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      Dificultades y controversias en el manejo hospitalario de la hemorragia digestiva baja Translated title: Difficulties and controversies in hospitalized patients with lower gastrointestinal bleeding

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          Abstract

          Objetivos: la hemorragia digestiva baja (HDB) es una causa frecuente de ingreso hospitalario; pese a ello, no se conocen con exactitud los factores que influyen en su evolución. Los objetivos de este trabajo fueron comparar los cambios en el manejo de la HDB en nuestro Servicio entre los años 2005 y 2007, así como analizar diferentes parámetros que pudieran influir en su pronóstico. Pacientes y métodos: se incluyeron retrospectivamente todos los ingresos por HDB durante el periodo 2005-2006 y prospectivamente los del 2006-2007. En todos se realizó historia clínica, exploración -incluyendo tacto rectal- y análisis sanguíneo. Se realizó colonoscopia en la mayoría de los pacientes. Resultados: se incluyeron 137 pacientes en el 2005-2006: requirieron transfusión de hemoderivados el 36%. El 31% había presentado algún episodio de HDB previamente. El 62% presentó una evolución favorable. El tiempo desde el ingreso hasta la colonoscopia y la estancia media fueron de 4,1 y 10,2 días respectivamente. En el 2006-2007 se incluyeron 96 pacientes: requirieron transfusión el 42%. El 33% había presentado HDB previamente. La evolución fue favorable en el 67%. El tiempo hasta la colonoscopia y la estancia media fueron de 2,6 y 7,7 días respectivamente. Los divertículos fueron el hallazgo más frecuente en ambos periodos. Conclusiones: durante el 2006-2007 la estancia media de los pacientes con HDB ingresados en el Servicio de Aparato Digestivo se redujo respecto al 2005-2006 en un 25% y el tiempo de realización de la colonoscopia en un 37%; esto no logró más localizaciones del punto sangrante ni una disminución en la recurrencia de la hemorragia.

          Translated abstract

          Objectives: lower intestinal bleeding (LGIB) is a frequent reason for hospitalization; however, the prognostic factors have not been clearly defined. The aim of this paper was to analyze several clinical parameters and the management of this entity in our department from 2005 to 2007. Material and methods: all hospitalized patients with LGIB were retrospectively (2005-2006) and prospectively (2006-2007) included. Medical records, physical examination (anal digital examination included), blood testing, and colonoscopic examination (in most of patients) were performed. Results: 137 patients were included during 2005-2006: 36% of them required blood transfusion; thirty-one percent of patients showed previous episodes of LGIB, and 62% had a favorable outcome. Time from admission to colonoscopy was 4.1 days, and length of stay was 10.2 days. In the 2006-2007 study 96 patients were included: 42% of them required blood transfusion, thirty-three percent of patients showed previous episodes of LGIB, and 68% had a favorable outcome. Time from admission to colonoscopy was 2.6 days, and length of stay was 7.7 days. The most frequent etiology was diverticulosis in both studies. Conclusions: hospital length of stay and time from admission to colonoscopy in patients with LGIB was reduced by 25% and 37%, respectively, in the 2005-2006 period with regard to the 2006-2007 one; however, there were no more bleeding points or a decrease in bleeding recurrence.

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          Most cited references 29

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          Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study.

          The aims of this prospective study were to document the incidence of colon immediate postpolypectomy bleeding (IPPB) according to grade, and to identify potential risk factors of IPPB in patients who have received complete colonoscopy and polypectomy because of a colorectal polyp. This was a prospective, cross-sectional study of 5,152 patients treated at 11 tertiary medical centers between July 2003 and July 2004. Patient-related, polyp-related, and procedure-related variables were evaluated as potential risk factors for IPPB. IPPB was defined as a bleeding occurring during the procedure and was graded as G1-G4. Risk factors associated with IPPB were analyzed by univariate and multivariate logistic regression analysis. A total of 9,336 colonic polyps were removed in 5,152 patients, and 262 (2.8%) colorectal polyps in 215 patients presented with IPPB. Polyp-based multivariate analysis revealed that old age (>or=65 yr), comorbid cardiovascular or chronic renal disease, anticoagulant use, polyp size greater than 1 cm, gross morphology of polyps such as pedunculated polyp or laterally spreading tumor, poorer bowel preparation, cutting mode of the electrosurgical current, and the inadvertent cutting of a polyp before current application were significant risk factors for IPPB. Nine factors have been found to be associated with IPPB and polypectomy should be undertaken with caution under these conditions.
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            Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial.

            We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care. Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy. A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1-6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups-including: mortality 2%versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22%versus 30%, surgery 14%versus 12%, or late rebleeding 16%versus 14% (mean follow-up of 62 and 58 months). Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.
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              Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.

              Although most diagnostic GI endoscopic procedures in Germany are performed on an outpatient basis, there is no large-scale prospective evaluation of complication rates. Ninety-four gastroenterologists and internists from all regions of Germany recorded the number of EGD, colonoscopies, and polypectomies performed over a period of 1 year. All serious complications occurring in relation to the procedure, including the use of medication, were recorded in a structured protocol. A total of 110,469 EGDs, 82,416 colonoscopies, and 14,249 polypectomies were evaluated. The "reach-the-cecum-rate" was 97% (median). The overall complication rates for EGD, colonoscopy, and polypectomy were low compared with published data (0.009%, 0.02%, and 0.36%, respectively). The perforation rates were 0.0009%, 0.005%, and 0.06%, respectively, the rates of significant hemorrhage 0.002%, 0.001%, and 0.26%, respectively, and the mortality rates 0.0009%, 0.001%, and 0.007%, respectively. The rates of cardiorespiratory complications associated with EGD and colonoscopy were 0.005% and 0.01%, respectively. The overall complication rate for all procedures (diagnostic and therapeutic) was lower for gastroenterologists (1 per 5155 procedures) than internists (1 per 1539 procedures). Most of the adverse events associated with diagnostic endoscopy were attributable to use of medication. The severity score ranged from 2 to 5 for most of the adverse events occurring as a result of diagnostic procedures and 2 to 50 for polypectomy. The severity sum score per 10,000 procedures was 26 for EGD, 67 for colonoscopy, and 1185 for polypectomy. Outpatient endoscopy performed in practice settings by German gastroenterologists and internists is safe. The low complication rates may partly be explained by the high degree of experience resulting from the larger numbers of procedures performed relative to the numbers performed by gastroenterologists in hospitals and in other countries.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                diges
                Revista Española de Enfermedades Digestivas
                Rev. esp. enferm. dig.
                Sociedad Española de Patología Digestiva (Madrid, Madrid, Spain )
                1130-0108
                September 2008
                : 100
                : 9
                : 560-564
                Affiliations
                orgnameCentro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)
                orgnameHospital Universitario de La Princesa orgdiv1Servicio de Hepatogastroenterología
                Article
                S1130-01082008000900006
                10.4321/s1130-01082008000900006

                This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 International License.

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