Cremone Cristiano, Esch Anouk, Gagniere Charlotte, Fugazza Alessandro, Mesli Faria, Levy Michael, Amiot Aurelien, Laurent Alexis, LeBaleur Yann, Hemery Francois, De'Angelis Nicolas, Brunetti Francesco, Sobhani Iradj
EC2M3: Department of Academic Research (EA7375) Université Paris Est Créteil (UPEC) - Val de Marne, France.
Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy.
Endosc Int Open. 2017 Nov;5(11):E1119-E1127. doi: 10.1055/s-0043-118001. Epub 2017 Nov 8.
Urgent endoscopy is often used to diagnose and sometimes treat acute upper gastrointestinal syndromes (hemorrhage, toxic ingestion, and occlusion). However, its suitability concerning the management of lower gastrointestinal conditions in emergency circumstances is controversial.
We studied the role of emergency colonoscopy in diagnosis and treatment of all consecutive patients presenting with acute lower gastrointestinal symptoms referred to our hospital on an emergency basis. All patients were first managed by physicians from the emergency room and/or the intensive care unit (ICU); the treatments included fluid resuscitation, blood transfusion, and antibiotic or cardiotonic as needed. Bowel cleansing was performed to purge the colon of clots, stool, and blood when clinically possible; alternatively, a bowel enema was used. Patients only underwent a computed tomography (CT) scan prior to the colonoscopy in clinically relevant situations. Colonoscopy was performed within 6 - 36 hours after hospitalization or the beginning of the clinical symptoms (hemorrhage, sepsis, colon distension) or occlusion, as assessed by abdominal CT scan.
From 2010 to 2015, 603 patients underwent urgent colonoscopy; among them, 214 (36 %) presented with lower GI bleeding, while 264 (44 %) had symptoms suggestive of intestinal ischemia; almost half (49 %, n = 295) of the patients were hospitalized in the ICU. Patients received therapies, such as clips (15 %), epinephrine injections (5 %), bipolar coagulation (7 %), or devolvulation (3 %) using colonoscopy or antibiotic therapy when needed. No perforation was observed after colonoscopy and only three cases of hemorrhage recurrence were documented as complications after the procedure. Overall, 192 patients died within 1 month after colonoscopy due to four independent risk situations, as follows: septic shock, heart transplantation, multiorgan failure, and ischemic colitis. Only 67 (35 %) underwent urgent intestinal surgery when ischemic colitis was identified, and this did not have a significant effect on the mortality rate.
Urgent bedside colonoscopy is feasible and safe for routine use. The highest advantage was observed in patients with red blood hemorrhage, diarrhea, and colon distension when symptoms were not associated with multiorgane failure, heart transplantation, or septic shock. As revealed by colonoscopy and pathological features, ischemic colitis is associated with a bad prognosis, and patients experience a higher rate of early mortality regardless of whether they undergo urgent colon surgery.
急诊内镜检查常用于诊断急性上消化道综合征（出血、中毒性摄入和梗阻），有时也用于治疗。然而，其在紧急情况下处理下消化道疾病的适用性存在争议。
我们研究了急诊结肠镜检查在诊断和治疗所有因急性下消化道症状紧急转诊至我院的连续患者中的作用。所有患者首先由急诊室和/或重症监护病房（ICU）的医生进行处理；治疗措施包括液体复苏、输血以及根据需要使用抗生素或强心剂。在临床可行时进行肠道清洁，以清除结肠内的血凝块、粪便和血液；如有必要，也可使用灌肠。仅在临床相关情况下，患者在结肠镜检查前进行计算机断层扫描（CT）。结肠镜检查在住院后或临床症状（出血、脓毒症、结肠扩张）或梗阻开始后的6至36小时内进行，由腹部CT扫描评估。
2010年至2015年期间，603例患者接受了急诊结肠镜检查；其中，214例（36%）出现下消化道出血，264例（44%）有提示肠道缺血的症状；近一半（49%，n = 295）的患者入住ICU。患者接受了诸如使用结肠镜检查夹闭（15%）、注射肾上腺素（5%）、双极电凝（7%）或套扎（3%）等治疗，或根据需要进行抗生素治疗。结肠镜检查后未观察到穿孔，术后仅记录到3例出血复发并发症。总体而言，192例患者在结肠镜检查后1个月内死亡，原因有以下四种独立风险情况：感染性休克、心脏移植、多器官功能衰竭和缺血性结肠炎。当确诊为缺血性结肠炎时，仅67例（35%）患者接受了急诊肠道手术，这对死亡率没有显著影响。
急诊床边结肠镜检查常规使用可行且安全。在无多器官功能衰竭、心脏移植或感染性休克相关症状的红细胞出血、腹泻和结肠扩张患者中观察到最大优势。如结肠镜检查和病理特征所示，缺血性结肠炎预后不良，无论患者是否接受急诊结肠手术，早期死亡率均较高。
