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Efficacy of Combination Therapy with Epinephrine Local Injection and Hemostatic Clips on Active Diverticular Bleeding. J Clin Med 2022; 11:jcm11175195. [PMID: 36079125 PMCID: PMC9457277 DOI: 10.3390/jcm11175195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Epinephrine local injection is a hemostatic procedure used in active diverticular bleeding that elicits vasoconstriction and tamponade effects. We compared the additional benefit of combination therapy with HSE-C (hypertonic saline epinephrine injection with clipping) to clipping monotherapy. Retrospective data on diverticular bleeding between 2011 and 2016 was reviewed. Those with an active bleeding source confirmed by colonoscopy (excluding non-bleeding vessels and adherent clots) who received either HSE-C or clipping were evaluated. Endpoints were rates of successful primary hemostasis, recurrent bleeding, and surgical intervention during hospitalization. A total of 320 patients with diverticular bleeding were evaluated, on which either HSE-C (n = 35) or clipping monotherapy (n = 18) was performed. Rates of successful primary hemostasis (91.4% vs. 66.7%, p = 0.048) and direct placement of endoclips (60.0% vs. 16.7%, p = 0.004) were significantly higher in the HSE-C group. Although not statistically significant, the HSE-C group had a higher rate of early rebleeding (18.8% vs. 8.3%, p = 0.653), while no difference was seen in the number of patients requiring surgery (11.4% vs. 5.5%, p = 0.651). HSE-C is associated with a higher rate of successful primary hemostasis for severe active diverticular bleeding but has no significant difference in reducing early recurrent bleeding or the number of patients requiring surgery, suggesting that hemostatic effects may be temporary.
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Gobinet-Suguro M, Nagata N, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kawagishi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Uemura N, Itawa E, Sugimoto M, Fukuzawa M, Kawai T, Kaise M, Itoi T. Treatment strategies for reducing early and late recurrence of colonic diverticular bleeding based on stigmata of recent hemorrhage: a large multicenter study. Gastrointest Endosc 2022; 95:1210-1222.e12. [PMID: 34979112 DOI: 10.1016/j.gie.2021.12.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 12/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Treatment strategies for colonic diverticular bleeding (CDB) based on stigmata of recent hemorrhage (SRH) remain unstandardized, and no large studies have evaluated their effectiveness. We sought to identify the best strategy among combinations of SRH identification and endoscopic treatment strategies. METHODS We retrospectively analyzed 5823 CDB patients who underwent colonoscopy at 49 hospitals throughout Japan (CODE-BLUE J-Study). Three strategies were compared: find SRH (definitive CDB) and treat endoscopically, find SRH (definitive CDB) and treat conservatively, and without finding SRH (presumptive CDB) treat conservatively. In conducting pairwise comparisons of outcomes in these groups, we used propensity score-matching analysis to balance baseline characteristics between the groups being compared. RESULTS Both early and late recurrent bleeding rates were significantly lower in patients with definitive CDB treated endoscopically than in those with presumptive CDB treated conservatively (<30 days, 19.6% vs 26.0% [P < .001]; <365 days, 33.7% vs 41.6% [P < .001], respectively). In patients with definitive CDB, the early recurrent bleeding rate was significantly lower in those treated endoscopically than in those treated conservatively (17.4% vs 26.7% [P = .038] for a single test of hypothesis; however, correction for multiple testing of data removed this significance). The late recurrent bleeding rate was also lower, but not significantly, in those treated endoscopically (32.0% vs 36.1%, P = .426). Definitive CDB treated endoscopically showed significantly lower early and late recurrent bleeding rates than when treated conservatively in cases of SRH with active bleeding, nonactive bleeding, and in the right-sided colon but not left-sided colon. CONCLUSIONS Treating definitive CDB endoscopically was most effective in reducing recurrent bleeding over the short and long term, compared with not treating definitive CDB or presumptive CDB. Physicians should endeavor to find and treat SRH for suspected CDB.
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Affiliation(s)
- Maya Gobinet-Suguro
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba Hospital, Ibaraki, Japan; Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan; Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kana Kawagishi
- Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, and Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| | - Eri Itawa
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Mitushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Kishino T, Nagata N, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kawagishi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Kaise M. Endoscopic direct clipping versus indirect clipping for colonic diverticular bleeding: A large multicenter cohort study. United European Gastroenterol J 2022; 10:93-103. [PMID: 35020977 PMCID: PMC8830273 DOI: 10.1002/ueg2.12197] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Direct and indirect clipping treatments are used worldwide to treat colonic diverticular bleeding (CDB), but their effectiveness has not been examined in multicenter studies with more than 100 cases. OBJECTIVE We sought to determine the short- and long-term effectiveness of direct versus indirect clipping for CDB in a nationwide cohort. METHODS We studied 1041 patients with CDB who underwent direct clipping (n = 360) or indirect clipping (n = 681) at 49 hospitals across Japan (CODE BLUE-J Study). RESULTS Multivariate analysis adjusted for age, sex, and important confounding factors revealed that, compared with indirect clipping, direct clipping was independently associated with reduced risk of early rebleeding (<30 days; adjusted odds ratio [AOR] 0.592, p = 0.002), late rebleeding (<1 year; AOR 0.707, p = 0.018), and blood transfusion requirement (AOR 0.741, p = 0.047). No significant difference in initial hemostasis rates was observed between the two groups. Propensity-score matching to balance baseline characteristics also showed significant reductions in the early and late rebleeding rates with direct clipping. In subgroup analysis, direct clipping was associated with significantly lower rates of early and late rebleeding and blood transfusion need in cases of stigmata of recent hemorrhage with non-active bleeding on colonoscopy, right-sided diverticula, and early colonoscopy, but not with active bleeding on colonoscopy, left-sided diverticula, or elective colonoscopy. CONCLUSIONS Our large nationwide study highlights the use of direct clipping for CDB treatment whenever possible. Differences in bleeding pattern and colonic location can also be considered when deciding which clipping options to use.
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Affiliation(s)
- Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.,Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan.,Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, Toyoake, Aichi, Japan.,Emergency and Critical Care Center, Saiseikai Yokohama Tobu Hospital, Kanagawa, Yokohama, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Naha, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Nakagami-gun, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kana Kawagishi
- Department of Gastroenterology, Kitasato University, School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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Hayasaka J, Kikuchi D, Odagiri H, Nomura K, Ochiai Y, Okamura T, Suzuki Y, Mitsunaga Y, Dan N, Tanaka M, Yamashita S, Matsui A, Hoteya S. Effectiveness of Clipping for Definitive Colonic Diverticular Bleeding in Preventing Early Recurrent Bleeding. Intern Med 2022; 61:451-460. [PMID: 35173136 PMCID: PMC8907776 DOI: 10.2169/internalmedicine.7702-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Clipping is a common technique for managing colonic diverticular bleeding (CDB), despite the lack of published evidence regarding its effectiveness. We aimed to evaluate the effectiveness of clipping for CDB in preventing early recurrent bleeding. Methods This dual-center retrospective study included 93 patients who underwent emergency hospitalization for bloody stool, diagnosed with definitive CDB, and treated with clipping or conservative treatment. The primary outcome was early recurrent bleeding. A logistic regression analysis was performed to assess the association between the occurrence of early recurrent bleeding and clipping with adjustment for propensity scores. Secondary outcomes included death, transfusion, length of hospitalization, need for transcatheter arterial embolization or surgery, and adverse events. Results The patient characteristics were similar between the clipping (n=85) and conservative treatment (n=8) groups. The rate of early recurrent bleeding was significantly lower in the clipping group than in the conservative treatment group [23.5% (20 cases) vs. 75% (6 cases), p=0.005]. In the propensity score-adjusted logistic regression analysis, the odds ratio for early recurrent bleeding in the clipping group was 0.094 (95% confidence interval, 0.008-0.633, p=0.026). Secondary outcomes were not significantly different between the two groups. Stigmata of recent hemorrhage (SRH) at the time of recurrent bleeding was identified in 79.2% of patients (19/24). In the clipping group, recurrent bleeding was observed in 62.5% of cases (10/16) from the same diverticulum. However, early recurrent bleeding tended to be less likely with direct clipping (p=0.072). Conclusion Clipping for definite CDB was more effective in preventing early recurrent bleeding than conservative treatment.
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Affiliation(s)
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Japan
- Department of Gastroenterology, Toranomon Hospital Kajigaya, Japan
| | | | - Kosuke Nomura
- Department of Gastroenterology, Toranomon Hospital, Japan
| | | | | | - Yugo Suzuki
- Department of Gastroenterology, Toranomon Hospital, Japan
| | | | - Nobuhiro Dan
- Department of Gastroenterology, Toranomon Hospital, Japan
| | - Masami Tanaka
- Department of Gastroenterology, Toranomon Hospital, Japan
| | - Satoshi Yamashita
- Department of Gastroenterology, Toranomon Hospital, Japan
- Department of Gastroenterology, Toranomon Hospital Kajigaya, Japan
| | - Akira Matsui
- Department of Gastroenterology, Toranomon Hospital, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Japan
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Nagata N, Niikura R, Ishii N, Kaise M, Omata F, Tominaga N, Kitagawa T, Ikeya T, Kobayashi K, Furumoto Y, Narasaka T, Iwata E, Sugimoto M, Itoi T, Uemura N, Kawai T. Cumulative evidence for reducing recurrence of colonic diverticular bleeding using endoscopic clipping versus band ligation: Systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:1738-1743. [PMID: 33295071 DOI: 10.1111/jgh.15370] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/18/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Either clipping or band ligation will become the most common endoscopic treatment for colonic diverticular bleeding (CDB). Rebleeding is a significant clinical outcome of CDB, but there is no cumulative evidence comparing reduction of short-term and long-term rebleeding between them. Thus, we conducted a systematic review and meta-analysis to determine which endoscopic treatment is more effective to reduce recurrence of CDB. METHODS A comprehensive search of the databases PubMed/MEDLINE and Embase was performed through December 2019. Main outcomes were early and late rebleeding rates, defined as bleeding within 30 days and 1 year of endoscopic therapy for CDB. Initial hemostasis, need for transcatheter arterial embolization, or surgery were also assessed. Overall pooled estimates were calculated. RESULTS Sixteen studies fulfilled the eligibility criteria, and a total of 790 participants were included. The pooled prevalence of early rebleeding was significantly lower for band ligation than clipping (0.08 vs 0.19; heterogeneity test, P = 0.012). The pooled prevalence of late rebleeding was significantly lower for band ligation than clipping (0.09 vs 0.29; heterogeneity test, P = 0.024). No significant difference of initial hemostasis rate was noted between the two groups. Pooled prevalence of need for transcatheter arterial embolization or surgery was significantly lower for band ligation than clipping (0.01 vs 0.02; heterogeneity test, P = 0.031). There were two cases with colonic diverticulitis due to band ligation but none in clipping. CONCLUSION Band ligation therapy was more effective compared with clipping to reduce recurrence of colonic diverticular hemorrhage over short-term and long-term durations.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.,Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Niikura
- Department of Gastroenterology, The University of Tokyo, Tokyo, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Mitsuru Kaise
- Gastroenterology Division, Nippon Medical School, Tokyo, Japan
| | - Fumio Omata
- Gastroenterology Division, St. Luke's International University, Tokyo, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan
| | - Tomoyuki Kitagawa
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Takashi Ikeya
- Division of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yohei Furumoto
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Division of Endoscopic Center, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Eri Iwata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.,Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Ichikawa, Chiba, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
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Kishino T, Kanemasa K, Kitamura Y, Fukumoto K, Okamoto N, Shimokobe H. Usefulness of direct clipping for the bleeding source of colonic diverticular hemorrhage (with videos). Endosc Int Open 2020; 8:E377-E385. [PMID: 32118110 PMCID: PMC7035034 DOI: 10.1055/a-1036-6077] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims The efficacy of endoclips for colonic diverticular hemorrhage remains unclear. The aim of the current study was to evaluate the safety and efficacy of endoclips versus endoscopic band ligation (EBL) for the treatment of colonic diverticular hemorrhage. Patients and methods At Nara City Hospital, 93 patients with colonic diverticular hemorrhage with stigmata of recent hemorrhage (SRH) were treated using endoclips or EBL between January 2013 and December 2018. We classified the patients treated by endoclips into the direct clipping group and indirect clipping group. Endoclips were placed directly onto the vessel if technically feasible (direct clipping). When direct placement of endoclips onto the vessel was not possible, the diverticulum was closed in a zipper fashion (indirect clipping). Patient demographics, rate of early rebleeding within 30 days after initial treatment, and complications were retrospectively evaluated. Results Of the 93 patients, 34, 28, and 31 were in the direct clipping group, indirect clipping group, and EBL group, respectively. Rates of early rebleeding in the direct clipping, indirect clipping, and EBL groups were 5.9 % (2/34), 35.7 % (10/28), and 6.5 % (2/31), respectively ( P = 0.006: direct clipping vs indirect clipping, P = 1: direct clipping vs EBL). No complications occurred in any groups. All patients who had early rebleeding in the direct clipping group underwent EBL, and no further bleeding occurred after repeat therapy. Conclusions Direct clip placement is acceptable as the first treatment choice for colonic diverticular hemorrhage. When direct placement of endoclips is not possible, EBL should be performed instead of indirect clipping.
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Affiliation(s)
- Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan,Corresponding author Takaaki Kishino, MD Department of Gastroenterology and HepatologyCenter for Digestive and Liver DiseasesNara City Hospital1-50-1 HigashikiderachoNara 630-8305Japan+81-742222478
| | - Kazuyuki Kanemasa
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Yoko Kitamura
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Kohei Fukumoto
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Okamoto
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Hideto Shimokobe
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
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7
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Kaise M, Nagata N, Ishii N, Omori J, Goto O, Iwakiri K. Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding. Dig Endosc 2020; 32:240-250. [PMID: 31578767 DOI: 10.1111/den.13547] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 12/13/2022]
Abstract
There is the East-West paradox in prevalence and phenotype of colonic diverticula, but colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding worldwide. Death from CDB can occur in elderly patients with multiple comorbidities, thus the management of CDB is clinically pivotal amid the aging populations in the East and West. Colonoscopy is the key modality for managing the condition appropriately; however, conventional endoscopic hemostasis by thermal coagulation and clipping cannot achieve the expected results of preventing early rebleeding and conversion to intensive intervention by surgery or transcatheter arterial embolization. Ligation therapy by endoscopic band ligation or endoscopic detachable snare ligation has emerged recently to enable more effective hemostasis for CDB, with an early rebleeding rate of approximately 10% and very rare conversion to intensive intervention. Ligation therapy might in turn reduce long-term rebleeding rates by eliminating the target diverticulum itself. Adverse events have been reported with ligation therapy including diverticulitis of the ascending colon in less than 1% of cases and perforation of the sigmoid colon in a few cases, thus more data are necessary to verify the safety of ligation therapy. Endoscopic hemostasis is indicated only for diverticulum with stigmata of recent hemorrhage (SRH), but the detection rates of SRH are relatively low. Therefore, efforts to increase detection are also key for improving CDB management. Urgent colonoscopy and triage by early contrast-enhanced computed tomography may be candidates to increase detection but further data are necessary in order to make a conclusion.
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Affiliation(s)
- Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastrointestinal Endoscopy, Tokyo Medical School, Tokyo, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Tokyo, Japan
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Honda H, Ishii N, Takasu A, Shiratori Y, Omata F. Risk factors of early rebleeding in the endoscopic management of colonic diverticular bleeding. J Gastroenterol Hepatol 2019; 34:1784-1792. [PMID: 30897246 DOI: 10.1111/jgh.14669] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The risk factors for early rebleeding following the management of colonic diverticular bleeding (CDB) are unclear. This study aimed to determine the risk factors for early rebleeding following initial colonoscopy. METHODS Overall, 370 patients with CDB were divided as having presumptive (229) or definite CDB with stigmata of recent hemorrhage (141) on the basis of initial colonoscopy. Definite CDB cases were treated by either endoscopic clipping (EC) or endoscopic band ligation (EBL) as a first-line treatment. Time-to-event analysis for early rebleeding was performed by Kaplan-Meier methods with log-rank test between the three groups (presumptive, EC, and EBL). Multivariate Cox proportional hazards regression was used to identify risk factors for early rebleeding. RESULTS There were 38 and 103 patients in the EC and EBL groups, respectively. Early rebleeding developed in 61 cases (16.5%). The cumulative incidence rates of early rebleeding at 1, 5, and 30 days were 7.7%, 16.4%, and 17.9% in the presumptive group; 1.9%, 7.0%, and 9.5% in the EBL group; and 2.6%, 34.9%, and 37.7% in the EC group, respectively (log-rank test, P = 0.00059). Moreover, 90.2% of early rebleeding occurred within 5 days. Adjusted hazard ratio (HR) was marginally lower in the presumptive group (HR = 0.50; 95% confidence interval, 0.26-1.01; P = 0.052) and significantly lower in the EBL-treated group than in the EC group (HR = 0.21; 95% confidence interval, 0.09-0.50; P = 0.0004). CONCLUSIONS Most early rebleeding occurred within 5 days after initial colonoscopy. EC was less effective than EBL in terms of early rebleeding.
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Affiliation(s)
- Hirokazu Honda
- Division of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Naoki Ishii
- Division of Gastroenterology, St. Luke's International University, Tokyo, Japan.,Division of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Ayaka Takasu
- Division of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Yasutoshi Shiratori
- Division of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Fumio Omata
- Division of Gastroenterology, St. Luke's International University, Tokyo, Japan
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Hookey L, Barkun A, Sultanian R, Bailey R. Successful hemostasis of active lower GI bleeding using a hemostatic powder as monotherapy, combination therapy, or rescue therapy. Gastrointest Endosc 2019; 89:865-871. [PMID: 30612959 DOI: 10.1016/j.gie.2018.10.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Acute lower GI bleeding is a frequent cause of hospital admission. The objective of this study was to evaluate the safety and performance of a hemostatic powder (TC-325/Hemospray) in the treatment of nonvariceal lower GI bleeding. METHODS Patients were enrolled into this prospective, multicenter, single-arm study at 4 tertiary care centers in Canada. Fifty patients with active lower GI bleeding of multiple different causes (52 bleeding sites) underwent topical endoscopic application of hemostatic powder. The primary endpoint was powder-related adverse events within 30 days of the index procedure. Secondary endpoints were initial hemostasis as well as recurrent bleeding and mortality within 30 days of the index procedure. RESULTS Most patients (96%) had a single bleeding site, and most bleeding (73%) was due to polypectomy. Overall, the powder was applied as monotherapy in 13 bleeding sites (25%), as combination therapy in 22 bleeding sites (42.3%), and as rescue therapy in 17 bleeding sites (32.7%). Hemostasis was achieved in 98% of patients. No patient experienced a powder-related adverse event. Five patients (10%) developed recurrent bleeding within 30 days. One patient (2%) died within 30 days of powder application, but the death was not directly related to hemostatic powder use. CONCLUSIONS The hemostatic powder is a safe and effective option for patients with lower GI bleeding of varying causes, and in particular, postpolypectomy hemorrhage. The hemostatic powder is effective as monotherapy, part of a combination approach, or as a rescue therapeutic option for the treatment of nonvariceal lower GI bleeding. (Clinical trial registration number: NCT02099435.).
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Affiliation(s)
| | - Alan Barkun
- Department of Medicine, Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
| | - Richard Sultanian
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Robert Bailey
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
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Okamoto N, Tominaga N, Sakata Y, Hara M, Yukimoto T, Tsuruta S, Yamanouchi K, Takeshita E, Matsunaga K, Ito Y, Miyahara K, Noda T, Yamaguchi D, Tsunada S, Tanaka Y, Kawakubo H, Tsuruoka N, Shimoda R, Ogata S, Fujimoto K. Lower Rebleeding Rate after Endoscopic Band Ligation than Endoscopic Clipping of the Same Colonic Diverticular Hemorrhagic Lesion: A Historical Multicenter Trial in Saga, Japan. Intern Med 2019; 58:633-638. [PMID: 30333407 PMCID: PMC6443565 DOI: 10.2169/internalmedicine.1473-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective This historical control study was performed to evaluate i) the rebleeding rate of bleeding colon diverticula treated with endoscopic band ligation (EBL) versus endoscopic clipping (EC) and ii) risk factors for rebleeding of diverticula initially treated by endoscopic hemostasis. Methods From January 2010 to December 2012, 68 patients were treated with EC, and from January 2013 to August 2016, 67 patients were treated with EBL. All patients in each group were followed up for one year to check for rebleeding. Results The rebleeding rate was lower in the EBL group (7 of 67, 10%) than in the EC group (21 of 68, 31%; p<0.01). This difference was mainly due to the lower rebleeding rate from the same hemorrhagic diverticulum initially treated by hemostasis (EBL: 4 of 67, 6%; EC: 15 of 68, 22%; p<0.01). The time span until rebleeding in the EBL group was ≤1 week. A multivariate analysis indicated that bleeding from the diverticula on the right side of the colon was a high-risk factor for rebleeding from the diverticula (odds ratio, 4.48; 95% confidence interval, 1.22-16.46; p=0.02). Conclusion The low rebleeding rate in the EBL group was attributed to the low degree of rebleeding from the same diverticulum, indicating that EBL was superior to EC in preventing rebleeding of an initially treated diverticulum.
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Affiliation(s)
- Norihiro Okamoto
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
- Department of Internal Medicine, Saga Medical School, Japan
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
| | | | - Megumi Hara
- Department of Preventive Medicine, Saga Medical School, Japan
| | - Takahiro Yukimoto
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
- Department of Internal Medicine, Saga Medical School, Japan
| | - Sanae Tsuruta
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
| | - Kohei Yamanouchi
- Department of Internal Medicine and Gastrointestinal Endoscopy, Takagi Hospital, Japan
| | - Eri Takeshita
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Keiji Matsunaga
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Yoichiro Ito
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Koichi Miyahara
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Takahiro Noda
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Daisuke Yamaguchi
- Department of Internal Medicine, National Hospital Organization Ureshino Medical Center, Japan
| | - Seiji Tsunada
- Department of Internal Medicine, National Hospital Organization Ureshino Medical Center, Japan
| | - Yuichiro Tanaka
- Department of Internal Medicine, Imari Arita Kyoritsu Hospital, Japan
| | - Hiroharu Kawakubo
- Department of Internal Medicine, Imari Arita Kyoritsu Hospital, Japan
| | - Nanae Tsuruoka
- Department of Internal Medicine, Saga Medical School, Japan
| | - Ryo Shimoda
- Department of Internal Medicine, Saga Medical School, Japan
| | - Shinichi Ogata
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
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Ishii N, Omata F, Nagata N, Kaise M. Effectiveness of endoscopic treatments for colonic diverticular bleeding. Gastrointest Endosc 2018; 87:58-66. [PMID: 28843587 DOI: 10.1016/j.gie.2017.08.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Several endoscopic modalities have been used for the treatment of colonic diverticular bleeding (CDB). The aim of this study was to evaluate the effectiveness of endoscopic treatment for CDB. METHODS We performed a systematic review and meta-analysis of the English literature. Main outcomes were initial hemostasis, early recurrent bleeding (recurrent bleeding within 30 days after endoscopic treatment), and need for transcatheter arterial embolization (TAE) or surgery. Proportions were collected from each study and were used to calculate pooled estimates. Heterogeneity was evaluated by I2. RESULTS Sixteen studies (384 patients with CDB) were included. Pooled estimates of initial hemostasis were coagulation, 1.00 (95% CI, .91-1.00) (I2 = .0%); clipping, .99 (95% CI, .97-1.00) (I2 = .0%); and ligation, .99 (95% CI, .95-1.00) (I2 = .0%). Pooled estimates of early recurrent bleeding were coagulation, .21(95% CI, .01-.51) (I2 = 61.2%); clipping, .19 (95% CI, .07-.35) (I2 = 77.3%); and ligation, .09 (95% CI, .04-.15) (I2 = .0%). Pooled estimates of need for TAE or surgery were coagulation, .18 (95% CI, .00-.61) (I2 = 68.9%); clipping, .08 (95% CI, .03-.16) (I2 = 36.8%); and ligation, .00 (95% CI, .00-.01) (I2 = .0%). The proportion of need for TAE or surgery in the ligation group was significantly lower than that in the clipping group (P = .003) and marginally lower than in the coagulation group (P = .086). No significant difference was found between coagulation and clipping groups (P = .44). CONCLUSIONS Ligation therapy was more effective compared with clipping to avoid TAE or surgery. Coagulation, clipping, and ligation were equivocal in terms of effectiveness for initial hemostasis and preventing early recurrent bleeding.
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Affiliation(s)
- Naoki Ishii
- Gastroenterology Division, Koga Hospital, Koga, Japan; Gastroenterology Division, St. Luke's International Hospital, Tokyo, Japan
| | - Fumio Omata
- Gastroenterology Division, St. Luke's International Hospital, Tokyo, Japan
| | - Naoyoshi Nagata
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Gastroenterology Division, Nippon Medical School, Tokyo, Japan
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ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 274] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
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Abstract
This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.
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Affiliation(s)
- Benjamin Sahn
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA.
| | - Samuel Bitton
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA
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Manejo de la hemorragia digestiva baja aguda: documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:534-45. [DOI: 10.1016/j.gastrohep.2013.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 12/16/2022]
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