Prince of Wales Hospital Department of Surgery Journal Club Presentation March 2000

1. Prince of Wales HospitalDepartment of SurgeryJournal Club PresentationMarch 2000 Kenny Ho General Surgery Registrar Colorectal Unit

2. Journal Club Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Haemorrhage New England Journal of Medicine 342: 78-82; 2000

3. Journal Club Dennis M Jensen, Gustavo A Machicado, Rome Jutabha, Thomas Kovacs Center for Ulcer Research and Education (CURE) haemostasis Research Unit, Digestive Diseae Resarch Center, Division of Digestive Diseases, University of California at Los Angeles Center for the Health Sciences, and the Veterans Affairs Greater Los Angeles Healthcare System, LA

4. Overview Ascertain the role of endoscopy in the management of lower gastrointestinal bleeding from diverticulosis

5. Research strategy Prospectively studied 121 patients with severe PR bleeding and diverticulosis

6. Questions Posed Outcome of diverticular haemorrhage treated medically and surgically, versus those treated medically and by colonoscopy

7. End Points Rate of recurrence of diverticular haemorrhage Length of stay Other complications

8. Medical Management Hospitalisation Monitoring Resuscitation in ICU, telemetry Cease NSAIDS, Aspirin Transfusion - packed cells, other blood products

9. Urgent Colonoscopy Performed within six to twelve hours after hospitalisation or diagnosis of PR bleeding Within 1 hour clearance of stool, blood, and clots, as documented by a physician

10. Bowel preparation Sulphate purge Golytely Colyte Orally or via nasogastric tube Five to six litres

11. Definition of Diverticular Haemorrhage Colonoscopic evidence of Active bleeding Non bleeding vessel Adherent clot

12. Study design Prospective Non-randomised Historical control Entry criteria PR bleeding Colonoscopic evidence of diverticulosis

13. Two Sequential Prospective Studies June 1986 to June 1992 June 1994 to December 1998 Enrolled patients who presented with PR bleeding and diagnosis of diverticulosis on colonoscopy

14. June 1986 to June 1992 Treated Medically and Surgically Enrolled 73 consecutive patients After diagnosis, observe, transfuse if continued or recurred Severe bleeding - if patient received at least three units of packed red sells in addition to an initial transfusion for resuscitation Severe bleeding - emergency hemicolectomy

15. June 1994 to December 1998 Treated Medically and Colonoscopically Enrolled 48 consecutive patients Medical treatment as per previous Colonoscopic treatment for definite diverticular haemorrhage based on colonoscopic evidence

16. Standardized Colonoscopic Treatments Active bleeding One to two mls (1:20,000) adrenaline Non bleeding vessel Bipolar coagulation Adherent clot One to two mls adrenaline, shave clot down to three to four mm above attachment with polypectomy snare, then bipolar coagulation

17. Prevalance

18. Incidental diverticulosis Other sources of bleeding found