Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis

Recent updates on classification and unsolved issues of diverticular disease: a narrative review

Recently, a paradigm shift has occurred in the classification of diverticular disease and the understanding of its pathogenesis. Diverticular disease is now defined as a variety of clinically significant conditions such as diverticulitis, diverticular bleeding, symptomatic uncomplicated diverticular disease, and segmental colitis associated with diverticulosis. Low-grade inflammation, visceral hypersensitivity, abnormal intestinal motility, and genetic factors have emerged as the key contributors to the pathogenesis of diverticular disease. Routine antibiotic use is no longer recommended for all cases of diverticulitis, and simple recurrence is not an indication for surgical treatment. Early colonoscopy with proper preparation is recommended for the treatment of diverticular bleeding, although recent studies have not shown significant efficacy in preventing recurrence. The roles of dietary fiber, nonabsorbable antibiotics, 5-aminosalicylates, and probiotics in the prevention of diverticular disease are controversial and require further investigation.

Emergency medicine updates: Lower gastrointestinal bleeding

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.

Ultra-minimally invasive endoscopic techniques and colorectal diseases: Current status and its future

Colorectal diseases are increasing due to altered lifestyle, genetic, and environmental factors. Colonoscopy plays an important role in diagnosis. Advances in colonoscope (ultrathin scope, magnetic scope, capsule) and technological gadgets (Balloon assisted scope, third eye retroscope, NaviAid G-EYE, dye-based chromoendoscopy, virtual chromoendoscopy, narrow band imaging, i-SCAN, etc.) have made colonoscopy more comfortable and efficient. Now in-vivo microscopy can be performed using confocal laser endomicroscopy, optical coherence tomography, spectroscopy, etc. Besides developments in diagnostic colonoscopy, therapeutic colonoscopy has improved to manage lower gastrointestinal tract bleeding, obstruction, perforations, resection polyps, and early colorectal cancers. The introduction of combined endo-laparoscopic surgery and robotic endoscopic surgery has made these interventions feasible. The role of artificial intelligence in the diagnosis and management of colorectal diseases is also increasing day by day. Hence, this article is to review cutting-edge developments in endoscopic principles for the management of colorectal diseases.

Is bowel preparation necessary for early colonoscopy in patients with suspected colonic diverticular bleeding?: A multicenter retrospective study with propensity score matching analysis

Objectives

There are few reports on bowel preparation for early colonoscopy in patients with suspected colonic diverticular bleeding (CDB). We aim to clarify in a retrospective, multicenter study.

Methods

In a multicenter retrospective cohort study at 10 institutions, we analyzed clinical features of patients diagnosed with CDB, who underwent early colonoscopy within 24 h. We compared patients who were prepared with polyethylene glycol lavage (PEL) and those without PEL. We evaluated the effects of PEL for early colonoscopy in patients with suspected CDB.

Results

A total of 129 (53%) underwent under preparation with PEL and 113 patients without PEL. The PEL group was younger, had fewer comorbidities, and had better performance status. After adjusting for these variables with propensity score matching, the PEL group had a significantly shorter hospital stay (7.9 ± 4.7 vs. 10.1 ± 5.2 days; p = 0.001), and a higher cecal intubation rate (91.1% vs. 50.0%; p < 0.001). There were no significant differences in adverse event rates, identification of stigmata of recent hemorrhage, or frequency in endoscopic hemostatic treatment.

Conclusions

PEL may be preferred for early colonoscopy in patients suspected of having CDB.

Clinical outcomes of lower gastrointestinal bleeding in patients managed with lower endoscopy: A tertiary center results

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is an urgent presentation with increasing prevalence and remains a common cause of hospitalization. The clinical outcome can vary based on several factors, including the cause of bleeding, its severity, and the effectiveness of management strategies. The aim of this study is to provide a comprehensive report on the clinical outcomes observed in patients with LGIB who underwent lower endoscopy.

METHODS

All patients who underwent emergency lower endoscopy for fresh bleeding per rectum, from May 2015 to December 2021, were included. The primary outcome was to identify the rate of rebleeding after initial control of bleeding. The second was to measure the clinical outcomes and the potential predictors leading to intervention and readmission.

RESULTS

A total of 84 patients were included. Active bleeding was found in 20% at the time of endoscopy. Rebleeding within 90 days occurred in 6% of the total patients; two of which (2.38%) were within the same admission. Ninety-day readmission was reported in 19% of the cases. Upper endoscopy was performed in 32.5% of the total cases and was found to be a significant predictor for intervention (OR 4.1, P = 0.013). Personal history of inflammatory bowel disease (IBD) and initial use of sigmoidoscopy were found to be significant predictors of readmission [(OR 5.09, P = 0.008) and (OR 5.08, P = 0.019)].

CONCLUSIONS

LGIB is an emergency that must be identified and managed using an agreed protocol between all associated services to determine who needs upper GI endoscopy, ICU admission, or emergency endoscopy within 12 hours.

Outcomes and performance of risk scores in acute lower gastrointestinal bleeding

Background and Aim

Treatment of acute lower gastrointestinal bleeding (LGIB) remains problematic, and clinical data is limited compared to that of upper GIB. This study aimed to describe the clinical outcomes and predictors of rebleeding and validate the performance of proposed scoring systems in patients with acute overt LGIB.

Methods

Patients with LGIB who underwent colonoscopies between 2013 and 2018 were retrospectively reviewed. Overt LGIB patients who presented within 72 h after bleeding onset were included. Demographics, comorbidities, initial management, endoscopic finding, and treatment outcomes were collected. Factors associated with rebleeding were explored, and the performance of Oakland, NOBLAD, and Strate scores regarding mortality and rebleeding were validated.

Results

A total of 537 patients from 3402 (age 72 years, 63-80) were included. Of this, 53% took antithrombotic agents and 59% required red cell transfusion, with a median of 4 red cell units. The most common diagnoses were diverticular bleeding (31.3%) and colorectal polyp/cancer (28.9%). The median time to colonoscopy was 2.3 days, and 80.3% of patients did not receive any hemostatic intervention. The 30-day mortality and rebleeding were 2.6% and 18.3%, respectively. Patients with radiation proctitis, angioectasia, diverticulosis and using dual antiplatelet drugs were associated with recurrent bleeding. The risk scores showed low performance in predicting recurrent bleeding and mortality.

Conclusion

Acute, overt LGIB was common among elders with comorbidities. The rebleeding risk was mostly linked to underlying lesions and the use of antiplatelet drugs. The performance of current risk stratification scores remains unsatisfactory and requires further development.

Clinical Factors Associated with Severity of Colonic Diverticular Bleeding and Impact of Bleeding Site

Factors associated with serious colonic diverticular bleeding (CDB) are unclear, although the incidence of CDB has increased. We carried out this study to clarify factors associated with serious CDB and rebleeding. Subjects included 329 consecutive patients hospitalized for confirmed or suspected CDB between 2004 and 2021. Patients were surveyed regarding backgrounds, treatment, and clinical course. Of 152 with confirmed CDB, 112 showed bleeding from the right colon, and 40 did from the left colon. Patients received red blood cell transfusions in 157 (47.7%), interventional radiology in 13 (4.0%), and surgery in 6 (1.8%) cases. Early rebleeding within one month occurred in 75 (22.8%) patients, and late rebleeding within one year occurred in 62 (18.8%). Factors associated with red blood cell transfusion included confirmed CDB, anticoagulants, and high shock index. The only factor related to interventional radiology or surgery was confirmed CDB, which was also associated with early rebleeding. Late rebleeding was associated with hypertension, chronic kidney disease and past CDB. Right CDB showed higher rates of transfusion and invasive treatment than left CDB. Confirmed CDB had high frequencies of transfusion, invasive treatment, and early rebleeding. Right CDB seemed to be a risk for serious disease. Factors related to late rebleeding were different from those related to early rebleeding of CDB.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

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.

Utility of early colonoscopy for acute lower gastrointestinal bleeding: a retrospective cohort study

BACKGROUND

Early colonoscopy (within 8-24 h) is recommended in different guidelines for acute lower gastrointestinal bleeding (LGIB). Despite this recommendation, evidence for its effectiveness are conflicting, and early colonoscopy is often not performed.

OBJECTIVES

We aimed to evaluate the utility of early colonoscopy by examining the findings during the procedure, and by comparing in-hospital and long-term outcomes between patients who did and did not undergo early colonoscopy.

DESIGN

This is a retrospective cohort study based on the electronic medical records of a large tertiary hospital in Israel.

METHODS

All patients hospitalized with acute LGIB to acute wards between 2012 and 2022 were included. First, structured and free-text procedure notes from patients who did undergo early colonoscopy were examined. Second, we compared in-hospital and long-term outcomes between patients who did and did not undergo early colonoscopy while adjusting for possible confounders using multivariable regression of the type appropriate for each outcome.

RESULTS

Overall, 953 patients were included, of which 90 underwent early colonoscopy. The majority (54%) were found insufficiently prepared. Common findings were diverticulosis (38%) and colon polyps (20%). The procedure was effective for hemostasis in only 13% of the cases. Early colonoscopy was not significantly associated with increased survival (exponentiated coefficient = 1.19, 95% CI: 0.76, 1.87), decreased length of hospitalization (exponentiated coefficient = 1.08, 95% CI: 0.97, 1.21), or increased blood hemoglobin at discharge (coefficient =-0.27, 95% CI: -0.58, 0.03).

CONCLUSIONS

Early colonoscopy was often not effective and was not associated with significantly improved outcomes.

Making Hematochezia of Unknown Origin Known: A Retrospective Analysis

INTRODUCTION

Hematochezia is observed frequently in daily practice. However, natural hemostasis often prevents identification of the bleeding source during observations. This study was conducted to clarify risk factors related to rebleeding in hematochezia patients without an identified cause of bleeding.

METHODS

We analyzed patients who were admitted to Dokkyo Medical University Hospital during April 1, 2009, through March 31, 2015, with the chief complaint of hematochezia. Main outcome measures included the rebleeding rate and the period until rebleeding in hematochezia patients without an identified bleeding source.

RESULTS

We selected 159 patients for analyses. Rebleeding was observed in 46 (28.9%) of 159 patients. The median period until first rebleeding was 166 days (2-3,046 days). Univariate analysis indicated that risk factors for rebleeding were male gender (p = 0.029), higher age (p = 0.023), antithrombotic medicines (p = 0.047), lower hemoglobin on admission (p = 0.024), and the presence of diverticula (p = 0.002). Multivariate analysis indicated the presence of diverticula (p = 0.023) and male gender (p = 0.043) as rebleeding risk factors.

DISCUSSION/CONCLUSION

In patients with hematochezia of unknown origin, risk factors for rebleeding indicated in this study, especially the presence of diverticula and male gender, should be given particular attention by physicians.

Optimal candidates for early colonoscopy in the management of acute lower gastrointestinal bleeding

BACKGROUND AND AIM

Early colonoscopy has not shown any advantages over elective colonoscopy in reducing the risk of early rebleeding (≤ 30 days) after acute lower gastrointestinal bleeding (ALGIB). Considering the heterogeneity among patients with ALGIB, we sought to evaluate appropriate candidates for early colonoscopy.

METHODS

A total of 592 patients with ALGIB were enrolled, and the clinical outcomes of early colonoscopy were investigated. Thereafter, the participants were divided into two groups: the recent bleeding group (n = 445), with hematochezia 0-6 h before hospital arrival, and non-recent bleeding group (n = 147). The clinical outcomes yielded by early colonoscopy were assessed in each group.

RESULTS

The multivariate analysis including the entire population revealed that early colonoscopy (< 24 h) did not reduce the risk of early rebleeding (adjusted odds ratio [AOR], 0.88; 95% confidence interval [CI], 0.55-1.39). However, in the subgroup analysis, early colonoscopy independently reduced the risk of early rebleeding in the recent bleeding group (AOR, 0.56; 95% CI, 0.33-0.94). Moreover, a reduction in the need for radiological or surgical intervention (AOR, 0.34), transfusion (AOR, 0.62), and prolonged hospitalization (AOR, 0.42), as well as improvement in diagnostic yield (AOR, 1.78) and endoscopic treatment rates (AOR, 1.66), were observed. Early colonoscopy did not improve the outcomes of the non-recent bleeding group.

CONCLUSIONS

Early colonoscopy is not required for all patients with ALGIB. However, it may be suitable for those with hematochezia 0-6 h before hospital arrival, as it reduces early rebleeding and improves clinical outcomes.

Outcomes in high and low volume hospitals in patients with acute hematochezia in a cohort study

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79-1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17-3.52; P = 0.012) on multivariate logistic regression after adjusting for patients' characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding

Background

Lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization. However, recent data suggest low-risk patients may be safely evaluated as an outpatient. Here, we compare stable LGIB patients discharged from the emergency department (ED) with those admitted, determine factors associated with discharge and 30-day outcomes, and evaluate follow-up rates amongst the discharged cohort.

Methods

A retrospective study of stable LGIB patients (heart rate < 100 beats/min, systolic blood pressure > 100 mm Hg and blood on rectal exam) who presented to the ED was conducted. Factors associated with discharge and rates of outpatient follow-up were determined in the discharged cohort. Therapeutic interventions and 30-day outcomes (including re-bleeding, re-admission and mortality rates) were compared between the admitted and discharged groups.

Results

Ninety-seven stable LGIB patients were reviewed, of whom 38% were discharged and characteristics associated with discharge included age (P < 0.001), lack of aspirin (P < 0.002) and anticoagulant (P < 0.004) use, higher index hemoglobin (P < 0.001) and albumin (P < 0.001), lower blood urea nitrogen (P < 0.001) and creatinine (P = 0.008), lower Oakland score (P < 0.001), lower Charlson Comorbidity Index (P < 0.001) and lack of transfusion requirements (P < 0.001). There was no statistical difference in 30-day re-bleeding, re-admission or mortality rates between admitted and discharged patients. Discharged patients had a 46% outpatient follow-up rate.

Conclusions

While early discharge in low-risk LGIB patients appears to be safe and associated with a decrease in length of stay, further studies are needed to guide timely and appropriate outpatient evaluation.

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study

BACKGROUND & AIM

Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management.

METHODS

Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded.

RESULTS

Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients.

CONCLUSION

Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412].

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

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.

Efficacy of urgent colonoscopy for colonic diverticular bleeding: A propensity score-matched analysis using a nationwide database in Japan

BACKGROUND AND AIM

Although colonic diverticular bleeding (CDB) is considered to have good prognosis with conservative therapy, some cases are severe. The efficacy of urgent colonoscopy for CDB and clinical factors affecting CDB prognosis are unclear. This study aimed to evaluate the efficacy of urgent colonoscopy for CDB and identify risk factors for unfavorable events, including in-hospital death during admission, owing to CDB.

METHODS

We collected CDB patients' data using the Diagnosis Procedure Combination database system. We divided eligible patients into urgent and elective colonoscopy groups using propensity score matching and compared endoscopic hemostasis and in-hospital death rates and length of hospital stay. We also conducted logistic regression analysis to identify clinical factors affecting CBD clinical events, including in-hospital death, a relatively rare CDB complication.

RESULTS

Urgent colonoscopy reduced the in-hospital death rate (0.35% vs 0.58%, P = 0.033) and increased the endoscopic hemostasis rate (3.0% vs 1.7%, P < 0.0001) compared with elective colonoscopy. Length of hospitalization was shorter in the urgent than in the elective colonoscopy group (8 vs 9 days, P < 0.0001). Multivariate analysis also revealed that urgent colonoscopy reduced in-hospital death (odds ratio = 0.67, 95% confidence interval: 0.46-0.97, P = 0.036) and increased endoscopic hemostasis (odds ratio = 1.84, 95% confidence interval: 1.53-2.22, P <  0.0001).

CONCLUSION

Urgent colonoscopy for CDB may facilitate identification of the bleeding site and reduce in-hospital death. The necessity and appropriate timing of urgent colonoscopy should be considered based on patients' condition.

Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding

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.

ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding

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.

Survival Analysis of Geriatric Patients with Low Digestive Hemorrhage Attending an Emergency Department

BACKGROUND

The increase in life expectancy and low mortality have doubled the number of individuals older than 65 in the last 30 years.

METHODS

We conducted a retrospective study of 101 patients older than 80 years of age treated by low digestive hemorrhage (LDH) in an emergency department during 2018. Sociodemographic variables were evaluated, as well as comorbidity and survival at 18 months. Survival was assessed by a Kaplan-Meier test.

RESULTS

52.5% of the subjects were women. The average comorbidity of the sample was 1.97. The survival rate per year was 60%. The finding on colonoscopy shows no association with mortality. However, those patients on anticoagulant/antiplatelet therapy have a higher survival rate.

CONCLUSION

Survival per year is high, so urgent colonoscopy for an LDH should be performed after evaluating the patient's stability and functional status in a scheduled and outpatient manner.

Severe Acute Colonic Diverticular Bleeding: The Efficacy of Rapid Bowel Preparation With 1 L Polyethylene Glycol Ascorbate Solution and Direct Endoscopic Hemoclipping for Successful Hemostasis

Colonic diverticular bleeding is an established cause of painless acute lower gastrointestinal hemorrhage. Colonoscopy, performed within 24 hours of presentation, is the usual initial diagnostic procedure in such patients. In order to improve the diagnostic and therapeutic yield of urgent colonoscopy, adequate colon cleansing is required in patients with signs and symptoms of ongoing bleeding. We hereby delineate the importance of rapid bowel preparation with a very-low-volume novel 1 L polyethylene glycol ascorbate solution in the setting of acute severe colonic diverticular bleeding. The 1-L regimen may demonstrate similar efficacy to that of traditional higher volume preparations and it can substantially reduce the time for bowel preparation. Therefore, it can be considered for bowel purge when colonoscopy has to be rapidly planned in critical patients. This article further illustrates that the endoscopic technique using epinephrine followed by direct hemoclipping may be added to the armamentarium for acute colonic diverticular hemorrhage as the first treatment, especially in elderly patients with multiple comorbid conditions. While ample evidence surrounding the efficacy of the clipping method persists in the literature, rapid bowel preparation with 1 L polyethylene glycol ascorbate solution's imperativeness to achieve hemostasis with direct hemoclipping remains elusive.

Use of over-the-scope clips in the colon in clinical practice: results from a German administrative database

BACKGROUND : The efficacy and safety of over-the-scope (OTS) clips in the colon is limited. This study aimed to evaluate OTS clip use in the colon in routine colonoscopy.

METHODS

Using administrative data from a large health insurance company, patients with OTS clip placement during colonoscopy were identified and analyzed by specific administrative codes. Indication for OTS clipping was analyzed, and follow-up was evaluated for surgical and repeat endoscopic interventions.

RESULTS

In 505 patients, indications for OTS clips were iatrogenic perforations (n = 80; Group A), polypectomy (n = 315; Group B), colonic bleeding (n = 51; Group C), and various underlying diseases (n = 59; Group D). In 11 Group A patients (13.8 %), surgical interventions occurred, mostly within 24 hours after clipping (n = 9), predominantly overstitching (n = 8). OTS clipping during polypectomy (Group B) was for complications (e. g. bleeding in 27 %) or was applied prophylactically. Only five patients required early surgery, three of whom had colorectal cancer. In four Group C patients (7.8 %), surgical resections were performed (persistent bleeding n = 1, colorectal cancer n = 2), while six patients underwent early repeat colonoscopy for recurrent bleeding. During further follow-up (days 11-30), 17 patients underwent resection for colonic neoplasms (n = 12) or persistent bleeding (n = 4), but only one case could be directly traced back to local OTS clip complication.

CONCLUSION

Colonic OTS clipping appears safe and effective in selected indications and complications in clinical routine but must be anatomically and technically feasible, avoiding overuse.

What gastroenterologists should know about direct oral anticoagulants

Direct oral anticoagulants are being increasingly used in patients with non-valvular atrial fibrillation and venous thromboembolism, due to their improved efficacy/ safety ratio, a predictable anticoagulant effect without need for routine coagulation monitoring, and fewer food and drug interactions compared with vitamin K antagonists. Gastrointestinal bleeding remains a serious complication, whose management is challenging for gastroenterologists due to the lack of a standardized clinical approach. Clinical experience on periendoscopic management of these drugs is still limited and there is a paucity of clinical data supporting guidelines recommendations', and this ultimately turns out in different, unsubstantiated and potentially harmful practices of patient management. Present study will provide a thorough revision on the risk of GI bleeding for DOAC therapy and the identification of patient risk factors to individualize treatment. Moreover, the approach to management of DOACs in case of bleeding complications is discussed, and an algorithm of different strategies in presence or not of plasma level measurement is proposed. Finally the periendoscopic management for elective procedures will be reviewed, at the light of the guideline recommendations and new evidences from observational studies.

Systematic review with meta-analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding

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.

Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients

BACKGROUND AND AIM

Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited.

METHODS

Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses.

RESULTS

A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period.

CONCLUSIONS

Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.

Early Colonoscopy Does Not Improve Outcomes of Patients With Lower Gastrointestinal Bleeding: Systematic Review of Randomized Trials

BACKGROUND & AIMS

Guidelines recommend colonoscopy evaluation within 24 hours of presentation or admission in patients with high-risk or severe acute lower gastrointestinal bleeding (LGIB). Meta-analyses of the timing of colonoscopy have relied primarily on observational studies that had major potential for bias. We performed a systematic review of randomized trials to determine optimal timing of colonoscopy for patients hospitalized with acute LGIB.

METHODS

We searched publication databases through July 2019 and abstracts from gastroenterology meetings through November 2019 for randomized trials of patients with acute LGIB or hematochezia. We searched for studies that compared early colonoscopy (within 24 hours) with elective colonoscopy beyond 24 hours and/or other diagnostic tests. Our primary outcome was further bleeding, defined as persistent or recurrent bleeding after index examination. Secondary outcomes included mortality, diagnostic yield (identifying source of bleeding), endoscopic intervention, and any primary hemostatic intervention (endoscopic, surgical, or interventional radiologic). We performed dual independent review, data extraction, and risk of bias assessments. We performed the meta-analysis using a random-effects model.

RESULTS

Our final analysis included data from 4 randomized trials. Further bleeding was not decreased among patients who received early vs later, elective colonoscopy (relative risk [RR] for further bleeding with early colonoscopy, 1.57; 95% CI. 0.74-3.31). We did not find significant differences in the secondary outcomes of mortality (RR, 0.93; 95% CI, 0.05-17.21), diagnostic yield (RR, 1.09; 95% CI, 0.99-1.21), endoscopic intervention (RR, 1.53; 95% CI, 0.67-3.48), or any primary hemostatic intervention (RR, 1.33; 95% CI, 0.92-1.92).

CONCLUSIONS

In a meta-analysis of randomized trials, we found that colonoscopy within 24 hours does not reduce further bleeding or mortality in patients hospitalized with acute LGIB. Based on these findings, patients hospitalized with acute LGIB do not generally require early colonoscopy.

Urgent Versus Standard Colonoscopy for Management of Acute Lower Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospitalization. However, the optimum timing of colonoscopy following patient presentation remains unclear. This systematic review and meta-analysis aims to evaluate the effect of urgent versus standard colonoscopy timing on management of acute LGIB.

MATERIALS AND METHODS

Medline, EMBASE, CENTRAL, and PubMed were searched up to January 2020. Randomized controlled trials were eligible for inclusion if they compared patients with hematochezia receiving urgent (<24 h) versus standard (>24 h) colonoscopy. Nonrandomized observational studies were also included based on the same criteria for additional analysis. Pooled estimates were calculated using random effects meta-analyses and heterogeneity was quantified using the inconsistency statistic. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Of 3782 potentially relevant studies, 4 randomized controlled trials involving 463 patients met inclusion criteria. Urgent colonoscopy did not differ significantly to standard timing with respect to length of stay (LOS), units of blood transfused, rate of additional intervention required, or mortality. Colonoscopy-related outcomes such as patient complications, rebleeding rates, and diagnosis of bleeding source did not differ between groups. However, meta-analysis including nonrandomized studies (9 studies, n=111,950) revealed a significantly higher rate of mortality and complications requiring surgery in the standard group and shorter LOS in the urgent group. Overall GRADE certainty of evidence was low in the majority of outcomes.

CONCLUSIONS

Timing of colonoscopy in acute LGIB may not significantly affect patient outcomes. Timing should therefore be decided on a case-by-case basis.

Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room

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.

Colonoscopic management of diverticular disease

Diverticula are the most common incidental finding during routine colonoscopy, and their prevalence increases with patient age. The term “diverticular disease” encompasses the range of clinical manifestations and complications that can occur with colonic diverticula, including diverticular bleeding, diverticulitis-associated strictures, and acute diverticulitis. Colonoscopy is a vital tool in the diagnosis and management of diverticular disease and can be useful in a variety of regards. In this editorial, we concisely delineate the current approach to and practices in colonoscopic management of diverticular disease. In particular, we discuss treatment options for diverticular bleeding, propose consideration of colonic stenting as a bridge to surgery in patients with diverticulitis-associated strictures, and the need for diagnostic colonoscopy following an episode of acute diverticulitis in order to rule out underlying conditions such as colonic malignancy or inflammatory bowel disease. In addition, we offer practical tips for performing safe and successful colonoscopy in patients with dense diverticulosis coli.

Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage

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.

Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding

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.

Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding

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.

Paradigm shift: the Copernican revolution in diverticular disease

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.

Early Versus Standard Colonoscopy: A Randomized Controlled Trial in Patients With Acute Lower Gastrointestinal Bleeding: Results of the BLEED Study

GOALS

The aim of our study was to examine differences in length of hospital stay (LOHS) between patients with lower gastrointestinal bleeding who received either an early colonoscopy (within 24 h of presentation) or a standard colonoscopy (within 1 to 3 d).

BACKGROUND

Diagnostic management of lower gastrointestinal bleeding has been extensively debated in recent literature, especially whether colonoscopy within 24 hours of presentation is feasible and safe.

STUDY

In this single center, nonblinded, randomized controlled trial, patients presenting at the emergency department with acute hematochezia were eligible if they required hospital admission. A total of 132 patients were included. Primary outcome was LOHS. Secondary outcomes included yield of colonoscopy, blood transfusion requirements, recurrent bleedings, complications, interventions related to complications, and 30-day mortality. The follow-up period was 1 month.

RESULTS

In total, 63 patients were randomized for <24 hours colonoscopy and 69 for standard colonoscopy. In the intention to treat analysis, LOHS was significantly lower in patients that underwent an early colonoscopy, compared with the standard group: median 2.0 days (inter quartile range, 2.0 to 4.0) versus median 3.0 days (inter quartile range, 2.0 to 4.0) (P=0.009). Recurrent bleedings and hospital readmissions were significantly more frequent in the <24-hour group: 13% versus 3% (P=0.04) and 11% versus 2% (P=0.02), respectively. No difference was observed regarding the number of patients diagnosed with a confirmed or presumptive bleeding source. In both groups, blood transfusion rate was similar and 30-day mortality was 0.

CONCLUSIONS

Early colonoscopy reduces LOHS, but also results in lower clinical efficacy compared with standard colonoscopy.

Colonic diverticular bleeding and predictors of the length of hospitalization: An observational study

BACKGROUND AND AIM

A significant percentage of patients with colonic diverticular bleeding (CDB) experience bleeding that is severe enough to necessitate prolonged hospitalization. Prolonged hospitalization causes deterioration in patients' quality of life, as well as difficulties with cost-effective utilization of medical resources, and is a financial burden to the society. Therefore, we investigated the factors associated with the length of hospitalization for the optimal management of patients hospitalized with CDB.

METHODS

This study included patients who were hospitalized for the treatment of CDB and underwent colonoscopy between July 2008 and February 2016. Logistic regression analysis was performed to investigate the association between the length of hospitalization and the patients' baseline characteristics, in-hospital procedures performed, and the clinical outcomes.

RESULTS

The study included 223 patients. Diabetes mellitus (odds ratio [OR] 3.4, P = 0.014) and blood transfusion (OR 3.1, P = 0.0006) were identified as risk factors for prolonged hospitalization (≥ 8 days). Urgent colonoscopy (OR 0.41, P = 0.0072) predicted a shorter length of hospitalization (≤ 7 days). The study also indicated that endoscopic treatment showed a stronger association with urgent colonoscopy (OR 7.8, P < 0.0001) than with elective colonoscopy and that urgent colonoscopy was not associated with an increased rate of adverse events or re-bleeding.

CONCLUSIONS

Compared with elective colonoscopy, urgent colonoscopy shortens the length of hospitalization in patients with CDB. Moreover, it is not associated with an increased rate of adverse events. Urgent colonoscopy may be impracticable in a few cases; however, if possible, aggressive urgent colonoscopy should be considered for the efficient management of the patient's hospital stay.

Red blood cell transfusions for emergency department patients with gastrointestinal bleeding within an integrated health system

STUDY OBJECTIVE

To assess trends over time in red blood cell (RBC) transfusion practice among emergency department (ED) patients with gastrointestinal (GI) bleeding within an integrated healthcare system, inclusive of 21 EDs.

METHODS

Retrospective cohort of ED patients diagnosed with GI bleeding between July 1st, 2012 and September 30th, 2016. The primary outcome was receipt of an RBC transfusion in the ED. Secondary outcomes included 90-day rates of RBC transfusion, repeat ED visits, rehospitalization, and all-cause mortality. Logistic regression was used to obtain confounder-adjusted outcome rates.

RESULTS

A total of 24,868 unique patient encounters were used for the primary analysis. The median hemoglobin level in the ED prior to RBC transfusion decreased from 7.5 g/dl to 6.9 g/dl in the first versus last twelve months of the study period (p < 0.0001). A small trend was observed in the overall adjusted rate of ED RBC transfusion (absolute quarterly change of -0.1%, R2 = 0.18, p = 0.0001) largely attributable to the subgroup of patients with hemoglobin nadirs between 7.0 and 9.9 g/dl (absolute quarterly change of -0.4%, R2 = 0.38, p < 0.0001). Rates of RBC transfusions through 90 days likewise decreased (absolute quarterly change of -0.4%, R2 = 0.85, p < 0.0001) with stable to decreased corresponding rates of repeat ED visits, rehospitalizations and mortality.

CONCLUSION

Rates of ED RBC transfusion decreased over time among patients with GI bleeding, particularly in those with hemoglobin nadirs between 7.0 and 9.9 g/dl. These findings suggest that ED providers are willing to adopt evidence-based restrictive RBC transfusion recommendations for patients with GI bleeding.

The role of colonoscopy and endotherapy in the management of lower gastrointestinal bleeding

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.

Early Colonoscopy for Diverticular Bleeding Does Not Reduce Risk of Postdischarge Recurrent Bleeding: A Propensity Score Matching Analysis

BACKGROUND & AIMS

Colonoscopy within 24 hours (early colonoscopy) is recommended for patients with colonic diverticular bleeding, but it is unclear if this strategy improves postdischarge outcomes. We aimed to determine whether early colonoscopy is associated with decreased risk of rebleeding and hospital re-admission within 30 days.

METHODS

We performed a retrospective cohort study using Marketscan (Truven Health Analytics, Inc, Ann Arbor, MI), a nationwide insurance claims database. From January 2004 through September 2015, patients with a primary diagnosis of diverticular bleeding who underwent inpatient colonoscopy were included. We used propensity score matching to account for differences between recipients of early vs delayed colonoscopy. Multivariable logistic regression was performed to determine the association between early colonoscopy and rebleeding or hospital re-admission within 30 days of discharge.

RESULTS

In total, 20,010 patients underwent colonoscopy for diverticular bleeding; 11,690 underwent early colonoscopy. After propensity matching, 8320 pairs of patients were analyzed. In the matched analysis, higher proportions of patients who received early colonoscopy underwent additional colonoscopies (73%), compared with patients who did not receive early colonoscopy (4%) (P < .0001), but lower proportions received endoscopic interventions (3% vs 8%; P < .0001). On multivariable analysis, early colonoscopy (odds ratio [OR], 1.34; 95% CI, 1.08-1.66; P = .007), transfusion requirement (OR, 2.31; 95% CI, 1.88-2.83; P < .0001), and baseline chronic kidney disease (OR, 2.13; 95% CI, 1.49-3.04; P < .0001) were associated with increased risk of rebleeding within 30 days. Early colonoscopy (OR, 1.18; 95% CI, 1.02-1.36; P = .03), endoscopic intervention (OR, 1.37; 95% CI, 1.03-1.81; P = .03), transfusion requirement (OR, 2.17; 95% CI, 1.88-2.51; P < .0001), coronary artery disease (OR, 1.27; 95% CI, 1.06-1.51; P = .009), and chronic kidney disease (OR, 1.98; 95% CI, 1.54-2.54; P < .0001) were associated with increased re-admission to the hospital within 30 days.

CONCLUSIONS

In a propensity-matched analysis, we associated early colonoscopy with increased risk of rebleeding events and hospital re-admissions. However, these observations might be due to confounding factors.

Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review

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.

Initial management for acute lower gastrointestinal bleeding

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.

Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.

Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation

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.

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

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.

The role of early colonoscopy in patients presenting with acute lower gastrointestinal bleeding: a systematic review and meta-analysis

OBJECTIVE

The use of early colonoscopy in the management of acute lower gastrointestinal bleeding (LGIB) is controversial, with disparate evidence. We aim to formally characterize the utility of early colonoscopy (within 24 h) in managing acute LGIB.

DESIGN

A systematic literature search to August 2016 identified fully published and abstracts of randomized controlled trials (RCTs) and observational studies assessing early colonoscopy in acute LGIB. Single-arm studies were also included to define incidence. Primary outcomes were overall rebleeding rates and time to rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events (AEs). Odds ratios (OR) and weighted mean differences (WMD) were calculated.

RESULTS

Of 897 citations, 10 single-arm, 9 observational studies, and 2 RCTS were included (25,781 patients). Rebleeding was no different between patients undergoing early colonoscopy and controls (seven studies, OR = 0.89, 95% CI 0.49-1.62), or RCT data only (OR = 1.00, 95% CI 0.52-1.62). Early colonoscopy detected more definitive sources of bleeding (OR = 4.12, 95% CI 2.00-8.49), and was associated with shorter LOS colonoscopy (WMD = -1.52, 95% CI -2.54 to -0.50 days). No other differences were noted between early and late colonoscopy. AEs occurred in 4.0%, (95% CI 2.9%; 5.4%) of early colonoscopies. Included studies were of low quality, with significant heterogeneity for some outcomes.

CONCLUSION

Early colonoscopy in acute LGIB does not decrease rebleeding, mortality or need for surgery, but is associated with increased detection of definitive sources of bleeding, shorter LOS, with low complication incidence. However, the quality of evidence is low, highlighting the need for additional high-level studies.

A rational approach to the patient with hematochezia

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.

Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review

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.