| Summary: | 博士 === 中山醫學大學 === 醫學研究所 === 93 === Background: Colonoscopy is usually first considered in massive lower astrointestinal (GI) bleeding because it is accessible in detecting the cause and is effective in treating the bleeding. Few studies have investigated the value of colonoscopy for patients with comorbid diseases, especially critically ill patients, acquired significant lower GI bleeding after admission to ward or intensive care units.
Aims: To get a clinical picture of the frequency, the etiology and the clinical impact of lower GI bleeding acquired by critically ill adults during their stay in the ward or intensive care units of an university-affiliated hospital in Taiwan.
Methods: (1). In the first study, we collect the data of hospitalized patients with acute lower gastrointestinal bleeding during their hospital stay. From January 2001 to December 2003, 107 hospitalized patients with acute lower gastrointestinal bleeding were evaluated by urgent colonoscopy. Our analyses compared the etiology and clinical characteristics of bleeding in patients with (Group A) and without (Group B) one or more comorbid illnesses.
(2). In the second study, we study the critically ill patients in intensive care units and try to emphasize the role of urgent colonoscopy in these patients. From July 1, 2000 to June 30, 2003, 55 (0.94%) out of 5860 patients admitted to ICU acquired during their stay in the ICU a lower GI bleeding that required a colonoscopy done on an emergency basis. The baseline characteristics, data on the maneuver (colonoscopy), diagnosis of bleeding lesion, and outcomes of patients were collected and analyzed.
Results: (1). In the first study, Group A patients (patients with comorbid diseases) tended to have longer hospital stays, more severe anemic conditions, and more transfusion requirements. The overall mortality rate was 29.5% in group A and 4.3% in group B (patients without comorbid disease) (p<0.05). Bleeding-related mortality was not significantly different between these two groups. Colitis, rectal ulcer, and angiodysplasia were the leading causes of lower gastrointestinal bleeding in group A. Rectal ulcer was a more common cause of bleeding in group A (16.4%) than in group B (2.1%) (p <0.05), and it resulted in longer hospital stays and more severe anemia and leukocytosis compared to patients with other causes of lower gastrointestinal bleeding.
(2). In the second study, the colonoscopy was successful in determining the source of bleeding in most patients (67.3%); its source was located in the left colon in most instances (78.4%). Colitis (ischemic, infectious or non-specific), rectal ulcers, tumors and diverticular diseases were the most frequent causes of bleeding. No serious adverse events happened during the colonoscopy. Overall in-hospital mortality was 52.7%, however, the bleeding was the immediate cause of death in only two patients. By employing multivariate regression analysis, we identified that an APACHE II score higher than 18 was the only independent predictor of mortality in our patients with lower GI bleeding after ICU admission. Neither endoscopic diagnosis nor therapeutic procedure by colonoscopy affected the final outcome.
Conclusions: Patients with acute LGI bleeding that starts after hospitalization of patients for other comorbid illnesses have distinctive etiologies and clinical characteristics compared with patients admitted to the hospital only for acute LGI bleeding. Colitis, hemorrhagic rectal ulcer, and angiodysplasia are the leading causes of LGI bleeding in patients with comorbid illnesses, while diverticular disease and carcinoma were significantly rare in these patients. Hemorrhagic rectal ulcer is an important but obscure cause of acute LGI bleeding in elderly patients with significant comorbid diseases. Bedsides, this study describes that the sources of lower GI bleeding in patients staying in ICUs are different from those in outpatients. Urgent colonoscopy in these patients is safe and has similar diagnostic accuracy and therapeutic capability. However, a lower rate of spontaneous cessation of bleeding, a higher rate of rebleeding, and an extremely high mortality rate in this population reflect the severe general condition of the underlying diseases. The APACHE II score, rather than whether a patient received a urgent colonoscopy, may better predict outcomes in this high-risk population. Knowledge of these data may help critical care clinicians estimate the potential benefits or hazards of urgent colonoscopy in critically ill patients and make the most advantageous clinical decision.
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