Inpatient flexible sigmoidoscopy (FS) is frequently requested to investigate overt lower gastrointestinal bleeding (LGIB), a condition where evidence based guidelines lack clarity. We sought to evaluate the benefit of FS in this setting, specifically: diagnostic yield, requirement for endoscopic therapy and comparison to diagnostic CT. Ultimately, to determine if FS is being over utilised.Methods
We retrospectively reviewed electronic healthcare records for all inpatients that underwent FS for LGIB (January 2016 – January 2018) at Barnet General Hospital. Recording the diagnosis on discharge; endoscopic findings; radiological findings and intervals between admission, endoscopy and discharge.Results
87 inpatients underwent FS for LGIB (44 male and 43 female patients, mean age of 69 years (range=70)). Median length of stay was 6 days (range=126). The median duration from admission to FS and FS to discharge was 2 days (range=125) and 3 days (range=49), respectively. Accounting for multiple pathologies in a single patient, documented discharge diagnoses included: diverticular disease (35.8%), haemorrhoids (15.8%) inflammatory bowel disease (7.4%) malignancy (5.3%) and infective colitis (5.3%), no cause was found in 10.5%. 46 (52.9%) patients underwent a CT scan. Findings included: diverticular disease (31.3%), colitis (19.7%) and malignancy (4.9%). FS findings included diverticular disease (44.4%), colitis (17.8%), haemorrhoids (15.6%), polyps (2.2%) and malignancy (1.1%). 41.3% of CT scans were unremarkable. FS did not identify a cause in 66.7% of cases. 54.3% of findings on CT matched endoscopic findings. 2 (2.0%) patients required surgery. 2 (2.0%) patients required interventional radiology. 5 patients (5.7%) required endoscopic therapy (2 APC for radiation proctitis, 1 haemorrhoid banding, 1 post-polypectomy bleed, 1 rectal packing), 4 (80.0%) had active bleeding during FS; with no association with comorbidities or anticoagulation. 24 (27.6%) of patients required blood transfusion. 23 (26.0%) patients underwent outpatient colonoscopy.Conclusions
FS has limited diagnostic and therapeutic yield, identifying a cause for LGIB in a third of inpatients. Most patients did not require endoscopic therapy and were not actively bleeding during FS. Endoscopic therapy was more likely if bleeding was from a rectal source (radiation proctitis, haemorrhoids, recent polypectomy). We recommend inpatient pathways incorporate clinical examination for assessment of haemorrhoids and CT scan, with most patients being managed conservatively followed by outpatient colonoscopy. Inpatient FS for LGIB in the majority is not recommended. Further studies and clear national guidance is required.