Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.

The purpose of this study was to prospectively evaluate (a) the diagnosis and treatment of 80 consecutive patients with severe, ongoing hematochezia from unknown source and (b) the effectiveness and safety of urgent colonoscopy after oral purge. Fifty-two men and 28 women (mean age, 64.5 yr) received a mean of 6.5 U of blood and had negative anoscopy, rigid sigmoidoscopy, and nasogastric tube aspiration before our evaluation. Because of ongoing severe hematochezia in the intensive care unit, urgent diagnosis and treatment was recommended by the attending physicians and surgeons. Emergency panendoscopy was performed before purge. Urgent colonoscopy was performed in the intensive care unit after patients received oral purge and their gut was cleared of blood, clots, and stool. The final diagnosis in these patients was 74% colonic lesions (30% angiomata, 17% diverticulosis, 11% polyps or cancer, 9% focal ulcers, 7% other), 11% upper gastrointestinal lesions, and 9% presumed small bowel lesions. No lesion site was identified in 6%. Clinically significant fluid retention (medically controlled) occurred in 4% of patients after purge. Sixty-four percent of patients had intervention for control of bleeding: 39% had therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography. For 22 patients who also had emergency visceral angiography, the diagnostic yield was 14% and the complication rate was 9%. Our conclusions for patients with severe ongoing hematochezia from an unknown site were as follows. (a) Oral purge was effective and safe for cleansing the colon of stool, clots, and blood. Sulfate purge appeared to be safer than saline purge. (b) Before urgent colonoscopy and purge, emergency panendoscopy was indicated to exclude an upper gastrointestinal bleeding source. (c) Urgent colonoscopy after purge was effective, safe, and often diagnostic. (d) Compared with urgent colonoscopy, urgent visceral angiography was often nondiagnostic. However, the examinations may be complementary. (e) Hemostasis via colonoscopy has a definitive role in the treatment of some focal colonic lesions such as bleeding angiomata.