a significantly higher number of definitive diagnoses than colo-noscopies performed after a longer period of time (52). The number of endoscopic interventions was also higher among earlier colonoscopies according to this (retrospective) study.

Another concern in urgent colonoscopy is patient preparation. Chaudhry et al. (13) showed that in patients with acute lower gastrointestinal bleeding a high diagnostic yield (97%) was achieved even without bowel preparation and that hemostasis could also be effectively achieved. The authors were able to control active bleeding in 17 of 27 patients (63%) using endoscopic intervention. The results are on the whole—especially concerning diagnostic yield in urgent colonoscopy—similar with and without bowel preparation (overview provided in 63). One argument for performing urgent colonoscopy without bowel cleansing is that the localization (height) of blood found in the colon can provide information about the bleeding site—though it should be noted that colonic motility could move digestive contents forward or backward. In general, current recommendations (3) rather advise cleansing the colon as thoroughly as possible, even in situations of acute lower gastrointestinal bleeding. This improves evaluation of the mucosa, which in turn enhances recognition of smaller lesions and minimizes the risk of complications resulting from poor visualization.

Bowel cleansing is usually performed with an electrolyte solution (polyethylene glycol basis). For optimal preparation of the colon, the patient must consume 3-4 L of solution. The solution should be drunk quickly, i. e., within a few hours so that colonoscopy can be performed as soon as possible. Patients generally tolerate consumption of 1-2 L of this salty tasting solution per hour. It may be helpful to administer a prokinetic antiemetic such as metoclopramide or to administer the solution using a na-sogastric tube (2). Concerns about reactivating a bleeding source by forced large bowel cleansing have not been confirmed.

The endoscopist should attempt total intubation of the colon, i. e., he should try whenever possible to reach the base of the cecum. This is important for two reasons: first, a substantial proportion of bleeding sites are located in the a c

Fig. 13.4 Diverticular bleeding.

a Colonic mucosa covered with fresh blood. b A sea of blood visible behind a fold after irrigation.

c After further irrigation and suction a diverticulum is visible with a slightly eroded mucosa near the orifice. d Several hemoclips (Olympus) are applied to the suspected bleeding source.

Fig. 13.4 Diverticular bleeding.

a Colonic mucosa covered with fresh blood. b A sea of blood visible behind a fold after irrigation.

c After further irrigation and suction a diverticulum is visible with a slightly eroded mucosa near the orifice. d Several hemoclips (Olympus) are applied to the suspected bleeding source.

Fig. 13.5 Visible vessel in a diverticular orifice.

a Visible vessel protruding from a small diverticular orifice making it unrecognizable.

b Visible vessel is closed mechanically using a hemoclip (Olympus).

Fig. 13.5 Visible vessel in a diverticular orifice.

a Visible vessel protruding from a small diverticular orifice making it unrecognizable.

b Visible vessel is closed mechanically using a hemoclip (Olympus).

Fig. 13.6 Visible vessel protruding from a diverticulum. Edematous swelling of the mucosa on the edge of the orifice.

Was this article helpful?

0 0
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment