Incidence, Risk Factors, and Clinical Effects of Recurrent Diverticular Hemorrhage: A Large Cohort Study

Long-Term Natural History of Presumptive Diverticular Hemorrhage

INTRODUCTION

The natural history of patients with well-documented presumptive diverticular hemorrhage (TICH) is unknown. Our aims are to report (i) rebleeding rates and clinical outcomes of presumptive TICH patients with and without rebleeding, (ii) conversion to definitive TICH during long-term follow-up (F/U), and (iii) risk factors of presumptive diverticular (TIC) rebleeding.

METHODS

This was a retrospective cohort study of prospectively collected results of presumptive TICH patients from 1994 to 2023. Presumptive TICH was diagnosed for patients with TICs without stigmata of recent hemorrhage and no other cause of bleeding found on anoscopy, enteroscopy, capsule endoscopy, computed tomography angiography, or tagged red blood cell scan. Patients with ≤6 months of F/U were excluded.

RESULTS

Of 139 patients with presumptive TICH, 104 were male and 35 female. The median age was 76 years. There were no significant differences in baseline demographics of rebleeders and non-rebleeders. During long-term median F/U of 73 months, 24.5% (34/139) rebled. A total of 56% (19/34) of rebleeders were diagnosed as definitive TICH, and they had significantly higher rates of readmission ( P < 0.001), reintervention ( P < 0.001), and surgery ( P < 0.001). During F/U, there were significantly higher rates of newly diagnosed hypertension and/or atherosclerotic cardiovascular disease in rebleeders ( P = 0.033 from a logistic model). All-cause mortality was 42.8%, but none was from TICH.

DISCUSSION

For presumptive TICH during long-term F/U, (i) 75.5% did not rebleed and 24.5% rebled. (ii) 56% of rebleeders were diagnosed as definitive TICH. (iii) New development of hypertension and atherosclerotic cardiovascular disease were risk factors of TIC rebleeding.

Urgent Contrast-Enhanced Computed Tomography before Early Colonoscopy in the Management of Colonic Diverticular Bleeding: A Multicenter Randomized Controlled Trial

INTRODUCTION

Contrast-enhanced computed tomography (CE-CT) has been gaining attention as an initial investigation in the management of colonic diverticular bleeding (CDB), yet the role of CE-CT other than its diagnostic yield has not been adequately clarified. We aimed to determine whether the use of urgent CE-CT improves identification of stigmata of recent hemorrhage (SRH) in subsequently performed early colonoscopy (≤24 h of arrival) or other clinical outcomes of CDB.

METHODS

We conducted a randomized, open-label, controlled trial at 23 institutions in Japan. Outpatients with suspected CDB were randomly assigned to undergo either urgent CE-CT followed by early colonoscopy (urgent-CE-CT + early-colonoscopy group) or early colonoscopy alone (early-colonoscopy group). The primary outcome was SRH identification. Secondary outcomes included successful endoscopic hemostasis, early (<30 days) and late (<1 year) rebleeding, length of hospital stay, and transfusion requirements.

RESULTS

In total, 240 patients, mostly in a hemodynamically stable condition, were randomized. A contrast extravasation on CE-CT was observed in 20 of 115 patients (17.4%) in the urgent-CE-CT + early-colonoscopy group. SRH was identified in 23 of 115 patients (20.0%) in the urgent-CE-CT + early-colonoscopy group and 21 of 118 patients (17.8%) in the early-colonoscopy group (difference, 2.2; 95% confidence interval [CI], -7.9 to 12.3; p = 0.739). Successful endoscopic hemostasis was achieved in 21 patients in each group (18.3% and 17.8%, respectively) (difference, 0.5; 95% CI, -9.4 to 10.4; p = 1.000). There were also no significant differences between groups in early and late rebleeding, length of hospital stay, and transfusion requirements.

CONCLUSION

The use of urgent CE-CT before early colonoscopy did not improve SRH identification or other clinical outcomes in patients with suspected CDB in a hemodynamically stable condition. The routine use of urgent CE-CT as an initial investigation is not recommended in this population, also considering the low rate of extravasation-positive cases (UMIN registry number, UMIN000026865).

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort

INTRODUCTION

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

METHODS

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

RESULTS

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

DISCUSSION

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Lower Gastrointestinal Hemorrhage

This JAMA Clinical Guidelines Synopsis summarizes the 2023 American College of Gastroenterology guidelines on management of patients with acute lower gastrointestinal bleeding.

Active surveillance pharmacovigilance for Clostridioides difficile infection and gastrointestinal bleeding: an analytic framework based on case-control studies

BACKGROUND

Active surveillance pharmacovigilance is an emerging approach to identify medications with unanticipated effects. We previously developed a framework called pharmacopeia-wide association studies (PharmWAS) that limits false positive medication associations through high-dimensional confounding adjustment and set enrichment. We aimed to assess the transportability and generalizability of the PharmWAS framework by using medical claims data to reproduce known medication associations with Clostridioides difficile infection (CDI) or gastrointestinal bleeding (GIB).

METHODS

We conducted case-control studies using Optum's de-identified Clinformatics Data Mart Database of individuals enrolled in large commercial and Medicare Advantage health plans in the United States. Individuals with CDI (from 2010 to 2015) or GIB (from 2010 to 2021) were matched to controls by age and sex. We identified all medications utilized prior to diagnosis and analysed the association of each with CDI or GIB using conditional logistic regression adjusted for risk factors for the outcome and a high-dimensional propensity score.

FINDINGS

For the CDI study, we identified 55,137 cases, 220,543 controls, and 290 medications to analyse. Antibiotics with Gram-negative spectrum, including ciprofloxacin (aOR 2.83), ceftriaxone (aOR 2.65), and levofloxacin (aOR 1.60), were strongly associated. For the GIB study, we identified 450,315 cases, 1,801,260 controls, and 354 medications to analyse. Antiplatelets, anticoagulants, and non-steroidal anti-inflammatory drugs, including ticagrelor (aOR 2.81), naproxen (aOR 1.87), and rivaroxaban (aOR 1.31), were strongly associated.

INTERPRETATION

These studies demonstrate the generalizability and transportability of the PharmWAS pharmacovigilance framework. With additional validation, PharmWAS could complement traditional passive surveillance systems to identify medications that unexpectedly provoke or prevent high-impact conditions.

FUNDING

U.S. National Institute of Diabetes and Digestive and Kidney Diseases.

Patient Outcomes of Definitive Diverticular Hemorrhage After Colonoscopic, Medical, Surgical, or Embolization Treatment

BACKGROUND

There are few reports of clinical outcomes or the natural history of definitive diverticular hemorrhage (DDH).

AIMS

To describe 1-year clinical outcomes of patients with documented DDH treated with colonoscopic hemostasis, angioembolization, surgery, or medical treatment.

METHODS

DDH was diagnosed when active bleeding or other stigmata of hemorrhage were found in a colonic diverticulum during urgent colonoscopy or extravasation on angiography or red blood cell (RBC) scanning. This was a retrospective analysis of prospectively collected data of DDH patients from two referral centers between 1993 and 2022. Outcomes were compared for the four treatment groups. The Kaplan-Meier analysis was for time-to-first diverticular rebleed.

RESULTS

162 patients with DDH were stratified based on their final treatment before discharge-104 colonoscopic hemostasis, 24 medical treatment alone, 19 colon surgery, and 15 angioembolization. There were no differences in baseline characteristics, except for a higher Glasgow-Blatchford score in the angioembolization group vs. the colonoscopic group. Post-treatment, the colonoscopic hemostasis group had the lowest rate of RBC transfusions and fewer hospital and ICU days compared to surgical and embolization groups. The medical group had significantly higher rates of rebleeding and reintervention. The surgical group had the highest postoperative complications.

CONCLUSIONS

Medically treated DDH patients had significantly higher 1-year rebleed and reintervention rates than the three other treatments. Those with colonoscopic hemostasis had significantly better clinical outcomes during the index hospitalization. Surgery and embolization are recommended as salvage therapies in case of failure of colonoscopic and medical treatments.

Long-term Risks of Recurrence After Hospital Discharge for Acute Lower Gastrointestinal Bleeding: A Large Nationwide Cohort Study

BACKGROUND & AIMS

Currently, large, nationwide, long-term follow-up data on acute lower gastrointestinal bleeding (ALGIB) are scarce. We investigated long-term risks of recurrence after hospital discharge for ALGIB using a large multicenter dataset.

METHODS

We retrospectively analyzed 5048 patients who were urgently hospitalized for ALGIB at 49 hospitals across Japan (CODE BLUE-J study). Risk factors for the long-term recurrence of ALGIB were analyzed by using competing risk analysis, treating death without rebleeding as a competing risk.

RESULTS

Rebleeding occurred in 1304 patients (25.8%) during a mean follow-up period of 31 months. The cumulative incidences of rebleeding at 1 and 5 years were 15.1% and 25.1%, respectively. The mortality risk was significantly higher in patients with out-of-hospital rebleeding episodes than in those without (hazard ratio, 1.42). Of the 30 factors, multivariate analysis showed that shock index ≥1 (subdistribution hazard ratio [SHR], 1.25), blood transfusion (SHR, 1.26), in-hospital rebleeding (SHR, 1.26), colonic diverticular bleeding (SHR, 2.38), and thienopyridine use (SHR, 1.24) were significantly associated with increased rebleeding risk. Multivariate analysis of colonic diverticular bleeding patients showed that blood transfusion (SHR, 1.20), in-hospital rebleeding (SHR, 1.30), and thienopyridine use (SHR, 1.32) were significantly associated with increased rebleeding risk, whereas endoscopic hemostasis (SHR, 0.83) significantly decreased the risk.

CONCLUSIONS

These large, nationwide follow-up data highlighted the importance of endoscopic diagnosis and treatment during hospitalization and the assessment of the need for ongoing thienopyridine use to reduce the risk of out-of-hospital rebleeding. This information also aids in the identification of patients at high risk of rebleeding.

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.

Characterization of Prevalent, Post-Endoscopy, and Incident Esophageal Cancer in the United States: A Large Retrospective Cohort Study

BACKGROUND & AIMS

Efforts to assess and improve the effectiveness of Barrett's esophagus (BE) screening and surveillance are ongoing in the United States. Currently, there are limited population-based data in the United States to guide these efforts.

METHODS

We performed a retrospective cohort study using data from large commercial and Medicare Advantage health plans in the United States from 2004 - 2019. We identified individuals with BE and analyzed the proportion who developed EAC. EACs were classified as prevalent EAC (diagnosed within 30 days of index endoscopy), post-endoscopy esophageal adenocarcinoma (PEEC, diagnosed 30 - 365 days after index endoscopy), and incident EAC (diagnosed 365 days or more after index endoscopy). Using this cohort, we performed a nested case-control study to identify factors associated with prevalent EAC at BE diagnosis and study healthcare utilization prior to BE diagnosis.

RESULTS

We identified 50,817 individuals with incident BE. Of the 366 who developed EAC, 67.2%, 13.7%, and 19.1% were diagnosed with prevalent EAC, PEEC, and incident EAC respectively. Factors positively associated with prevalent EAC versus BE without prevalent EAC included male sex, dysphagia, weight loss, and Charlson-Deyo comorbidity score. In those with prevalent EAC, most patients with dysphagia or weight loss had their symptoms first recorded within three months of EAC diagnosis. Healthcare utilization rates were similar between those with and without prevalent EAC.

CONCLUSIONS

Two-thirds of EACs among individuals with BE are diagnosed at the time of BE diagnosis. Additionally, PEEC accounts for 14% of these EACs. These results may guide future research studies that investigate novel BE diagnostic strategies that reduce the morbidity and mortality of EAC.

Treatment strategies for reducing early and late recurrence of colonic diverticular bleeding based on stigmata of recent hemorrhage: a large multicenter study

BACKGROUND AND AIMS

Treatment strategies for colonic diverticular bleeding (CDB) based on stigmata of recent hemorrhage (SRH) remain unstandardized, and no large studies have evaluated their effectiveness. We sought to identify the best strategy among combinations of SRH identification and endoscopic treatment strategies.

METHODS

We retrospectively analyzed 5823 CDB patients who underwent colonoscopy at 49 hospitals throughout Japan (CODE-BLUE J-Study). Three strategies were compared: find SRH (definitive CDB) and treat endoscopically, find SRH (definitive CDB) and treat conservatively, and without finding SRH (presumptive CDB) treat conservatively. In conducting pairwise comparisons of outcomes in these groups, we used propensity score-matching analysis to balance baseline characteristics between the groups being compared.

RESULTS

Both early and late recurrent bleeding rates were significantly lower in patients with definitive CDB treated endoscopically than in those with presumptive CDB treated conservatively (<30 days, 19.6% vs 26.0% [P < .001]; <365 days, 33.7% vs 41.6% [P < .001], respectively). In patients with definitive CDB, the early recurrent bleeding rate was significantly lower in those treated endoscopically than in those treated conservatively (17.4% vs 26.7% [P = .038] for a single test of hypothesis; however, correction for multiple testing of data removed this significance). The late recurrent bleeding rate was also lower, but not significantly, in those treated endoscopically (32.0% vs 36.1%, P = .426). Definitive CDB treated endoscopically showed significantly lower early and late recurrent bleeding rates than when treated conservatively in cases of SRH with active bleeding, nonactive bleeding, and in the right-sided colon but not left-sided colon.

CONCLUSIONS

Treating definitive CDB endoscopically was most effective in reducing recurrent bleeding over the short and long term, compared with not treating definitive CDB or presumptive CDB. Physicians should endeavor to find and treat SRH for suspected CDB.

Patient Factors Associated With Gastroesophageal Reflux Disease Diagnostic Evaluation Strategies: A Retrospective Cohort Study Using Real-World Evidence From a Large U.S. Medical Claims Database

Background and Aims

Barrett's esophagus (BE) screening is not highly utilized in the United States, and there are few data describing providers' approach to screening. To fill this gap and guide the implementation of future BE screening strategies, we studied evaluation practice patterns for gastroesophageal reflux disease (GERD) by nongastroenterologists.

Methods

We performed a retrospective cohort study of patients with chronic GERD using health claims data from the United States between 2005 and 2019. We used up to 5 years of data after the diagnosis of chronic GERD to determine patient factors associated with completion of a gastroenterology encounter. We also identified patient factors associated with whether the first gastroenterology encounter was a direct-access upper endoscopy or an office visit.

Results

We identified 484,023 patients diagnosed with chronic GERD by a nongastroenterology provider. The cumulative incidence of completing a gastroenterology encounter within 5 years was 38.7%. Gastrointestinal symptoms, such as dysphagia (adjusted hazard ratio [aHR] = 2.11, 95% confidence interval [CI] = 1.94-2.30), abdominal pain (aHR = 1.89, 95% CI = 1.85-1.94), and melena (aHR = 1.73, 95% CI = 1.65-1.82), were strongly associated with completion of a gastroenterology encounter. The patient factors strongly associated with direct-access upper endoscopy included dysphagia (aHR = 1.68, 95% CI = 1.52-1.85), weight loss (aHR = 1.46, 95% CI = 1.28-1.63), and melena (aHR = 1.42, 95% CI = 1.28-1.56).

Conclusion

A total of 38.7% of patients with chronic GERD complete a gastroenterology encounter within 5 years of diagnosis, and gastrointestinal alarm symptoms are the most strongly associated factors for receiving gastroenterology care. These findings highlight the importance of incorporating primary care providers in the development of new BE screening programs.

Endoscopic Detachable Snare Ligation Therapy for Colonic Diverticular Hemorrhage Improves Procedure Time Compared to Endoscopic Band Ligation

BACKGROUND

The clipping method is widely used in endoscopic hemostasis for colonic diverticular hemorrhage. Recently, rebleeding was shown to be less common in ligation therapy than in clipping. Ligation methods include endoscopic band ligation (EBL) and endoscopic detachable snare ligation (EDSL). No studies have compared procedure times for EBL and EDSL. The present study aimed to compare EDSL and EBL in terms of procedure time.

METHODS

In this single-center retrospective observational cohort study, we evaluated the data of 39 patients who underwent EBL or EDSL for colonic diverticular hemorrhage. The primary and secondary outcomes measured were the total procedure time and early rebleeding rate, respectively.

RESULTS

Among the 39 patients included in the study, 18 underwent EBL, and 21 underwent EDSL for hemostasis. The median total pro- cedure times for the EBL and EDSL groups were 50 (range, 30-80) minutes and 35 (range, 18-55) minutes, respectively, demonstrating that the total colonoscopy time was significantly shorter in the EDSL group (P < .001). The early rebleeding rate was 11.1% (2/18) in the EBL group and 4.8% (1/21) in the EDSL group (P = .246).

CONCLUSION

Important improvements in procedure time were achieved in the EDSL group. Based on our results, we believe that EDSL may reduce patient and endoscopist burden.

Risk factors of re‐bleeding within a year in colonic diverticular bleeding patients

Background/Aims

Although colonic diverticular bleeding (CDB) is common, few reports have described the effects of antithrombotic agents (ATs) on CDB. This study aimed to clarify the risk factors of re‐bleeding within a year in CDB patients.

Methods

We retrospectively analyzed the risk of re‐bleeding in CDB patients. Among 324 patients who were hospitalized for acute lower gastrointestinal bleeding at our institution during the period from 2015 to 2019, we used 76 patients who were diagnosed as CDB. Risk factors for re‐bleeding were determined by Cox proportional hazard models.

Results

Of 76 patients analyzed, 32 were taking ATs, nine of whom were taking multiple agents. Twenty‐six patients re‐bled within a year. Compared with the patients without re‐bleeding, patients with re‐bleeding within a year had been treated by antithrombotic therapy more frequently (62% vs. 32%, p = 0.013). Cox proportional hazard model revealed that treatment with ATs (hazard ratio 3.89, 95% confidence interval 1.53–10.74, p = 0.004) was an independent risk factor for re‐bleeding within a year.

Conclusion

ATs were found to be an independent risk factor related to re‐bleeding within a year in patients with CDB.

Risk factors for short-term re-bleeding in patients with colonic diverticular bleeding: a multicenter retrospective study

BACKGROUND AND AIM

Few studies have evaluated risk factors for short-term re-bleeding in patients with colonic diverticular bleeding (CDB). We aimed to reveal risk factors for re-bleeding within a month in patients with CDB.

METHODS

We retrospectively analyzed clinical course of patients with CDB diagnosed at 10 institutions between 2015 and 2019. Risk factors for re-bleeding within a month were assessed by Cox proportional hazards models.

RESULTS

Among 370 patients, 173 (47%) patients had been under the use of antithrombotic agents (ATs) and 34 (9%) experienced re-bleeding within a month. Multivariate analysis revealed that the use of ATs was an independent risk factor for re-bleeding within a month (HR 2.38, 95% CI 1.10-5.50, p = .028). Furthermore, use of multiple ATs and continuation of ATs were found to be independent risk factors for re-bleeding within a month (HR 3.88, 95% CI 1.49-10.00, p = .007 and HR 3.30, 95% CI 1.23-8.63, p = .019, respectively). Two of 370 patients, who discontinued ATs, developed thromboembolic event.

CONCLUSIONS

Use of ATs was an independent risk factor for short-term re-bleeding within a month in patients with CDB. This was especially the case for the use of multiple ATs and continuation of ATs. However, discontinuation of ATs may increase the thromboembolic events those patients.

Causes of gastrointestinal bleeding in oral anticoagulant users compared to non-users in a population-based study

BACKGROUND/AIMS

Causes of gastrointestinal bleeding (GIB) in patients on oral anticoagulants (OACs) are not well established. The aims of the study were to compare the causes of GIB in patients on OACs and those not on OAC therapy.

METHODS

A nationwide study of all GIB events in patients on OACs in Iceland from 2014-2019 was conducted. Bleeding events were obtained through ICD-10 codes and review of endoscopy databases, confirmed by review of medical records. For comparison, patients not on OACs from previous Icelandic population-based studies were used.

RESULTS

Among 752 GIB events in 12,005 patients on OACs, 273 (1.9%) had verified upper and 391 (2.7%) had verified lower GIB. For lower GIB, multivariate analysis showed that OAC users were more likely to have colonic polyps (OR 6.6, 95% CI: 2.4 - 17.8, p < .001) or colorectal cancer (OR 3.7, 95% CI: 2.0 - 7.0, p < .001) but less likely to have ischemic colitis (OR 0.11, 95% CI: 0.04 - 0.26, p < .001). For upper GIB, bleeding from mucosal erosions (OR 4.0 95% CI: 2.5 - 7.9, p < .001) and angiodysplasia (OR 3.6, 95%CI: 1.5 - 8.6, p = .003) were more common in OAC users.

CONCLUSIONS

A high proportion of GIB caused by colonic polyps and colorectal cancer among OAC patients indicates that OACs treatment may facilitate cancer diagnosis. The low proportion of ischemic colitis among those on OACs suggests that OACs provide a protective effect against ischemic colitis. OACs seem to increase the bleeding from angiodysplasia and mucosal erosive disease.

Impact of clinical characteristics of colonic diverticular bleeding in extremely elderly patients treated with direct oral anti-coagulant drugs: a retrospective multi-center study

Since there were no available data about colonic diverticular bleeding in extremely elderly patients (>80 years old) treated with direct oral anticoagulants (DOACs), we tried to determine clinical characteristics in those with colonic diverticular bleeding taking DOACs and to compare clinical outcomes of those in DOAC-treated to those in warfarin-treated . We enrolled DOAC-treated (n = 20) and warfarin-treated (n = 23) extremely elderly patients with diverticular bleeding diagnosed by colonoscopy. We performed a retrospective review of patients’ medical charts and endoscopic findings. We classified colonic diverticular bleeding based on endoscopic features due to modified previous study following three groups, type A (active bleeding), type B (non-active bleeding) and type C (bleeding suspected). Clinical outcomes such as number of recurrent bleeding, thrombotic events and mortality were estimated. There were no differences in endoscopical features and clinical characteristics between patients treated with DOAC and warfarin therapy. However, the number of recurrent bleeding, frequency of required blood transfusions and units of blood transfusion in warfarin-treated patients were significantly higher (p<0.05) compared to those in DOAC-treated groups. In addition, mortality and thrombotic events did not differ between DOAC- and warfarin-treated patients. Clinical outcomes suggest that DOACs can be recommended for extremely elderly patients with colonic diverticular disease.

Safety and Effectiveness of Endoscopic Band Ligation for Colonic Diverticular Bleeding in Elderly Patients

INTRODUCTION

Colonic diverticulosis increases with age, leading to a higher risk of colonic diverticular bleeding (CDB) in the elderly. As life expectancy continues to increase, the need for endoscopic hemostasis for CDB in the elderly can also be expected to increase. However, there have been no reports to date on the feasibility of endoscopic hemostasis for elderly CDB patients. Several recent studies have addressed the effectiveness of endoscopic band ligation (EBL) for CDB. In this study, we evaluate the safety and effectiveness of EBL in elderly CDB patients compared to younger CDB patients.

METHODS

We retrospectively analyzed the medical records of consecutive patients treated with EBL for the first time at a tertiary referral center between March 2011 and November 2017. Patients were grouped according to age into those at least 75 years old (the Elderly) and those <75 years old (the Nonelderly). Patient characteristics, technical success, and complications were compared between the two groups.

RESULTS

EBL was performed in 153 patients during the study period (49 Elderly patients and 104 Nonelderly patients). Elderly patients were less likely to be male (p < 0.001) and had lower hemoglobin levels on admission (p < 0.001). Bleeding on the right side of the splenic flexure was observed more frequently in the Nonelderly (p = 0.002). Charlson Comorbidity Index (CCI) and use of antithrombotic agents were significantly higher in the Elderly (p < 0.001 and p < 0.001, respectively). Active bleeding tended to be observed more frequently in the Elderly (p = 0.054), while the difference was not significant. There were no significant differences in the shock index, procedure time, or units of packed red blood cells transfused between the 2 groups. No significant differences in the technical success rate (97.1 vs. 98%, p = 0.76), early rebleeding rate (10.2 vs. 14.4%, p = 0.47), or other complications (2 vs. 1%, p = 0.58) were observed. Perforation and abscess formation were not observed in either group. Female gender, left-sidedness, higher CCI, and lower hemoglobin level were all significantly more frequently observed in the Elderly on multiple logistic regression analysis.

DISCUSSION/CONCLUSION

EBL may be similarly safe and effective for the treatment of CDB in the elderly as in the nonelderly.

Risk Factors for Late Rebleeding of Colonic Diverticular Bleeding in Elderly Individuals

Objectives

This study aimed to examine the clinical characteristics of colonic diverticular bleeding (CDB) in elderly individuals.

Methods

This retrospective case-control study was conducted at a single tertiary center. A total of 519 patients (356 men and 163 women; mean age of 73.1 ± 12.5 years) with CDB and hospitalized between January 2004 and May 2019 were analyzed. The subjects were divided into two groups: the elderly (274 individuals aged ≥75 years; mean age, 82.1 ± 5.3 years) and non-elderly (245 individuals aged <75 years; mean age, 63.0 ± 10.3 years) groups. Primary outcomes were early and late rebleeding rates, and secondary outcomes were the risk factors for late rebleeding in elderly individuals. Rebleeding occurring within 30 days of hospitalization was defined as early rebleeding, whereas rebleeding occurring after 31 days was defined as late rebleeding.

Results

The early rebleeding rates were 30.6% and 33.1% (p = 0.557) in the elderly and non-elderly groups, respectively. The late rebleeding rates were 42.3% and 30.6% (p = 0.005) in the elderly and non-elderly groups, respectively. The 3-year recurrence-free survival was 63.6% in the elderly group and 75.6% in the non-elderly group (log-rank test: p < 0.001). Multivariate analysis revealed the use of non-steroidal anti-inflammatory drugs (NSAIDs) [odds ratio (OR), 3.55], chronic kidney disease (OR, 2.89), and presence of bilateral diverticula (OR, 1.83) as the independent risk factors for late rebleeding in elderly individuals.

Conclusions

Elderly individuals with CDB require careful follow-up even after discharge. Furthermore, it is important to consider discontinuing NSAIDs to prevent rebleeding.

Relationship between colonic diverticulosis and colon neoplasms in Japanese patients

BACKGROUND AND AIM

Colonic diverticulosis (CD) has been reported to be associated with presence of colon neoplasms (CNs) in Western patients, since most of the associated risk factors are common between them. However, such correlation has not been fully investigated in Asian patients. In this study, the association of CNs with CD was evaluated in a multicenter investigation.

METHODS

We enrolled 5633 patients who underwent both colonoscopy and esophagogastroduodenoscopy due to annual follow-up, screening for positive occult blood testing and abdominal symptoms between January 2016 and December 2017 at three institutions. The relationship between the presence of CNs and CD was investigated, and predictors for presence of CNs were determined by multivariate logistic analysis.

RESULTS

The enrolled patients consisted of 1799 (31.9%) with CD (average age 70.0 years, male 64.0%) and 3834 without CD (66.0 years, male 52.9%), with the prevalence of CNs in those groups 46.6% and 44.2%, respectively (P = 0.090). Predictors for early colon cancer were shown to be age (OR 1.02, 95% CI 1.01-1.04, P = 0.010), laxatives use (OR 1.76, 95% CI 1.17-2.64, P = 0.007), gastric neoplasms (OR 2.16, 95% CI 1.23-3.81, P = 0.008), and CD (OR 1.64, 95% CI 1.16-2.31, P = 0.005). Early colon cancer in the distal colon was most frequently detected in patients with right-sided CD (RR 2.50, P = 0.001).

CONCLUSION

In Japanese patients, early colon cancer was more frequently found in those with as compared to those without CD. The presence of CD may be an important indicator for an index colonoscopy examination to detect colon cancer. (Clinical-trial-registry: UMIN000038985).

Distinguishing features between patients with acute diverticulitis and diverticular bleeding: Results from the REMAD registry

BACKGROUND

Pathogenesis of acute diverticulitis and diverticular bleeding remains poorly defined, and few data compare directly risk factors for these complications.

AIMS

to assess differences in clinical features, lifestyles factors and concurrent drug use in patients with acute diverticulitis and those with diverticular bleeding.

METHODS

Data were obtained from the REMAD Registry, an ongoing 5-year prospective, observational, multicenter, cohort study conducted on 1,217 patients. Patient- and clinical- related factors were compared among patients with uncomplicated diverticular disease, patients with previous acute diverticulitis, and patients with previous diverticular bleeding.

RESULTS

Age was significantly lower (OR 0.48, 95% CI: 0.34-0.67) and family history of diverticular disease was significantly higher (OR 1.60, 95% CI: 1.11-2.31) in patients with previous diverticulitis than in patients with uncomplicated diverticular disease, respectively. Chronic obstructive pulmonary disease was significantly higher in patients with previous diverticular bleeding as compared with both uncomplicated diverticular disease (OR 8.37, 95% CI: 2.60-27.0) and diverticulitis (OR 4.23, 95% CI: 1.11-16.1).

CONCLUSION

This ancillary study from a nationwide Registry showed that some distinctive features identify patients with acute diverticulitis and diverticular bleeding. These information might improve the assessment of risk factors for diverticular complications.

Association Between Statin Use at the Time of Intra-abdominal Surgery and Postoperative Adhesion-Related Complications and Small-Bowel Obstruction

IMPORTANCE

Adhesion-related complications (ARCs), including small-bowel obstruction, are common complications of intra-abdominal surgery. Statins, which have antifibrotic pleiotropic effects, inhibit adhesion formation in murine models but have not been assessed in humans.

OBJECTIVE

To assess whether statin use at the time of intra-abdominal surgery is associated with a reduction in ARCs.

DESIGN, SETTING, AND PARTICIPANTS

These 2 separate retrospective cohort studies (The Health Improvement Network [THIN] and Optum's Clinformatics Data Mart [Optum]) compared adults receiving statins with those not receiving statins at the time of intra-abdominal surgery. Individuals undergoing intra-abdominal surgery from January 1, 1996, to December 31, 2013, in the United Kingdom and from January 1, 2000, to December 31, 2016, in the US were included in the study. Those with obstructive events before surgery or a history of inflammatory bowel disease were excluded. Data analysis was performed from September 1, 2012, to November 24, 2020.

EXPOSURE

The primary exposure was statin use at the time of surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was ARCs, defined as small-bowel obstruction or need for adhesiolysis, occurring after surgery. Sensitivity analyses included statin use preceding but not concurrent with surgery, fibrate use, and angiotensin-converting enzyme inhibitor use. All analyses were adjusted for age, sex, and conditions associated with microvascular disease, such as hypertension, hyperlipidemia, obesity, and tobacco use; surgical approach and site; and diagnosis of a malignant tumor.

RESULTS

A total of 148 601 individuals met the inclusion criteria for THIN (mean [SD] age, 49.6 [17.7] years; 70.1% female) and 1 188 217 for Optum (mean [SD] age, 48.2 [16.4] years; 72.6% female). A total of 2060 participants (1.4%) experienced an ARC in THIN and 54 136 (4.6%) in Optum. Statin use at the time of surgery was associated with decreased risk of ARCs (THIN: adjusted hazard ratio [HR], 0.81; 95% CI, 0.71-0.92; Optum: adjusted HR, 0.92; 95% CI, 0.90-0.95). Similar associations were appreciated between statins and small-bowel obstruction (THIN: adjusted HR, 0.80; 95% CI, 0.70-0.92; Optum: adjusted HR, 0.88; 95% CI, 0.85-0.91).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, among individuals in 2 separate cohorts undergoing intra-abdominal surgery, statin use may be associated with a reduced risk of postoperative ARCs. Statins may represent an inexpensive, well-tolerated pharmacologic option for preventing ARCs.

Risk factors for endoscopic severity of diverticular disease of the colon and its outcome: a real-life case-control study

BACKGROUND

Diverticular disease is an increasing global problem.

AIMS

To assess the factors associated with the severity of diverticular disease and its outcome, analyzing a real-life population.

METHODS

A cohort of patients, submitted to colonoscopy from 1 January 2012 to 30 April 2018 was revised. The endoscopic severity of diverticular disease was scored according to the Diverticular Inflammation and Complications Assessment (DICA) classification.

RESULTS

A cohort of 11 086 patients was identified during the study period, 5635 with diverticulitis and 5451 without diverticulosis. Blood hypertension, diabetes and angiotensin receptor blocker users occurred more frequently in the study group, while the prevalence of colorectal cancer (CRC) was significantly lower. Age >70 years, BMI >30 and blood hypertension were factors independently related to the presence of diverticulosis, while diabetes and CRC were significantly associated with the absence of diverticulosis. Female sex, age, smoke, appendectomy, proton-pump inhibitors and acetyl-salicylic acid use were directly related to the severity of diverticular disease, while CRC and colonic polyp occurrence were inversely related to the severity of diverticular disease, significantly. Female sex, age >70 years and smoke were significantly related to the severity of diverticular disease. CRC and colonic polyps were significantly less in DICA 3 patients. DICA 3 patients were more often symptomatic, at higher risk of hospital admission, longer hospital stay and higher mean costs.

CONCLUSIONS

Several factors are associated with the severity of diverticular disease according to the DICA classification. The DICA classification is also predictive of the outcome of the disease in terms of hospital admission, stay and costs.

Etiopathogenetic Mechanisms in Diverticular Disease of the Colon

This article reviews epidemiological evidence of heritability and putative mechanisms in diverticular disease, with greatest attention to 3 recent studies of genetic associations with diverticular disease based on genome-wide or whole-genome sequencing studies in large patient cohorts. We provide an analysis of the biological plausibility of the significant associations with gene variants reported and highlight the relevance of ANO1, CPI-17 (aka PPP1R14A), COLQ6, COL6A1, CALCB or CALCA, COL6A1, ARHGAP15, and S100A10 to colonic neuromuscular function and tissue properties that may result in altered compliance and predispose to the development of diverticular disease. Such studies also identify candidate genes for future studies.

Direct Oral Anticoagulant Use and Risk of Diverticular Hemorrhage: A Systematic Review of the Literature

BACKGROUND

Anticoagulants carry a significant risk of gastrointestinal bleeding. With the increase in use and availability of direct oral anticoagulants ("DOACs") more data are available regarding the risks of these medications. With diverticular bleeds being common, and hospitalization associated with gastrointestinal bleed increasing 30-day mortality, it is paramount to better understand the potential risks of using DOACs in this population.

METHODS

A systematic review of the literature was undertaken, using the databases PubMed, EMBASE, Cochrane Library, and CINAHL. Two reviewers independently searched the literature, and initial screening was performed through title and abstract reading. Search terms included "direct" AND "anticoagulant" AND "diverticular bleed" OR "diverticular hemorrhage". The references of the selected studies were manually reviewed for any further relevant articles.

RESULTS

Literature search across the databases garnered 182 articles-157 unique abstracts after duplicate removal. Based on inclusion and exclusion criteria, 6 studies were deemed relevant. The selected studies' reference lists yielded no further relevant articles.

DISCUSSION

Across the 6 studies, the incidence of diverticular bleeding in patients using DOACs was extremely low. Of 23,990 patients taking DOACs identified from two separate institutions, only 60 were found to have diverticular hemorrhage. Similarly, among 15,056 patients with diverticular hemorrhage, only 246 (1.6%) among them were taking DOACs. Generally, the studies found no increased diverticular bleeding rate between patients taking DOACs and those who were taking other anticoagulants, such as warfarin, or the general population. The studies also did not find an increased risk of rebleeding with DOAC continuation.

CONCLUSION

The evidence suggests the risk of diverticular bleed among DOAC users is equivocal to those not taking DOACs, and the overall incidence of diverticular bleed in the DOAC population is low. As it stands, the risk of thrombotic events from not starting DOACs apparently outweighs the risk of diverticular bleed.