The Role of Flexible Sigmoidoscopy in Acute Lower GI Bleeding

Abstract

Background: Acute lower gastrointestinal (LGI) bleeding is defined as brisk blood loss from a source distal to the Ligament of Treitz. Flexible sigmoidoscopy remains the initial endoscopic investigation of choice in many centres despite suggestions that colonoscopy hastens diagnosis. Aims and Methods: This study aimed to determine the role of flexible sigmoidoscopy as a first line investigation in acute LGI bleeding. All patients admitted to a high dependency bleeding unit between 1st January 2007 and 1st August 2007 with suspected LGI bleeding were included. A retrospective review of all endoscopy reports was performed. We recorded the bowel preparation, nature of procedure and diagnosis. Subsequent investigations were documented and findings noted. Results: 133 patients were included. 64 patients (49%) were over 70 years of age, 29(22%) being over 80 years. 7 (5%) were under 30 years of age. The commonest cause of bleeding was diverticular disease (31%) followed by colitis (9%). 12% had 2 or more diagnostic findings. Flexible sigmoidoscopy was the first line endoscopic investigation in 86 patients (65%). 62 (72%) of these were unprepared examinations. In 11 patients (13%) views were inadequate due to the presence of blood,9 of which were unprepared tests. A diagnosis was subsequently made at colonoscopy in 8 cases. 5 of the 7 patients under the age of 30 had an unprepared flexible sigmoidoscopy, with a diagnosis being made in all instances. 31 (36%) patients had further imaging: 25 (80%) proceeded to colonoscopy and 6 (19%) had a barium enema. In the patients who had both a flexible sigmoidoscopy and a colonoscopy (n = 25) an additional diagnosis was made in 19 patients (76%). Colonoscopy was the first line endoscopic procedure for 22 patients (17%). 4 of these were performed without preparation although 2 subsequently had the procedure repeated with preparation. 23 patients had no lower GI endoscopic procedures. Of interest, 47 of the 120 patients aged 30-80 years underwent a colonoscopy within 6 months of their admission (39%). Conclusion: Flexible sigmoidoscopy was the investigation of choice for 65% of patients in this audit. Of these, 87% were complete studies and just over a third required further imaging. Of the 25 who had subsequent colonoscopy, only 7 were for inadequate views obtained with unprepared sigmoidoscopies. Just 47 patients (35%) underwent colonoscopy. This audit suggests flexible sigmoidoscopy remains a useful investigation for LGI bleeding, and that age as well as other clinical factors may be useful in selecting patients who would benefit from direct colonoscopy. Further prospective studies will be required to assess the benefits of such a model.