Objective: To investigate the value of urgent colonoscopy in the diagnosis of severe acute lower gastrointestinal bleeding and the optimal bowel preparation before examination.
Methods: The clinical data were collected from 188 patients undergoing wither urgent or elective colonoscopy for severe acute lower gastrointestinal bleeding in Nanfang Hospital. Univariate analysis was used to assess the effect of the timing of colonoscopy on the diagnostic rate of hemorrhage, and a multivariate model which stratified bowel cleanliness was used to analyze the impact of bowel cleanliness on the diagnostic rate of urgent colonoscopy.
Results: Of the 188 patients, 118 underwent urgent colonoscopy and 70 underwent elective colonoscopy examinations. The diagnostic rates were comparable between the two groups (44.1% vs 41.4%, P=0.724), but urgent colonoscopy resulted in a significantly higher diagnostic rate for identifying the bleeding source (32.2% vs 18.6%, P=0.041). The proportion of the patients taking oral laxatives was significantly lower in urgent colonoscopy group (P<0.001). Oral laxatives versus enema resulted in good, moderate, and poor bowel cleanliness in 63.6% vs 13.5%, 28.6% vs 24.3%, and 7.8% vs 62.2% of the patients (P<0.001). Univariate analysis indicated that good bowel cleanliness was associated with a significantly higher diagnostic rate of colonoscopy than poor bowel cleanliness (P=0.012). Multivariate analysis showed that with good bowel cleanliness, urgent colonoscopy yielded a significantly higher diagnostic rate than elective colonoscopy (P=0.030); subgroup analyses suggested that good bowel cleanliness improved the diagnostic rate of urgent colonoscopy as compared with poor bowel cleanliness (P=0.015).
Conclusion: In patients with good bowel cleanliness, urgent colonoscopy yields a higher diagnostic rate than elective colonoscopy for severe acute lower gastrointestinal bleeding. Poor bowel cleanliness resulting from bowel preparation by enema significantly lowers the diagnostic performance of urgent colonoscopy. Oral laxatives are recommended over enemas for bowel preparation before urgent colonoscopy when the patients have stable hemodynamics.
目的: 探讨急性下消化道大出血患者进行急诊肠镜的必要性及最佳肠道准备方式。
方法: 收集近年南方医院188例急性下消化道大出血病例结肠镜检查相关资料，根据检查时机将患者分为急诊组与择期组，通过单因素分析不同肠镜检查时机对急性下消化道大出血诊断率的影响，在此基础上纳入肠道清洁度进行多因素分层分析，分析不同肠道清洁度对急诊肠镜诊断率的影响。
结果: 急诊组118例，择期组70例，两组的诊断率无统计学差异（P=0.724），但急诊组确定性出血灶的诊断率显著高于择期组（P=0.041），口服泻药的比例则显著低于择期组（P < 0.001）。肠道清洁度“优”、“良”、“差”在口服泻药及清洁灌肠的患者中的比例依次为63.6% vs 13.5%、28.6% vs 24.3%、7.8% vs 62.2%（P < 0.001）。单因素Logistic分析结果示，清洁度“优”较“差”显著提高肠镜诊断率（P=0.012），多因素logistic模型中，分组与清洁度的交互效应分析结果显示清洁度“优”时急诊组诊断率显著高于择期组（P=0.030）；亚组分析结果显示，急诊组清洁度“优”时诊断率显著高于清洁度“差”（P=0.015）。
结论: 当肠道清洁度为“优”时，急诊肠镜对急性下消化道大出血的诊断率优于择期肠镜，但通过清洁灌肠准备肠道时肠道清洁度差，从而降低了其诊断优势，因此在患者血流动力学稳定的前提下，急诊肠镜肠道准备应尽量选用口服泻药。