Acute lower gastrointestinal bleeding: crucial points in inpatient management for optimal urgent colonoscopy.

We are grateful for the opportunity to reply to the letter “Does the sentence “less is more” apply to bowel preparation?” by Pontone 1 . In accordance with the latest European Society of Gastrointestinal Endoscopy (ESGE) guidelines, which advise against unprepped endoscopy in acute lower gastrointestinal bleeding (LGIB) 2 , we totally agree that fasting and the cathartic effect of blood are not sufficient to obtain adequate bowel cleansing.

In addition to this, we would like to underscore the importance of some crucial factors that facilitate optimal quality of urgent colonoscopy in acute LGIB. General and hemodynamic assessment of the patient and adequate resuscitation are the essential steps to define eligibility for endoscopic examination and, in turn, the timing and type of bowel preparation (BP). The timing of endoscopy and the type of BP selected are mutually dependent on each other. Indeed, we have experienced that in high-risk patients with acute hemorrhagic shock and severe cardiovascular comorbidities, a very low-volume and therefore hyperosmolar bowel preparation can achieve optimal cleansing safely and more rapidly 3 . This approach has multiple advantages, including an increased likelihood of identifying the bleeding point, the possibility of performing targeted endoscopic treatment that results in effective hemostasis, and finally, the option to restart antithrombotic therapy sooner when indicated. In addition, we would like to underscore that 1 L of iso-osmolar bowel preparation is not equivalent to 1 L of hyperosmolar bowel preparation, and it is unlikely to have the same efficacy compared to 1 L of the newly available very-low-volume hyperosmolar bowel preparation.

It is useful to know that other groups have experienced similar good results using very-low-volume bowel preparation for colonoscopy in acute LGIB 4 . These observations have also been taken into consideration in the latest ESGE guidelines 2 , in which this strategy has been labelled as “encouraging.” Therefore, it is highly desirable to continue sharing this expanding knowledge.