Intensive Care Med (2005) 31:743–746

DOI 10.1007/s00134-005-2604-6 BRIEF REPORT

Chun-Che Lin
Yi-Chia Lee
Bedside colonoscopy for critically ill patients
Huei Lee with acute lower gastrointestinal bleeding
Jaw-Town Lin
Wei-Chi Ho
Tan-Hsia Chen
Hsiu-Po Wang

Received: 14 May 2004
Accepted: 1 March 2005
Published online: 1 April 2005

Springer-Verlag 2005
C.-C. Lin · W.-C. Ho · T.-H. Chen
Department of Internal Medicine,
Chung Shan Medical University Hospital,
No. 110, Sec. 1, Chien Kuo N. Rd., 402
Taichung, Taiwan
Y.-C. Lee · J.-T. Lin
Department of Internal Medicine,
National Taiwan University Hospital,
No. 7 Chung-Shan S. Rd, 10017 Taipei,
Taiwan
H. Lee
Institute of Toxicology,
Chung Shan Medical University Hospital,
No. 110, Sec. 1, Chien Kuo N. Rd., 402
Taichung, Taiwan
H.-P. Wang ())
Department of Emergency Medicine,
National Taiwan University Hospital,
No. 7 Chung-Shan S. Rd, 10017 Taipei,
Taiwan
e-mail: whp@ha.mc.ntu.edu.tw
Tel.: +886-2-23123456
Fax: +886-2-23947899
Abstract Objective: To determine
the clinical impact of bedside colo-
noscopy for critically ill patients with
acute lower gastrointestinal (GI)
bleeding. Design and setting: A 3-
year retrospective analysis (chart re-
view). Medical intensive care unit
(ICU) of a 1,312-bed tertiary-care
center in Taiwan. Patients and par-
ticipants: Fifty-five people undergo-
ing bedside colonoscopy for lower GI
bleeding that developed while in the
ICU. Interventions: Bedside colo-
noscopy. Measurements and results:
Colonoscopy was successful in diag-
nosing the source of bleeding in 37
patients. Among them, colitis (15
patients, including ischemic, pseudo-
membranous, or radiation-induced)
and acute hemorrhagic rectal ulcer
(nine patients) were the most frequent
confirmed causes. In seven patients,
fresh blood was noticed above the
colonoscopically accessible area and
considered to originate from the
small bowel. No adverse event was
associated with colonoscopy. Spon-
taneous cessation of bleeding was
noted in 29 (29/55, 53%) patients,
whereas 16 (16/55, 29%) achieved
endoscopic hemostasis. Ten (10/55,
18%) patients failed primary hemo-
stasis or localization. Overall in-hos-
pital mortality was 53% (29/55);
however, hemorrhage-related death
occurred in only two patients. Con-
clusions: ICU patients with acute
lower GI bleeding have distinctive
causes. Bedside colonoscopy is ef-
fective for diagnosis in two-thirds of
patients, but only a minority of them
needs endoscopic hemostasis.
Keywords Colonoscopy ·
Gastrointestinal hemorrhage ·
Intensive care unit

Introduction orrhage [3–5]. For ICU patients with acquired hemor-

Critically ill patients often develop gastrointestinal (GI)
bleeding [1, 2]. Although the potential benefit of upper GI
endoscopy has been established [3,4], limited work has
addressed lower GI bleeding in these patients [5,6].
Jensen et al. [7] found urgent oral purge and colo-
noscopy effective in managing patients with severe he-
matochezia and demonstrated a 74% diagnostic rate with
potential therapeutic benefit. However, most studies have
enrolled patients admitted to the ICU primarily for hem-
rhage and hemodynamic instability, questions remain
concerning colonoscopy after purge.
We reviewed charts for patients with lower GI bleed-
ing from the medical ICU of our hospital to determine the
safety of colonoscopy and to characterize sources of
hemorrhage.
744

Materials and methods Table 1 Demographic data and clinical outcomes in 55 patients
who received bedside colonoscopy in intensive care units for lower
Among 5,860 adults (age over 18 years) admitted to the medical GI bleeding. Quantitative data are summarized as mean € standard
ICU of our hospital (1,312 beds, 46 medical-ICU beds) between deviation ( SD) ( APACHE II Acute Physiology and Chronic Health
July 2000 and June 2003, we identified 55 patients who underwent Evaluation II score [8], NSAID nonsteroidal anti-inflammatory
bedside colonoscopy for acute lower GI bleeding. Critical care drug)
physicians evaluated severity of hemorrhage and determined whe- Characteristics Patients (n=55)
ther it originated from a lower GI source. A bedside colonoscopy
was performed within 24 h if deemed appropriate by GI consul- Reasons for ICU admission
tants. Clinically significant lower-GI bleeding was defined as the Respiratory failure 25
passage of bright red blood per rectum with a decrease in hemo- Sepsis 13
globin of 2 g/dl in 24 h and/or transfusion of at least 2 units of Acute cerebrovascular accident 7
packed red blood cells [1]. Three exclusion criteria were: (a) sig- Congestive heart failure with circulatory 7
nificant cause of upper GI bleeding demonstrated by hematemesis compromise
or coffee-ground vomiting, nasogastric drainage, or esophagogas- Cardiopulmonary arrest post-resuscitation 3
troduodenoscopy; (b) admission to hospital or transfer to ICU be- Age (years) 74.8 (10.4)
cause of GI hemorrhage; and (c) hemodynamic stability sufficient Gender (male) 27
to undergo colonoscopy in the endoscopic suite. APACHE II 20.8 (5.9)
A 133-cm colonoscope (CF 240AI; Olympus Optical, Tokyo, Mechanical ventilation 37
Japan) was used. Bowel preparation consisted of enemas or oral Presence of shock 20
polyethylene glycol solution when appropriate. Endoscopic char- Decrease in hemoglobin (g/dl) 2.4 (1)
acteristics included successful cecal intubation, endoscopic diag- Presence of coagulopathy 16
nosis, mode of endoscopic hemostasis, and successful primary Use of anticoagulant or NSAID 10
hemostasis. Demographic data included age, gender, APACHE II Days to colonoscopy 9.2 (6.4)
(Acute Physiology and Chronic Health Evaluation II) score [8], use Cecal reach 32
of mechanical ventilation, presence of shock (systolic blood pres- Identification of bleeder 37
sure <90 mmHg and peripheral circulatory failure), decrease of Angiography 2
hemoglobin, coagulopathy, use of anticoagulant or other nons- Surgery 4
teroidal anti-inflammatory drug, and days to colonoscopy. Outcome Length of ICU stay (days) 21.8 (11.8)
variables included recurrent bleeding rate, angiography, surgery, In-hospital mortality 29
duration of ICU stay, and in-hospital mortality. Coagulopathy was
defined as a platelet count <50,000/mm3 or an international nor-
malized ratio >1.2. Primary hemostasis was defined as endoscopi-
cally verified cessation of bleeding for at least 1 min after hemo- colon in five. Endoscopic diagnoses were ischemic colitis
stasis. Recurrent bleeding was defined as overt hemorrhage with in ten patients, acute hemorrhagic rectal ulcers in nine,
instability of vital signs or reduction of hemoglobin level in excess pseudomembranous colitis in four, diverticular disease in
of 2 g/dl within 24 h after successful primary hemostasis [6].
Quantitative data were summarized as mean € standard deviation four, polyps in four, angiodysplasia in three, cancer in
(SD) and categorical variables as number (%). two, and radiation colitis in one.
During colonoscopy, spontaneous cessation of bleeding
without hemostasis occurred in 29 (29/55, 53%) patients.
Results In the other 26 patients, primary endoscopic hemostasis
was achieved in 16. Among them, six patients underwent
Fifty-five patients were evaluated (27 males/28 females, endoscopic therapy with diluted epinephrine (1:10,000)
mean age 74.8 years, range 47–90). Their reasons for ICU injection, five with hemoclipping, four with argon plasma
admission are illustrated in Table 1. The average APACHE coagulation, and one with ethanol injection. For the re-
II score was 20.8 (range 8–33). Of these 55 patients, 19 had maining ten patients, endoscopy identified the bleeders in
hemoglobin decreases of greater than 2 g/dl; 17 were four patients but subsequent hemostasis failed; of these,
transfused with more than 2 units, and 19 had both. two patients were treated supportively, one surgically, and
The clinical outcomes are also listed in Table 1. Cecal one angiographically. Three patients underwent surgery
intubation was achieved in 32 patients. Sources of due to failed localization; two had bleeding ulcers in the
bleeding were diagnosed in 37 (37/55, 67%) patients: In distal ileum and one in the jejunum. One patient underwent
23, a bleeder was confirmed after a complete colonoscopy angiography due to failed localization. An ileal bleeder
to the cecum. In the remaining 14 cases, a distal bleeding was found and required intra-arterial vasopressin infusion.
source with proximal brownish stool made further ad- The final two patients were treated supportively for ob-
vance unnecessary. Bleeders could not be identified in 18 scure bleeding sources. After successful primary hemo-
patients. In ten, localization was impossible due to blood stasis, in-hospital rebleeding occurred in three patients,
interference. In seven, bleeding sources were thought to with one treated supportively and two re-endoscopically.
originate from the small bowel because fresh blood was Overall, in-hospital mortality was 53% (29/55). Hemor-
still noted above the colonoscopically accessible area. In rhage-related death occurred in two patients. Other causes
one patient, poor preparation made colonoscopy impos- of death were septic shock (12/55), respiratory failure (9/
sible. Responsible lesions were in the left colon in 29 55), multiple organ failure (4/55), and cardiac arrhythmia
patients, in the transverse colon in three, and in the right (2/55). No complications were related to colonoscopy.
 745

Discussion Chaudhry et al. and Fabry et al. reported spontaneous

Most data on lower GI bleeding come from patients who
bled before admission [7,9]. Knowledge is limited on
hemorrhage that occurs during hospitalization. Our inci-
dence of 0.94% (55/5,860) suggests a rarity similar to the
range of 1.1–1.5% incidence for upper GI hemorrhage
acquired in the ICU [1,6]. For acute lower GI bleeding,
several diagnostic modalities, including colonoscopy,
angiography, scintigraphy, and dynamic enhanced com-
puted tomography (CT) have been utilized to identify the
bleeding source with a widely variable diagnostic rate
(45–95%) [9]. Colonoscopy has been emphasized for its
therapeutic effect, but safety is a major concern. In the
present study, we demonstrated an acceptable diagnostic
rate of 67% (37/55) without procedure-related complica-
tions. This demonstrates bedside colonoscopy after purge
is safe for critically ill inpatients.
Sources of lower GI bleeding in ordinary patients are
mostly in the left colon [9], with angiodysplasia, diver-
ticular disease, polyp, and carcinoma accounting for more
than 50% of cases of hematochezia [11,12]. For critically
ill patients with severe hematochezia, similar causes were
demonstrated in one study [7]. In our study, 78% (29/37)
of responsible lesions were in the left colon. However,
characterization of bleeders differed substantially. Isch-
emic colitis, acute hemorrhagic rectal ulcer, and pseudo-
membranous colitis predominated, and they corresponded
with comorbidity, older age, hemodynamic instability,
and prolonged antibiotic use. Colonic ischemia was
probably due to circulatory failure including heart failure,
sepsis, hypovolemia, burns, pancreatitis, and severe di-
arrhea [13]. Mesenteric atherosclerosis also puts older
subjects at risk for ischemia [14]. Acute hemorrhagic
rectal ulcer is common in elderly bedridden patients,
manifesting as massive hemorrhage [15]. Pseudomem-
branous colitis is well documented as a cause of lower GI
hemorrhage in ICU patients [16].
Although lower GI bleeding sometimes requires
endoscopic hemostasis, it can be self-limited [11,12].
cessation rates of lower GI bleeding of 68% and 78%,
respectively [9,17]. Chaudhry reported a primary hemo-
stasis rate of 63% and rebleeding rate of 3.5% [9]. In the
present study, we found a substantial likelihood of
spontaneous cessation (29/55, 53%) after optimization of
patients. Although a similar primary hemostasis rate (16/
26, 62%) was achieved, we had a higher rate (3/16, 19%)
of recurrent bleeding. This may be explained by sub-
stantial differences in responsible lesions, in addition to
poor patient hemodynamics and a higher prevalence of
coagulopathy [18]. Our study had an overall mortality
rate of 53% (29/55), a result that seems to be lower than
that of ICU patients with acute upper GI bleeding
(77.1%) [6]. However, our hemorrhage-related mortality
rate was low (2/55), which is compatible with reported
rates of 6.2% and 0% [5,6]. Similar to previous studies,
our finding implies that the majority of deaths are due to
deterioration of underlying disease rather than exsan-
guination.
Algorithms for diagnosing lower GI bleeding have
emphasized the role of multi-step radiological investiga-
tions. Scintigraphy and enhanced helical CT may provide
55–80% positive rates, but they remain diagnostic tools
without therapeutic value [19,20]. Angiography can offer
vasopressin infusion, embolization, and selective catheter
localization for potential therapy with 60–70% diagnostic
success and 50% hemostasis rate [9]. Although colonos-
copy requires a better optimization of patients, it offers a
lower rebleeding rate compared with an approximately
50% rebleeding rate after angiography.
In conclusion, this study indicates that ICU patients
with acute lower GI bleeding are uncommon and have
distinctive causes for their hemorrhage. Although bedside
colonoscopy after purge is safe with substantial diagnostic
accuracy in two-thirds of these patients, only a minority
needs endoscopic hemostasis. Knowledge of these data
may be helpful for clinicians to initiate medical therapy
before performing colonoscopy.

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