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Long B, Gottlieb M. Emergency medicine updates: Lower gastrointestinal bleeding. Am J Emerg Med 2024; 81:62-68. [PMID: 38670052 DOI: 10.1016/j.ajem.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/26/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS An understanding of literature updates can improve the care of patients with LGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine Rush, University Medical Center, Chicago, IL, USA
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Sano T, Ishikawa T, Azumi M, Sato R, Jimbo R, Kobayashi Y, Sato T, Iwanaga A, Yokoyama J, Honma T. Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization. Medicine (Baltimore) 2023; 102:e35092. [PMID: 37713820 PMCID: PMC10508449 DOI: 10.1097/md.0000000000035092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/15/2023] [Indexed: 09/17/2023] Open
Abstract
This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.
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Affiliation(s)
- Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Jimbo
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toshifumi Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Junji Yokoyama
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
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Timing of Colonoscopy for Hemodynamically Stable Patients With Acute Lower Gastrointestinal Bleeding. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:76-78. [PMID: 36729881 DOI: 10.1097/sle.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/12/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The detection rate of the etiology of the lower gastrointestinal system (GIS) hemorrhage has been low, although urgent colonoscopy has been performed. Even if the etiology has been specified, the possibility of rebleeding is uncertain. Furthermore, adequate bowel cleansing required for colonoscopy cannot be achieved in emergency situations, so the procedure may fail. The aim of this study is to compare the etiological diagnoses of patients with lower GIS bleeding after bowel preparation at their first hospitalization and after discharge. MATERIAL AND METHOD Patients who were hemodynamically stable after upper GIS bleeding were identified and divided into 2 groups. Colonoscopy was performed in the first group of patients at their first hospitalization. The second group of patients was called again for colonoscopy within 2 weeks after discharge. Patients were classified according to their age, gender, bleeding etiology, whether complete colonoscopy procedure was possible (The cecum was intubated, and the bowel cleansing was sufficient to evaluate the intestinal mucosa), and whether the colonoscopic intervention was performed. RESULTS The rate of patients who are hemodynamically stable and require emergency intervention at their first hospitalization is 5%. The colonoscopy repeat rate is 70% for the first hospitalization group, and the patients with no findings despite the second colonoscopy at a rate of 50% are re-evaluated electively. DISCUSSION Our study suggests that colonoscopy should be performed in elective conditions after a complete bowel cleansing in hemodynamically stable patients.
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Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023; 118:208-231. [PMID: 36735555 DOI: 10.14309/ajg.0000000000002130] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.
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McDonald MJ. Acute Gastrointestinal Bleeding – Locating the Source and Correcting the Disorder. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Devani K, Radadiya D, Charilaou P, Aasen T, Reddy CM, Young M, Brahmbhatt B, Rockey DC. Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Endosc Int Open 2021; 9:E777-E789. [PMID: 34079858 PMCID: PMC8159619 DOI: 10.1055/a-1352-3204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background and study aims Current guidelines conditionally recommend performing early colonoscopy (EC) (< 24 hours) in patients admitted with acute lower gastrointestinal bleeding (LGIB). It remains unclear whether this practice is implemented widely. Therefore, we used the Nationwide Inpatient Sample to investigate trends for timing of colonoscopy in patients admitted with acute LGIB. We also assessed trend of hospitalization and mortality in patients with LGIB.
Patients and methods Adult patients with LGIB admitted from 2005 to 2014 were examined. ICD-9-CM codes were used to extract LGIB discharges. Trends were assessed using Cochrane-Armitage test. Factors associated with mortality, cost of hospitalization, and length of stay (LOS) were assessed by multivariable mixed-effects and exact-matched logistic, linear regression, and accelerated-failure time models, respectively.
Results A total of 814,647 patients with LGIB were included. The most common etiology of LGIB was diverticular bleeding (49 %) and 45 % of patients underwent EC. Over the study period, there was no change in the trend of colonoscopy timing. Although admission with LGIB increased over the study period, the mortality rate decreased for patients undergoing colonoscopy. Independent predictors of mortality were age, surgery (colostomy/colectomy) during admission, intensive care unit admission, acute kidney injury, and blood transfusion requirement. Timing of colonoscopy was not associated with mortality benefit. However, cost of hospitalization was $ 1,946 lower and LOS was 1.6 days shorter with EC.
Conclusion Trends in colonoscopy timing in management of LGIB have not changed over the years. EC is associated with lower LOS and cost of hospitalization but it does not appear to improve inpatient mortality.
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Affiliation(s)
- Kalpit Devani
- Division of Gastroenterology and Liver Disease, Department of Internal Medicine, Prisma Health, University of South Carolina, Greenville, South Carolina, United States
| | - Dhruvil Radadiya
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Paris Charilaou
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Saint Peterʼs University Hospital/Rutgers – Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Tyler Aasen
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Chakradhar M. Reddy
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Mark Young
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Don C. Rockey
- Division of Gastroenterology, Department of Internal Medicine, Medical University of South Carolina, United States
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Ochi M, Kamoshida T, Hamano Y, Ohkawara A, Ohkawara H, Kakinoki N, Yamaguchi Y, Hirai S, Yanaka A. Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding. World J Clin Cases 2021; 9:2446-2457. [PMID: 33889610 PMCID: PMC8040177 DOI: 10.12998/wjcc.v9.i11.2446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/25/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colonoscopy within 24 h of hospital admission for colonic diverticular bleeding (CDB) is recommended. However, little is known about rates of rebleeding within 30 d. We posited that a group of patients who underwent contrast-enhanced computed tomography (CT) within 4 h of the last hematochezia and colonoscopy within 24 h would experience fewer incidences of rebleeding.
AIM To evaluate the outcomes of early colonoscopy for CDB among different groups of patients.
METHODS Data from 182 patients with CDB who underwent contrast-enhanced CT and colonoscopy between January 2011 and December 2018 at the study site were retrospectively reviewed. Patients were divided into groups based on the timing of the CT imaging, within or at 4 h were defined as urgent CTs (n = 100) and those performed after 4 h were defined as elective CTs (n = 82). Main outcomes included rebleeding within 30 d and the identification of stigmata of recent hemorrhage (SRH) (i.e., active bleeding, non-bleeding visible vessels, or adherent clots).
RESULTS In total, 182 patients (126 men and 56 women) with median ages of 68.6 (range, 37-92) and 73.7 (range, 48-93) years, respectively, underwent CT imaging and colonoscopy within 24 h of the last hematochezia. Patients for whom CT was performed within 4 h of the last hematochezia were included in the urgent CT group (n = 100) and patients for whom CT was performed after 4 h were included in the elective CT group (n = 82). SRH were identified in 35.0% (35/100) of the urgent CT cases and 7.3% (6/82) of the elective CT cases (P < 0.01). Among all patients with extravasation-positive images on CT, SRH was identified in 31 out of 47 patients (66.0%) in the urgent CT group and 4 out of 20 patients (20.0%) in the elective CT group (P < 0.01). Furthermore, rates of rebleeding within 30 d were significantly improved in the urgent CT and extravasation-positive cases (P < 0.05). Results from the evaluation of early colonoscopy did not show a difference in the ability to detect SRH identification or rebleeding rates. Only cases by urgent CT reduced risk of rebleeding due to the evidence of active bleeding on the image.
CONCLUSION To improve rates of rebleeding, colonoscopy is recommended within 24 h in patients with extravasation-positive CT images within 4 h of the last hema-tochezia. Otherwise, elective colonoscopy can be performed.
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Affiliation(s)
- Masanori Ochi
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Toshiro Kamoshida
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Yukako Hamano
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Atsushi Ohkawara
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Haruka Ohkawara
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Nobushige Kakinoki
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Yuji Yamaguchi
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Shinji Hirai
- Department of Gastroenterology, Hitachi General Hospital, Ibaraki 317-0077, Japan
| | - Akinori Yanaka
- Hitachi Medical Education and Research Center, University of Tsukuba, Ibaraki 317-0077, Japan
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Fujita M, Manabe N, Murao T, Suehiro M, Tanikawa T, Nakamura J, Yo S, Fukushima S, Osawa M, Ayaki M, Sasai T, Kawamoto H, Shiotani A, Haruma K. Differences in emergency endoscopy outcomes according to gastrointestinal bleeding location. Scand J Gastroenterol 2021; 56:86-93. [PMID: 33202164 DOI: 10.1080/00365521.2020.1847316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM With recent technological advances in the field of endoscopic hemostasis, the prognosis of patients with gastrointestinal (GI) bleeding has improved. However, few studies have reported on the clinical course of patients with GI bleeding. This study aimed to evaluate the differences in clinical outcomes of patients with lower GI bleeding (LGIB) compared with upper GI bleeding (UGIB) and the factors related to their prognosis. METHODS Patients who had undergone emergency endoscopy for GI bleeding were retrospectively reviewed. The severity of GI bleeding was evaluated using the Glasgow-Blatchford (GB), AIMS65, and NOBLADS scores. Patients in whom obvious GI bleeding relapsed and/or iron deficiency anemia persisted after emergency endoscopy were considered to exhibit rebleeding. RESULTS We reviewed 1697 consecutive patients and divided them into UGIB (1054 patients) and LGIB (643 patients) groups. The proportion of patients with rebleeding was significantly greater in the UGIB group than in the LGIB group; the mortality rate was significantly higher in the UGIB group than in the LGIB group. Multivariate analysis showed that a GB score ≥12 and an AIMS65 score ≥2 were significantly associated with rebleeding in the UGIB group, whereas a NOBLADS score ≥4 was significantly associated with rebleeding in the LGIB group. Notably, the influence of emergency endoscopy differed according to GI bleeding location. CONCLUSIONS The clinical course was significantly worse in patients with UGIB than in patients with LGIB. The influence of emergency endoscopy differed according to GI bleeding location.
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Affiliation(s)
- Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takahisa Murao
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Mitsuhiko Suehiro
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Tomohiro Tanikawa
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Jun Nakamura
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Shogen Yo
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Shinya Fukushima
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Motoyasu Osawa
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Maki Ayaki
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takako Sasai
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hirofumi Kawamoto
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Akiko Shiotani
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
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Kherad O, Restellini S, Almadi M, Strate LL, Ménard C, Martel M, Roshan Afshar I, Sadr MS, Barkun AN. Systematic review with meta-analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding. Aliment Pharmacol Ther 2020; 52:774-788. [PMID: 32697886 DOI: 10.1111/apt.15925] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/29/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal timing of colonoscopy in acute lower gastrointestinal bleeding (LGIB) remains controversial. AIM To characterise the utility of early colonoscopy (within 24 hours) in managing acute LGIB. METHODS A systematic literature search to October 2019 identified fully published articles and abstracts of randomised controlled trials (RCTs) and observational studies with control groups assessing early colonoscopy in acute LGIB. The primary outcome was rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events. Odds ratios (ORs) and mean differences (MD) were calculated. RESULTS Of 1116 citations, 4 RCTs (466 patients) and 13 observational studies with elective colonoscopy (>24 hours) as control group (1 061 281 patients) were included. No differences in rebleeding were noted between early and elective colonoscopy groups among RCTs alone (OR = 1.70; 0.79; 3.64), or observational studies alone (OR = 1.20; 0.69; 2.09). No other significant between-group differences in outcomes were found when restricting the analysis to RCTs. Among observational studies only, early colonoscopy was associated with lower rates of all-cause mortality (OR = 0.86; 0.75; 0.98), surgery (OR = 0.52; 0.42; 0.64), blood transfusion (OR = 0.81; 0.75; 0.87), units of blood transfusion (MD = -4.30; -6.24; -2.36) and shorter LOS (MD = -1.70; -1.70; -1.70 days). CONCLUSION In contradistinction to observational studies, data from RCTs do not support a role for early colonoscopy in the routine management of acute LGIB with regards to the most important clinical outcomes. Further research is needed to better identify patients with high-risk LGIB who may benefit from early colonoscopy.
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Affiliation(s)
- Omar Kherad
- Division of Internal Medicine, Hôpital de la Tour and University of Geneva, Geneva, Switzerland
| | - Sophie Restellini
- Division of Gastro-enterology and Hepatology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.,Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Majid Almadi
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada.,Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
| | - Charles Ménard
- Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Ira Roshan Afshar
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Mohamad Seyed Sadr
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
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11
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Lee HS, Kang SH, Rou WS, Eun HS, Joo JS, Kim JS, Lee ES, Moon HS, Kim SH, Sung JK, Lee BS, Jeong HY. Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room. Medicine (Baltimore) 2020; 99:e20311. [PMID: 32481401 DOI: 10.1097/md.0000000000020311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
For acute lower gastrointestinal bleeding (LGIB), lower gastrointestinal endoscopy is the preferred initial diagnostic test. However, it is difficult to perform urgently. Computed tomography (CT) is a convenient alternative.This study aimed to determine the diagnostic performance of CT compared to lower endoscopy as an initial test for evaluating acute LGIB.The medical records of 382 patients who visited our emergency department with hematochezia between January 2012 and January 2017 were retrospectively analyzed. Of them, 112 underwent CT, 65 underwent colonoscopy, and 205 underwent sigmoidoscopy as an initial test. For each method, sensitivity, specificity, positive predictive value, and negative predictive value were calculated upon active bleeding site detection and LGIB etiology diagnosis.The sensitivity, specificity, positive predictive value, and negative predictive value of CT for active bleeding site detection were 85.7%, 100%, 100%, and 96.9%, respectively, while those for identifying the etiology of LGIB were 87.4%, 40.0%, 83.5, and 47.6%, respectively.CT was not inferior to lower endoscopy for active bleeding site detection. Early localization and the exclusion of active bleeding were possible with CT. Etiology was diagnosed with high sensitivity and PPV by CT. Thus, CT can be an alternative initial diagnostic tool for evaluating acute LGIB.
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Affiliation(s)
- Hee Sung Lee
- Division of Gastroenterology, Department of Internal medicine, Chungnam National University School of Medicine, Daejeon, Korea
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12
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Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage. Can J Gastroenterol Hepatol 2020; 2020:3283940. [PMID: 32399458 PMCID: PMC7201635 DOI: 10.1155/2020/3283940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
AIM This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. METHODS This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. RESULTS Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68-12.0, P < 0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23-7.53, P=0.016). CONCLUSIONS In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.
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13
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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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14
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Niikura R, Nagata N, Yamada A, Honda T, Hasatani K, Ishii N, Shiratori Y, Doyama H, Nishida T, Sumiyoshi T, Fujita T, Kiyotoki S, Yada T, Yamamoto K, Shinozaki T, Takata M, Mikami T, Mabe K, Hara K, Fujishiro M, Koike K. Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding. Gastroenterology 2020; 158:168-175.e6. [PMID: 31563627 DOI: 10.1053/j.gastro.2019.09.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 09/11/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB). METHODS We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events. RESULTS SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group. CONCLUSIONS In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.
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Affiliation(s)
- Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan; Gastroenterological Endoscopy, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki-shi, Nagasaki, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui-shi, Fukui, Japan
| | - Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Ishikawa, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka-shi, Osaka, Japan
| | - Tetsuya Sumiyoshi
- Department of Gastroenterology, Tonan Hospital, Sapporo-shi, Hokkaido, Japan
| | - Tomoki Fujita
- Department of Gastroenterology, Otaru Ekisaikai Hospital, Otaru-shi, Hokkaido, Japan; Department of Gastroenterology, Sapporo Century Hospital, Sapporo-shi, Hokkaido, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai-shi, Yamaguchi, Japan
| | - Tomoyuki Yada
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine Kohnodai Hospital, Ichikawa-shi, Chiba, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka-shi, Osaka, Japan
| | - Tomohiro Shinozaki
- Department of Biostatistics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Shinjuku-ku, Tokyo, Japan
| | - Munenori Takata
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki-shi, Aomori, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate-shi, Hokkaido, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya-shi, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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15
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Zullo A, Gatta L, Vassallo R, Francesco VD, Manta R, Monica F, Fiorini G, Vaira D. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019; 32:541-553. [PMID: 31700230 PMCID: PMC6826076 DOI: 10.20524/aog.2019.0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)
| | - Luigi Gatta
- Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)
| | - Roberto Vassallo
- Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
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16
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Sengupta N. The role of colonoscopy and endotherapy in the management of lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101615. [PMID: 31785729 DOI: 10.1016/j.bpg.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/23/2019] [Indexed: 01/31/2023]
Abstract
Colonoscopy is an integral diagnostic and therapeutic tool in the management of patients with lower gastrointestinal bleeding (LGIB). After resuscitation, reversal of coagulopathy, and exclusion of a proximal source of bleeding, colonoscopy should be performed in most patients with LGIB. Bowel preparation, typically with polyethylene glycol based solutions, is needed to closely inspect the colonic mucosa for bleeding sources. Colonoscopy within 24 h is recommended for high-risk patients with ongoing bleeding, although there is limited evidence that this strategy improves clinical outcomes. When active or stigmata of bleeding is detected, endoscopic intervention is indicated and can reduce future rebleeding. The most common options for endoscopic intervention include clipping, endoscopic band ligation, and coagulation, however rigorous head-to-head comparisons of different endoscopic tools are unavailable. Future research is needed to determine the optimal timing of colonoscopy, appropriate reversal strategies for patients on antithrombotics, and the most effective endoscopic hemostatic therapy.
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Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, University of Chicago Medical Center 5841 S Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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17
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Jung K, Moon W. Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World J Gastrointest Endosc 2019; 11:68-83. [PMID: 30788026 PMCID: PMC6379746 DOI: 10.4253/wjge.v11.i2.68] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/02/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.
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Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
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18
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Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019; 25:69-84. [PMID: 30643359 PMCID: PMC6328962 DOI: 10.3748/wjg.v25.i1.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/17/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, Tokyo 108-8639, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
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19
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Saraireh H, Tayyem O, Siddiqui MT, Hmoud B, Bilal M. Early colonoscopy in patients with acute diverticular bleeding is associated with improvement in healthcare-resource utilization. Gastroenterol Rep (Oxf) 2018; 7:115-120. [PMID: 30976424 PMCID: PMC6454850 DOI: 10.1093/gastro/goy031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/15/2018] [Accepted: 05/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Diverticular bleeding (DB) is the most common cause of severe acute lower gastrointestinal bleeding (GIB) in developed countries. The role of early colonoscopy (<24 hours) continues to remain controversial and data on early colonoscopy in acute DB are scant. We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample. Methods Data from the nationwide inpatient sample from 2012 to 2014 were used. The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection. We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding. Discharges with no primary or secondary diagnosis of diverticulosis with bleeding, diverticulitis with bleeding, patients who were less than 18 years old and those who did not undergo colonoscopy during the admission were excluded. The primary outcomes were length of stay (LOS) and total hospitalization costs. Results A total of 88 600 patients were included in our analysis, amongst whom 45 020 (50.8%) had colonoscopy within 24 hours of admission (early colonoscopy), while 43 580 (49.2%) patients had colonoscopy after 24 hours of admission (late colonoscopy). LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy (3.7 vs 5.6 days, P < 0.0001). Total hospitalization costs were also significantly lower in patients with early colonoscopy ($9317 vs $11 767, P < 0.0001). There was no difference in mortality between both groups (0.7 vs 0.8%). After adjusting for potential confounders, the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant. Conclusions Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs. There was no significant difference in mortality observed. Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications. Further research is needed to identify which patients would benefit from early colonoscopy in DB.
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Affiliation(s)
- Hamzeh Saraireh
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | | | - Bashar Hmoud
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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20
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Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation. Gastrointest Endosc Clin N Am 2018; 28:379-390. [PMID: 29933782 DOI: 10.1016/j.giec.2018.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.
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21
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Niikura R, Nagata N, Yamada A, Doyama H, Shiratori Y, Nishida T, Kiyotoki S, Yada T, Fujita T, Sumiyoshi T, Hasatani K, Mikami T, Honda T, Mabe K, Hara K, Yamamoto K, Takeda M, Takata M, Tanaka M, Shinozaki T, Fujishiro M, Koike K. A multicenter, randomized controlled trial comparing the identification rate of stigmata of recent hemorrhage and rebleeding rate between early and elective colonoscopy in outpatient-onset acute lower gastrointestinal bleeding: study protocol for a randomized controlled trial. Trials 2018; 19:214. [PMID: 29615078 PMCID: PMC5883587 DOI: 10.1186/s13063-018-2558-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/24/2018] [Indexed: 12/25/2022] Open
Abstract
Background The clinical benefit of early colonoscopy within 24 h of arrival in patients with severe acute lower gastrointestinal bleeding (ALGIB) remains controversial. This trial will compare early colonoscopy (performed within 24 h) versus elective colonoscopy (performed between 24 and 96 h) to examine the identification rate of stigmata of recent hemorrhage (SRH) in ALGIB patients. We hypothesize that, compared with elective colonoscopy, early colonoscopy increases the identification of SRH and subsequently improves clinical outcomes. Methods This trial is an investigator-initiated, multicenter, randomized, open-label, parallel-group trial examining the superiority of early colonoscopy over elective colonoscopy (standard therapy) in ALGIB patients. The primary outcome measure is the identification of SRH. Secondary outcomes include 30-day rebleeding, success of endoscopic treatment, need for additional endoscopic examination, need for interventional radiology, need for surgery, need for transfusion during hospitalization, length of stay, 30-day thrombotic events, 30-day mortality, preparation-related adverse events, and colonoscopy-related adverse events. The sample size will enable detection of a 9% SRH rate in elective colonoscopy patients and a SRH rate of ≥ 26% in early colonoscopy patients with a risk of type I error of 5% and a power of 80%. Discussion This trial will provide high-quality data on the benefits and risks of early colonoscopy in ALGIB patients. Trial registration UMIN-CTR Identifier, UMIN000021129. Registered on 21 February 2016; ClinicalTrials.gov Identifier, NCT03098173. Registered on 24 March 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2558-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138655, Japan.
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138655, Japan.
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa-shi, Ishikawa, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka-shi, Osaka, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yanai-shi, Yamaguchi, Japan
| | - Tomoyuki Yada
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine Kohnodai Hospital, Ichikawa-shi, Chiba, Japan
| | - Tomoki Fujita
- Department of Gastroenterology, Otaru Ekisaikai Hospital, Otaru-shi, Hokkaido, Japan
| | - Tetsuya Sumiyoshi
- The Center for Digestive Disease, Tonan Hospital, Sapporo-shi, Hokkaido, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui-shi, Fukui, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki-shi, Aomori, Japan
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center City Hospital, Nagasaki-shi, Nagasaki, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate-shi, Hokkaido, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya-shi, Aichi, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka-shi, Osaka, Japan
| | - Mariko Takeda
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Munenori Takata
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Mototsugu Tanaka
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Tomohiro Shinozaki
- Department of Biostatistics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138655, Japan.,Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1138655, Japan
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22
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Oakland K, Isherwood J, Lahiff C, Goldsmith P, Desborough M, Colman KS, Guy R, Uberoi R, Murphy MF, East JE, Hopewell S, Jairath V. Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review. Endosc Int Open 2017; 5:E959-E973. [PMID: 28975147 PMCID: PMC5624283 DOI: 10.1055/s-0043-117958] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Investigations for lower gastrointestinal bleeding (LGIB) include flexible sigmoidoscopy, colonoscopy, computed tomographic angiography (CTA), and angiography. All may be used to direct endoscopic, radiological or surgical treatment, although their optimal use is unknown. The aims of this study were to determine the diagnostic and therapeutic yields of endoscopy, CTA, and angiography for managing LGIB, and their influence on rebleeding, transfusion, and hospital stay. PATIENTS AND METHODS A systematic search of MEDLINE, PubMed, EMBASE, and CENTRAL was undertaken to identify randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) published between 2000 and 12 November 2015 in patients hospitalized with LGIB. Separate meta-analyses were conducted, presented as pooled odds (ORs) or risk ratios (RR) with 95 % confidence intervals (CIs). RESULTS Two RCTs and 13 NRSIs were included, none of which examined flexible sigmoidoscopy, or compared endotherapy with embolization, or investigated the timing of CTA or angiography. Two NRSIs (57 - 223 participants) comparing colonoscopy and CTA were of insufficient quality for synthesis but showed no difference in diagnostic yields between the two interventions. One RCT and 4 NRSIs (779 participants) compared early colonoscopy (< 24 hours) with colonoscopy performed later; meta-analysis of the NRSIs demonstrated higher diagnostic and therapeutic yields with early colonoscopy (OR 1.86, 95 %CI 1.12 to 2.86, P = 0.004 and OR 3.08, 95 %CI 1.93 to 4.90, P < 0.001, respectively) and reduced length of stay (mean difference 2.64 days, 95 %CI 1.54 to 3.73), but no difference in transfusion or rebleeding. CONCLUSIONS In LGIB there is a paucity of high-quality evidence, although the limited studies on the timing of colonoscopy suggest increased rates of diagnosis and therapy with early colonoscopy.
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Affiliation(s)
| | - Jennifer Isherwood
- Department of General Surgery, Milton Keynes Hospital, Milton Keynes, United
Kingdom
| | - Conor Lahiff
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Petra Goldsmith
- Department of Transplantation, Royal Liverpool Hospital, Liverpool, United
Kingdom
| | | | | | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United
Kingdom
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals, Oxford,
United Kingdom
| | | | - James E. East
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United
Kingdom
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London,
Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University Hospital,
London, Ontario, Canada
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23
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Chen CH, Yang CC, Yeh YH, Mo LR. Endoscopic management of colonic diverticular bleeding. ADVANCES IN DIGESTIVE MEDICINE 2017. [DOI: 10.1002/aid2.12085] [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: 11/06/2022]
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