RESUMEN
BACKGROUND: Urgent colonoscopy is not always the preferred initial intervention in severe lower GI bleeding because of the need for a large volume of oral bowel preparation, the time required for administering the preparation, and concern regarding adequate visualization. OBJECTIVE: To evaluate the feasibility, safety, and outcomes of immediate unprepared hydroflush colonoscopy for severe lower GI bleeding. DESIGN: Prospective feasibility study of immediate colonoscopy after tap-water enema without oral bowel preparation, aided by water-jet pumps and mechanical suction devices in patients admitted to the intensive care unit with a primary diagnosis of severe lower GI bleeding. SETTING: Tertiary referral center. MAIN OUTCOME MEASUREMENTS: Primary outcome measurement was the percentage of colonoscopies in which the preparation permitted satisfactory evaluation of the entire length of the colon suspected to contain the source of bleeding. Secondary outcome measurements were visualization of a definite source of bleeding, length of hospital and intensive care unit (ICU) stays, rebleeding rates, and transfusion requirements. RESULTS: Thirteen procedures were performed in 12 patients. Complete colonoscopy to the cecum was performed in 9 of 13 patients (69.2%). However, endoscopic visualization was thought to be adequate for definitive or presumptive identification of the source of bleeding in all procedures, with no colonoscopy repeated because of inadequate preparation. A definite source of bleeding was identified in 5 of 13 procedures (38.5%). The median length of ICU stay was 1.5 days; of hospital stay, 4.3 days. Recurrent bleeding during the same hospitalization, requiring repeated endoscopy, surgery, or angiotherapy, was seen in 3 of 12 patients (25%). LIMITATIONS: Uncontrolled feasibility study of selected patients. CONCLUSION: Immediate unprepared hydroflush colonoscopy in patients with severe lower GI bleeding is feasible with the hydroflush technique.
Asunto(s)
Enfermedades del Colon/diagnóstico , Colonoscopía/métodos , Enema/métodos , Hemorragia Gastrointestinal/diagnóstico , Anciano , Anciano de 80 o más Años , Transfusión Sanguínea/estadística & datos numéricos , Enfermedades del Colon/terapia , Enema/instrumentación , Estudios de Factibilidad , Femenino , Hemorragia Gastrointestinal/terapia , Hemostasis Endoscópica , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Gravedad del Paciente , Satisfacción del Paciente/estadística & datos numéricos , Estudios Prospectivos , Recurrencia , AguaRESUMEN
BACKGROUND: Preliminary research suggests that rectally administered nonsteroidal antiinflammatory drugs may reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In this multicenter, randomized, placebo-controlled, double-blind clinical trial, we assigned patients at elevated risk for post-ERCP pancreatitis to receive a single dose of rectal indomethacin or placebo immediately after ERCP. Patients were determined to be at high risk on the basis of validated patient- and procedure-related risk factors. The primary outcome was post-ERCP pancreatitis, which was defined as new upper abdominal pain, an elevation in pancreatic enzymes to at least three times the upper limit of the normal range 24 hours after the procedure, and hospitalization for at least 2 nights. RESULTS: A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03). CONCLUSIONS: Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00820612.).