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We are writing with regard to the recently published British Society of Gastroenterology (BSG) lower GI bleeding (LGIB) guidelines.1 We have significant concerns about some of the recommendations.
The quick reference flowchart suggests that patients with stable LGIB (shock index <1), classed as having a major (risk scored) bleed, should be admitted for a lower GI endoscopy on the next available list. This is inconsistent with the main body of the guideline which states: a colonoscopy on the next available list. We find this recommendation concerning, particularly as it has implications for endoscopy unit resources, inpatient services, and patient safety. Delivering urgent inpatient colonoscopy in this cohort of patients is logistically challenging.
Is a colonoscopy necessary for all? The acute LGIB national audit showed that 73.9% of patients presented with rectal bleeding, 13.4% with rectal clots, and only 4.2% had melaena. This is in keeping with the audit’s LGIB diagnoses (26.4% diverticular disease, 16.7% benign anorectal conditions, 12.7% haemorrhoids, and 13.6% colitis), the majority (69.4%) of LGIB diagnoses arose or typically affect the left colon,2 and hence should be manageable at sigmoidoscopy.
We have concerns about the safety of colonoscopy in acutely unwell patients who are elderly. The nationwide LGIB audit showed that the median age of patients was 74 years. The guideline states colonoscopy appears to be safe, with no evidence of increased complications compared with other interventions. However, the studies referenced for safety are based on a much younger cohort of patients; mean ages of 65,3 684 and 52 years.5
With regards to timing of colonoscopy, the guideline reviews several studies that show no clear benefit on mortality for early colonoscopy (<24 hours). A large metanalysis cited compared early versus late colonoscopy in 22 720 patients, again there was no difference in mortality (0.3% vs 0.4%, p=0.24). Patients who underwent early colonoscopy had a shorter length of hospital stay (2.9 vs 4.6 days, p<0.001), decreased need for blood transfusion (44.6% vs 53.8%, p<0.001) and lower hospitalisation costs ($22 142 vs $28 749, p<0.001). However, again this was a relatively young population; the mean age of the patients was 59 years in the early colonoscopy cohort and 66 in the late cohort.6
Bowel preparation is critical for effective colonoscopy. The guideline does not suggest a specific regime but references studies that allude to the necessity of given bowel preparation via a nasogastric tube which is not without risk in the frail elderly patient. The American College of Gastroenterology clinical guideline for managing acute LGIB states; ‘Many patients with acute LGIB are unable to tolerate rapid colon preparation and thus a nasogastric tube can be placed to facilitate this process. In studies of urgent colonoscopy, as many as one-third of patients required a nasogastric tube to facilitate rapid bowel preparation’.7 This confirms that bowel preparation would be a significant challenge in this setting, and having to administer bowel preparation via nasogastric tube would be logistically demanding on acute wards.
Even with the guideline’s estimated five additional colonoscopies per hospital per month, implementing the recommendation for a next list colonoscopy in stable patients with a major bleed would have significant ramifications. National Health Service (NHS) hospitals are under considerable strain due to increasing demand and workforce shortfalls. Endoscopy services are also under huge strain due to increasing demand for symptomatic and screening procedures.8 Moreover, with much of the evidence cited being based on non-UK studies with a younger population than what would typically present in the UK, it is questionable if an urgent inpatient colonoscopy over a sigmoidoscopy is appropriate, or deliverable in the NHS.
Contributors AMV wrote the letter; NB, AC and BRD reviewed the letter and made adjustments to the text.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Patient consent for publication Not required.
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