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Okada T, Mikamo T, Nakashima A, Yanagitani A, Tanaka K, Isomoto H. Construction of a Model for Predicting the Severity of Diverticular Bleeding in an Elderly Population. Intern Med 2022; 61:2247-2253. [PMID: 35022353 PMCID: PMC9424098 DOI: 10.2169/internalmedicine.8761-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective To identify the risk factors for severe diverticular bleeding in an elderly population. Methods Using a comprehensive computerized hospital database, severe and non-severe diverticular bleeding cases were compared for 19 factors: the age, sex, body mass index, comorbid conditions (hypertension, cardiovascular disease, cerebrovascular disease, and chronic renal failure, including those undergoing dialysis), history of diverticular bleeding, use of low-dose aspirin, use of antiplatelet agent besides aspirin, use of anticoagulant agent, use of prednisolone, use of non-steroidal anti-inflammatory drugs, use of cyclooxygenase-2 selective inhibitors, changes in vital signs, hypoalbuminemia, bilateral diverticula, identification of bleeding lesion, and rebleeding. Severe bleeding was defined as the need for blood transfusion, emergency surgery, or vascular embolization. Patients A total of 258 patients were admitted for lower gastrointestinal bleeding between August 2010 and July 2020, among whom 120 patients over 65 years old diagnosed with diverticular bleeding were included in this study. Results Fifty-one patients (43%) had severe diverticular bleeding. Independent risk factors for severe diverticular bleeding were as follows: change in vital signs [odds ratio (OR), 5.23; 95% confidence interval (CI), 1.9-14.4; p=0.0014], hypoalbuminemia (OR, 12.3; 95% CI, 1.97-77.3; p=0.0073), bilateral diverticula (OR, 3.47; 95% CI, 1.33-9.02; p=0.011), and rebleeding (OR, 5.92; 95% CI, 2.21-15.8; p<0.001). The area under the receiver operating characteristic curve was 0.79 after cross validation. Conclusion Severe diverticular bleeding in elderly population may be predicted by changes in their vital signs, hypoalbuminemia, bilateral diverticula, and rebleeding.
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Affiliation(s)
| | | | | | | | | | - Hajime Isomoto
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Japan
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Lock J, Wiegering A, Germer CT. [Indications for surgical treatment of diverticular disease]. Chirurg 2021; 92:694-701. [PMID: 34100113 DOI: 10.1007/s00104-021-01432-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The correct medical indications are the fundamental decision process for the surgical treatment and ensuring the quality. OBJECTIVE Description of the indications for surgical treatment of the various types of diverticular disease according to the current level of evidence. MATERIAL AND METHODS The narrative review is based on current national and international guidelines and a selective literature search. RESULTS There are basically three main indications for resection of the sigmoid colon. 1) Prophylactic for avoidance of complications after successful conservative treatment of acute complicated diverticulitis with macroabscess formation and high risk of recurrence (classification of diverticular disease, CDD, type 2b). 2) In patients with persistent symptoms and impaired quality of life resection of the sigmoid colon of various types (CDD types 1-3) can effectively enable a significant improvement in the quality of life and is therefore to be recommended in cases of individually acceptable perioperative risks. 3) Indications for urgent resection of the sigmoid colon are present for free perforation or failure of conservative treatment. CONCLUSION The indications for surgery should be defined by the type of diverticular disease, the aim of surgical treatment, the evaluation of the efficacy of surgical treatment in comparison to conservative treatment and an individual appraisal of the risks.
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Affiliation(s)
- Johan Lock
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - A Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - C-T Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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Covino M, Papa V, Tursi A, Simeoni B, Lopetuso LR, Vetrone LM, Franceschi F, Rapaccini G, Gasbarrini A, Papa A. Development and Validation of Predictive Assessment of Complicated Diverticulitis Score. J Pers Med 2021; 11:jpm11020080. [PMID: 33572940 PMCID: PMC7911244 DOI: 10.3390/jpm11020080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex (p < 0.001), constipation (p = 0.002), hemoglobin < 11.9 g/dL (p < 0.001), C reactive protein > 80 mg/L (p < 0.001), severe obesity (p = 0.049), and no proton pump inhibitor treatment (p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Valerio Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, 70031 Andria, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
| | - Loris Riccardo Lopetuso
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Lorenzo Maria Vetrone
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Gianludovico Rapaccini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Alfredo Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-0151
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Overt gastrointestinal bleeding following haploidentical haematopoietic stem cell transplantation: incidence, outcomes and predictive models. Bone Marrow Transplant 2021; 56:1341-1351. [PMID: 33414512 DOI: 10.1038/s41409-020-01187-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 01/04/2023]
Abstract
Gastrointestinal bleeding (GIB) accounts for a significant proportion of life-threatening bleeding cases occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT). However, data on GIB after haploidentical HSCT (haplo-HSCT) are not available. A total of 3180 patients received haplo-HSCT at Peking University People's Hospital from January 2015 to November 2019, and GIB occurred in 188 of these patients (incidence of 5.9%). Platelet counts <30 × 109/L, viral hepatitis, acute kidney injury (AKI), gastrointestinal disease or bleeding before HSCT and sinusoidal obstruction syndrome (SOS) were determined to be significant risk factors for the occurrence of GIB after haplo-HSCT. Grade III-IV acute graft-versus-host disease (aGVHD), AKI, thrombotic microangiopathy (TMA), disseminated intravascular coagulation (DIC) and gastrointestinal disease or bleeding before HSCT were significantly related to mortality in patients with GIB after haplo-HSCT. The predictive models developed for the occurrence and mortality of GIB performed well in terms of discrimination, and they might assist clinicians with personalised strategies for GIB prevention and treatment in patients after haplo-HSCT.
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [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: 02/07/2023] Open
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6
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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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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Kinjo K, Matsui T, Hisabe T, Ishihara H, Kojima T, Chuman K, Yasukawa S, Beppu T, Koga A, Ishikawa S, Kishi M, Takatsu N, Hirai F, Yao K, Ueki T, Washio M. Risk factors for severity of colonic diverticular hemorrhage. Intest Res 2018; 16:458-466. [PMID: 30090045 PMCID: PMC6077309 DOI: 10.5217/ir.2018.16.3.458] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS Colonic diverticular hemorrhage (DH) was a rare disease until the 1990s, and its incidence has increased rapidly since 2000 in Japan. In recent years, colonic DH has been the most frequent cause of lower gastrointestinal bleeding (LGIB). Nearly all cases of DH are mild, with the bleeding often stopping spontaneously. Some cases, however, require surgery or arterial embolization. In this study, using a cohort at Fukuoka University Chikushi Hospital, we investigated factors associated with severe colonic DH. METHODS Among patients with LGIB who underwent colonoscopy at our hospital between 1995 and 2013, DH was identified in 273 patients. Among them, 62 patients (22.7%) were defined as having severe colonic DH according to recurrence of bleeding in a short period, and/or the necessity of transfusion, arterial embolization, or surgery. We then evaluated risk factors for severe DH among DH patients in this retrospective cohort. RESULTS Among the 273 patients with DH, use of non-steroidal anti-inflammatory drugs (NSAIDs) (odds ratio [OR], 2.801; 95% confidence interval [CI], 1.164-6.742), Charlson Risk Index (CRI) ≥2 (OR, 3.336; 95% CI, 1.154-7.353), right-sided colonic DH (OR, 3.873; 95% CI, 1.554-9.653), and symptoms of cerebral hypoperfusion (such as light-headedness, dizziness, or syncope) (OR, 2.926; 95% CI, 1.310-6.535) showed an increased risk of severe DH even after controlling for other factors. CONCLUSIONS Severe DH occurred in 23% of DH patients, and NSAID use, CRI ≥2, right-sided colonic DH, and symptoms of cerebral hypoperfusion are suggested to be predictors of severe DH.
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Affiliation(s)
- Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Hiroshi Ishihara
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiki Kojima
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kenta Chuman
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Shigeyoshi Yasukawa
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Tsuyoshi Beppu
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Akihiro Koga
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Satoshi Ishikawa
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Masahiro Kishi
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Noritaka Takatsu
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kenshi Yao
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Masakazu Washio
- Department of Community Health and Clinical Epidemiology, St. Mary's College, Kurume, Japan
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Gilshtein H, Kluger Y, Khoury A, Issa N, Khoury W. Massive and recurrent diverticular hemorrhage, risk factors and treatment. Int J Surg 2016; 33 Pt A:136-9. [PMID: 27500962 DOI: 10.1016/j.ijsu.2016.07.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/26/2016] [Accepted: 07/29/2016] [Indexed: 01/22/2023]
Abstract
AIM Diverticular hemorrhage may be massive or recurrent, requiring surgical management. The aim of our study is to define risk factors that predict rebleeding or need for urgent operation in patients with diverticular hemorrhage. METHODS Retrospective study was conducted on patients who were admitted for diverticular hemorrhage. Data pertaining to patient and bleeding characteristics, method of diagnosis, blood transfusion and type of operation were collected. Multivariate analysis model compared patients who experienced single bleeding episode with those with recurrent episodes, and patients who underwent surgery with those who did not. RESULTS One hundred and four patients met the inclusion criteria. Thirty four patients experienced more than one bleeding episode. Ten patients needed surgery for recurrent bleeding. Five patients presented with hemodynamic instability, none of them required surgical treatment. Neither patients' comorbidity nor anticoagulant and antiaggregant treatments were associated with increased risk for recurrent hemorrhage. Diabetes mellitus was correlated with decreased risk for recurrent hemorrhage, OR = 0.21, (CI 95% (0.06-0.73)); p = 0.014. Independent risk factor for massive recurrent diverticular hemorrhage requiring surgery was right sided diverticulosis, OR = 4.6(CI 95% (2.1-19)); p = 0.006. CONCLUSIONS Right colon diverticulosis rather than patient characteristics and medical treatment should prompt for aggressive management with lower threshold for surgical intervention.
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Affiliation(s)
- Hayim Gilshtein
- Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel; Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Areen Khoury
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Nidal Issa
- Department of General Surgery, Hasharon Medical Center, Petah Tikva, Israel
| | - Wisam Khoury
- Colorectal Surgery Unit, Rambam Health Care Campus, Haifa, Israel; Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.
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Lorenzo D, Gallois C, Lahmek P, Lesgourgues B, Champion C, Charpignon C, Faroux R, Bour B, Remy AJ, Naouri C, Picon M, Poncin E, Macaigne G, Seyrig JA, Bernardini D, Bellaïche G, Grasset D, Henrion J, Heluwaert F, Piperaud R, Bordes G, Bourhis F, Arpurt JP, Pariente A, Nahon S. Middle-term mortality and re-bleeding after initial diverticular bleeding: A nationwide study of 365 mostly elderly French patients. United European Gastroenterol J 2016; 5:119-127. [PMID: 28405330 DOI: 10.1177/2050640616647816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS The aim of this study was to determine the mortality and re-bleeding rates, and the risk factors involved, in a cohort of patients with previous diverticular bleeding (DB). METHODS In 2007, data on 2462 patients with lower gastrointestinal (GI) bleeding were collected prospectively at several French hospitals. We studied the follow-up of patients with DB retrospectively. The following data were collected: age, mortality rates and re-bleeding rates, drug intake, surgery and comorbidities. RESULTS Data on 365 patients, including 181 women (mean age 83.6 ± 9.8 years) were available. The median follow-up time was 3.9 years (IQR 25-75: 1.7-5.4). Of these, 148 patients died (40.5%). Among the 70 patients (19.2%) who had at least one re-bleeding episode, nine died and three underwent surgical procedures. Anticoagulation and antiplatelet therapy was discontinued in 70 cases (19.2%). The independent risk factors contributing to mortality were age > 80 years (HR = 3.18 (2.1-4.9); p < 0.001) and a Charlson comorbidity score > 2 (1.91 (1.31-2.79); p = 0.003). Discontinuation of therapy was not significantly associated with a risk of death due to cardiovascular events. No risk factors responsible for re-bleeding were identified, such as antiplatelet and anticoagulant therapy in particular. CONCLUSIONS In this cohort, the rates of mortality and DB re-bleeding after a median follow-up time of 3.9 years were 19.2% and 40.5%, respectively. The majority of the deaths recorded were not due to re-bleeding.
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Affiliation(s)
- Diane Lorenzo
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Claire Gallois
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Pierre Lahmek
- Service d'addictologie. Hôpital Emile Roux AP-HP, Limeil-Brévannes, France
| | - Bruno Lesgourgues
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Christine Champion
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
| | - Claire Charpignon
- Service d'Hépato-Gastroentérologie. Centre Hospitalier Intercommunal Villeneuve Saint-Georges, Villeneuve Saint-Georgess, France
| | - Roger Faroux
- Service d'Hépato-Gastroentérologie. Centre hospitalier départemental de Vendée, La Roche-sur-Yon, France
| | - Bruno Bour
- Service d'Hépato-Gastroentérologie. Centre hospitalier-LeMans, Le Mans, France
| | - André-Jean Remy
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Perpignan, Perpignan, France
| | - Chantal Naouri
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Mâcon, Mâcon, France
| | - Magali Picon
- Service d'Hépato-Gastroentérologie. Centre hospitalier d'Aix-en-Provence, Aix-en-Provence, France
| | - Eric Poncin
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Dax, Dax, France
| | - Gilles Macaigne
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Marne La Vallée, Lagny-sur-Marne, France
| | - Jacques-Arnaud Seyrig
- Service d'Hépato-Gastroentérologie. Centre hospitalier du centre Bretagne, Pontivy, France
| | - David Bernardini
- Service d'Hépato-Gastroentérologie. Centre hospitalier intercommunal de Toulon, Toulon, France
| | - Guy Bellaïche
- Service d'Hépato-Gastroentérologie. Centre hospitalier intercommunal d'Aulnay-sous-Bois, Aulnay-sous-Bois, France
| | - Denis Grasset
- Service d'Hépato-Gastroentérologie. Centre hospitalier Bretagne Atlantique, Vannes, France
| | - Jean Henrion
- Service d'Hépato-Gastroentérologie. Hôpital de Jolimont, Haine-Saint-Paul, Belgium
| | - Frédéric Heluwaert
- Service d'Hépato-Gastroentérologie. Centre hospitalier Annecy Genevois, Annecy, France
| | - René Piperaud
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Laon, Laon, France
| | - Gilbert Bordes
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Digne les Bains, Dignes, France
| | - Francois Bourhis
- Service d'Hépato-Gastroentérologie. Hôpital d'Aix Les Bains et de Chambery, Chambery, France
| | - Jean-Pierre Arpurt
- Service d'Hépato-Gastroentérologie. Centre hospitalier d'Avignon, Avignon, France
| | - Alexandre Pariente
- Service d'Hépato-Gastroentérologie. Centre hospitalier de Pau, Pau, France
| | - Stéphane Nahon
- Service d'Hépato-Gastroentérologie. Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France
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Joaquim N, Caldeira P, Antunes AG, Eusébio M, Guerreiro H. Risk factors for severity and recurrence of colonic diverticular bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:3-9. [DOI: 10.17235/reed.2016.4190/2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cirocchi R, Grassi V, Cavaliere D, Renzi C, Tabola R, Poli G, Avenia S, Farinella E, Arezzo A, Vettoretto N, D'Andrea V, Binda GA, Fingerhut A. New Trends in Acute Management of Colonic Diverticular Bleeding: A Systematic Review. Medicine (Baltimore) 2015; 94:e1710. [PMID: 26554768 PMCID: PMC4915869 DOI: 10.1097/md.0000000000001710] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colonic diverticular disease is the most common cause of lower gastrointestinal bleeding. In the past, this condition was usually managed with urgent colectomy. Recently, the development of endoscopy and interventional radiology has led to a change in the management of colonic diverticular bleeding.The aim of this systematic review is to define the best treatment for colonic diverticular bleeding.A systematic bibliographic research was performed on the online databases for studies (randomized controlled trials [RCTs], observational trials, case series, and case reports) published between 2005 and 2014, concerning patients admitted with a diagnosis of diverticular bleeding according to the PRISMA methodology.The outcomes of interest were: diagnosis of diverticulosis as source of bleeding; incidence of self-limiting diverticular bleeding; management of non self-limiting bleeding (endoscopy, angiography, surgery); and recurrent diverticular bleeding.Fourteen studies were retrieved for analysis. No RCTs were found. Eleven non-randomized clinical controlled trials (NRCCTs) were included in this systematic review. In all studies, the definitive diagnosis of diverticular bleeding was always made by urgent colonoscopy. The colonic diverticular bleeding stopped spontaneously in over 80% of the patients, but a re-bleeding was not rare. Recently, interventional endoscopy and angiography became the first-line approach, thus relegating emergency colectomy to patients presenting with hemodynamic instability or as a second-line treatment after failure or complications of hemostasis with less invasive treatments.Colonoscopy is effective to diagnose diverticular bleeding. Nowadays, interventional endoscopy and angiographic treatment have gained a leading role and colectomy should only be entertained in case of failure of the former.
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Affiliation(s)
- Roberto Cirocchi
- From the Department of Digestive Surgery and Liver Unit, St Maria Hospital, Terni, Italy (RC, VG); Surgical Oncology, Forlì Hospital, Forlì, Italy (DC); Department of General and Oncologic Surgery, University of Perugia, St Maria Hospital, Perugia, Italy (CR); Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland (RT); Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy (GP); Department of Endocrine Surgery, University of Perugia, Perugia, Italy (SA); Department of Digestive Surgery, ULB-Hopital Erasme, Brussels, Belgium (EF); Department of Surgical Sciences, University of Torino, Torino, Italy (AA); Department of Surgery, Montichiari, Ospedali Civili Brescia, Italy (NV); Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy (VD); Department of Colorectal Surgery, Galliera Hospital, Genoa, Italy (GAB); and Surgical Research Unit, Medical University of Graz, Austria and First Department of Surgery, Hippokration Hospital, University of Athens Medical School, Athens, Greece (AF)
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13
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis 2014; 16:O189-96. [PMID: 24320820 DOI: 10.1111/codi.12516] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 02/08/2023]
Abstract
AIM Complications of colonic diverticula, perforation and bleeding are a source of morbidity and mortality. A variety of drugs have been implicated in these complications. We present a systemic review and meta-analysis of the literature to assess the importance of this relationship. METHOD A systematic review of articles in PubMed, Cochrane Reviews, Embase and Google Scholar was undertaken in February 2013. An initial literature search yielded 2916 results that were assessed for study design and topicality. Twenty-three articles were included in the review. A qualitative data synthesis was conducted using forest plots of studies comparing single medication with complications. RESULTS Individual studies demonstrated the odds of perforation and abscess formation with nonsteridal anti-inflammatory drugs (NSAIDs) (1.46-10.30), aspirin (0.66-2.40), steroids (2.17-31.90) and opioids (1.80-4.51) and the odds of bleeding with NSAIDs (2.01-12.60), paracetamol (0-3.75), aspirin (1.14-3.70) and steroids (0.57-5.40). Pooled data showed significantly increased odds of perforation and abscess formation with NSAIDs (OR = 2.49), steroids (OR = 9.08) and opioids (OR = 2.52). They also showed increased odds of diverticular bleeding from NSAIDs (OR = 2.69), aspirin (OR = 3.24) and calcium-channel blockers (OR = 2.50). Most studies did not describe the duration or dosage of medication used and did not systematically describe the severity of diverticular complications. CONCLUSION Various common medications are implicated in complications of diverticular disease.
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Affiliation(s)
- C L Kvasnovsky
- Department of Colorectal Surgery, King's College Hospital, London, UK
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Risk of recurrence and long-term outcomes after colonic diverticular bleeding. Int J Colorectal Dis 2014; 29:373-8. [PMID: 24337782 DOI: 10.1007/s00384-013-1804-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Diverticular disease is one of the most common causes of acute lower gastrointestinal bleeding. We aimed to evaluate the natural history, follow-up, and risk factors associated with re-bleeding (recurrence) in patients with colonic diverticular bleeding. METHODS We reviewed patients with proven colonic diverticular hemorrhage from September 1993 to June 2012 at our institution. Recurrence was the main outcome measure. RESULTS We identified 78 out of 95 patients with proven diverticular bleed who were treated non-operatively and were followed up for a median of 57.1 months. Thirty-seven (47 %) of these patients with a median age of 67 years developed recurrent diverticular bleed after a median time of 8.1 months. The bleeding originated from the left colon in 78 (83 %) out of 95 patients in the first bleeding episode and 31(84 %) out of 37 patients during the recurrent bleeding episode. Thirty-six patients (97 %) with recurrent diverticular bleed required surgical intervention. Old age at the time of initial bleeding was associated with recurrence (p = 0.001). Patients with diverticulitis (p < 0.0001), peripheral vascular (p = 0.01), and chronic renal diseases (p = 0.047) were found to have an increased risk for recurrent colonic diverticular bleed. We only had one perioperative mortality due to postoperative sepsis. All other mortalities were not directly associated with surgery. CONCLUSION Patients with a history of colonic diverticular bleed are prone to recur shortly thereafter. Certain risk factors including increased age, documented diverticulitis, history of peripheral vascular disease, and chronic renal failure may predispose to recurrence.
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Dao HE, Miller PE, Lee JH, Kermani R, Hackford AW. Transfer status is a risk factor for increased in-hospital mortality in patients with diverticular hemorrhage. Int J Colorectal Dis 2013; 28:273-6. [PMID: 22932906 DOI: 10.1007/s00384-012-1568-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Gastrointestinal tract hemorrhage is a common problem accounting for approximately 1 % of hospital admissions. It is estimated that one third of the episodes of lower gastrointestinal hemorrhage are secondary to diverticular disease. Inter-institutional transfer has been associated with delay in care and increased in-hospital mortality. We hypothesized that patients with diverticular hemorrhage that were transferred from an acute care hospital to tertiary care institutions have increased in-hospital morbidity and mortality when compared to primarily admitted patients. MATERIALS AND METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample for the year 2008. Patients with a primary discharge diagnosis of diverticular hemorrhage were selected. Multivariate logistic regression was used to identify the relationship between transfer status and in-hospital mortality. RESULTS A total of 99,415 hospitalizations for diverticular hemorrhage were identified. Transferred patients had higher in-hospital mortality rates compared to primarily admitted patients (3.5 vs. 1.8 %, p < 0.001), as well as increased length of stay (8.4 vs. 5.4 days, p < 0.001) and a higher rate of total abdominal colectomy (1.2 vs. 0.6 %, p < 0.001). Multivariate analysis indicated that transfer status was associated with increased in-hospital mortality [OR 1.8, 95 % CI 1.5-2.8, p < 0.001]. CONCLUSIONS Inter-institutional transfer for diverticular bleeding is associated with increased in-hospital mortality, increased total abdominal colectomy rate, as well as increased economic burden including mean length of stay and total hospital charges. Further prospective studies are needed to analyze the clinical information of patients requiring transfer to another hospital in order to identify those patients who would truly benefit from inter-institutional transfer.
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Affiliation(s)
- Haisar E Dao
- Department of Surgery, Division of Colorectal Surgery, CMP 2S, Steward St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA 02135, USA.
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Davies RJ. Commentary on: Risk factors predictive of severe diverticular hemorrhage. International Journal of Surgery, in press. Int J Surg 2011; 9:353-4. [PMID: 21296690 DOI: 10.1016/j.ijsu.2011.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 10/18/2022]
Affiliation(s)
- R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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