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Jensen DM. Endoscopic Diagnosis and Treatment of Colonic Diverticular Bleeding. Gastrointest Endosc Clin N Am 2024; 34:345-361. [PMID: 38395488 PMCID: PMC10901438 DOI: 10.1016/j.giec.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
This is a description and critical analysis of current diagnosis and treatment of diverticular hemorrhage. The focus is on colonoscopy for identification and treatment of stigmata of recent hemorrhage (SRH) in diverticula. A classification of definitive, presumptive, and incidental diverticular hemorrhage is reviewed and recommended. The approach to definitive diagnosis with urgent colonoscopy is put into perspective of other management strategies including angiography (of different types), nuclear medicine scans, surgery, and medical treatment. Advancements in diagnosis, risk stratification, and colonoscopic hemostasis are described including those that obliterate arterial blood flow underneath SRH and prevent diverticular rebleeding. Recent innovations are discussed.
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Affiliation(s)
- Dennis M Jensen
- David Geffen School of Medicine at UCLA, UCLA Medical Center, VA Greater Los Angeles Healthcare System, Building 115 Room 318, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003, USA.
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Garrido M, Gonçalves B, Ferreira S, Rocha M, Salgado M, Pedroto I. Treating Untreatable Rectal Varices. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:420-424. [PMID: 31832497 DOI: 10.1159/000496121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/08/2018] [Indexed: 12/20/2022]
Abstract
Background Rectal varices are portosystemic collaterals that arise as a complication of portal hypertension. Despite their significant prevalence among cirrhotic patients, clinically important bleeding occurs only in a minority. Various treatment options are available, with endoscopic therapies being widely used, and both interventional radiology and surgery being considered for refractory bleeding rectal varices. Case We report the case of a 61-year-old male with hepatic cirrhosis and bleedingrectal varices refractory to endoscopic therapy, successfully managed with a combination of transjugular intrahepatic portosystemic shunt (TIPS) and selective variceal embolization. Conclusions Radiological techniques are effective options for refractory bleeding. Adding embolization to TIPS implantation could represent a valid adjunctive measure for haemostasis of recurrent rectal variceal bleeding.
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Affiliation(s)
- Mónica Garrido
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal
| | - Belarmino Gonçalves
- Department of Interventional Radiology, Portuguese Oncology Institute, Porto, Portugal
| | - Sofia Ferreira
- Liver Transplant Unit, Porto University Hospital Centre, Porto, Portugal
| | - Marta Rocha
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal
| | - Marta Salgado
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal.,Institute of Biomedical Sciences of Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Isabel Pedroto
- Department of Gastroenterology, Porto University Hospital Centre, Porto, Portugal.,Institute of Biomedical Sciences of Abel Salazar (ICBAS), University of Porto, Porto, Portugal
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Zhao H, Zhao R, Hu J, Zhang X, Ma J, Shi Y, Ma W, Sheng J, Li L. Upper gastrointestinal hemorrhage in acute-on-chronic liver failure: prevalence, characteristics, and impact on prognosis. Expert Rev Gastroenterol Hepatol 2019; 13:263-269. [PMID: 30791764 DOI: 10.1080/17474124.2019.1567329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Upper gastrointestinal hemorrhage (UGH) is a life-threatening complication in patients with cirrhosis; however, data regarding the role of UGH in acute-on-chronic liver failure (ACLF) are limited. METHODS A prospective, observational cohort study was performed from February 2014 to Mach 2015. RESULTS UGH was identified in 170 of 492 cirrhotic patients with acute decompensation (AD) at the time of admission. Logistic regression analysis showed that fecal occult blood test positivity was an independent risk factor for UGH in patients with or without ACLF [OR(95%CI): 8.31(4.89-14.10), p < 0.001; and 6.29 (1.48-26.76), p = 0.031]. Other independent risk factors were a history of gastrointestinal bleeding [OR(95% CI): 13.43 (7.17-25.15), p < 0.001], older age [OR(95% CI): 0.98(0.96-0.99), p = 0.003], greater INR level [OR(95% CI): 0.48(0.28-0.81), p = 0.007] in patients without ACLF. Multivariate Cox proportional hazard model analysis indicated that UGH did not increase mortality at different times in cirrhotic patients with acute decompensation. CONCLUSIONS UGH is a frequent complication in cirrhotic patients with AD, even those with ACLF. Positive fecal occult blood tests and previous GI bleeding were shown to be associated with the risk of UGH. UGH did not significantly increase the risk of mortality in cirrhotic patients with AD or ACLF.
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Affiliation(s)
- Hong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ruihong Zhao
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianhua Hu
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Xuan Zhang
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jianke Ma
- b Department of Infectious Diseases , Cixi People's Hospital , Cixi , China
| | - Yemin Shi
- c Department of Infectious Diseases , Yuyao People's Hospital , Ningbo , China
| | - Weihang Ma
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Jifang Sheng
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Lanjuan Li
- a State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
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Marya NB, Jawaid S, Foley A, Han S, Patel K, Maranda L, Kaufman D, Bhattacharya K, Marshall C, Tennyson J, Cave DR. A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to nonhematemesis GI bleeding (with videos). Gastrointest Endosc 2019; 89:33-43.e4. [PMID: 29935143 PMCID: PMC6501558 DOI: 10.1016/j.gie.2018.06.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients presenting with nonhematemesis GI bleeding (NHGIB) represent a diagnostic challenge for physicians. We performed a randomized controlled trial to assess the benefits of deployment of a video capsule soon after admission in the management of patients presenting with melena, hematochezia, or severe anemia compared with standard of care management. METHODS Patients admitted with NHGIB were randomized and placed into 1 of 2 study groups. In the experimental group, patients ingested a video capsule soon after admission to the hospital. These patients had further endoscopic workup based on the findings from the capsule. Patients in the control group underwent endoscopic evaluation (ie, upper endoscopy, capsule endoscopy, and/or colonoscopy) to identify the source of bleeding as directed by the attending gastroenterologist's interpretation of their clinical presentation. The primary endpoint for this study was the rate of localization of bleeding during hospitalization. RESULTS Eighty-seven patients were included in this study: 45 randomized to the standard of care arm and 42 to the early capsule arm. A bleeding source was localized in 64.3% of the patients in the early capsule arm and in 31.1% of the patients in the standard of care arm (P < .01). The likelihood of endoscopic localization of bleeding over time was greater for patients receiving early capsule endoscopy compared with those in the standard of care arm (adjusted hazard ratio, 2.77; 95% confidence interval, 1.36-5.64). CONCLUSIONS For patients admitted to the hospital for NHGIB, early capsule endoscopy is a safe and effective alternative for the detection of the source of bleeding. (Clinical trial registration number: NCT02442830.).
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Affiliation(s)
- Neil B. Marya
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California, USA
| | - Salmaan Jawaid
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - Arne Foley
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - Samuel Han
- University of Colorado, Aurora, Colorado, USA
| | - Krunal Patel
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - Louise Maranda
- Department of Quantitative Health Sciences, University of Massachusetts, Worcester, Massachusetts, USA
| | - Daniel Kaufman
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | | | - Christopher Marshall
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - Joseph Tennyson
- Department of Emergency Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | - David R. Cave
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW Hematochezia is a common clinical presentation, with significant morbidity and economic burden. These patients often require costly interventions including hospitalization, blood transfusions, and radiologic or endoscopic procedures. The purpose of this review is to give a rational, concise approach to the patient with hematochezia, with special consideration of recent advances in the literature. RECENT FINDINGS Recent studies pertaining to hematochezia have evaluated risk stratification, endoscopic intervention, evaluation of small bowel bleeding, and management of anticoagulation. SUMMARY A step-wise approach to hematochezia helps determine the cause and provide the appropriate management of these patients. We propose five steps beginning with hemodynamic assessment and risk stratification, then focused history and physical examination, endoscopic intervention when warranted, and consideration of small bowel bleeding in selected instances.
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In Reply. J Clin Gastroenterol 2017; 51:86-87. [PMID: 27941584 DOI: 10.1097/mcg.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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