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Saino M, Aoyama T, Yamane M, Masuda S, Nomura R, Shigita K, Asayama N, Fukumoto A, Mukai S, Nagata S. Optimal candidates for early colonoscopy in the management of acute lower gastrointestinal bleeding. J Gastroenterol Hepatol 2022; 37:1290-1297. [PMID: 35338527 DOI: 10.1111/jgh.15839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/25/2022] [Accepted: 03/20/2022] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Masachika Saino
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Masahiro Yamane
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Satoshi Masuda
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Risa Nomura
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Kenjiro Shigita
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoki Asayama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Akira Fukumoto
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Shinichi Mukai
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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3
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Devani K, Radadiya D, Charilaou P, Aasen T, Reddy CM, Young M, Brahmbhatt B, Rockey DC. Trends in hospitalization, mortality, and timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Endosc Int Open 2021; 9:E777-E789. [PMID: 34079858 PMCID: PMC8159619 DOI: 10.1055/a-1352-3204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background and study aims Current guidelines conditionally recommend performing early colonoscopy (EC) (< 24 hours) in patients admitted with acute lower gastrointestinal bleeding (LGIB). It remains unclear whether this practice is implemented widely. Therefore, we used the Nationwide Inpatient Sample to investigate trends for timing of colonoscopy in patients admitted with acute LGIB. We also assessed trend of hospitalization and mortality in patients with LGIB.
Patients and methods Adult patients with LGIB admitted from 2005 to 2014 were examined. ICD-9-CM codes were used to extract LGIB discharges. Trends were assessed using Cochrane-Armitage test. Factors associated with mortality, cost of hospitalization, and length of stay (LOS) were assessed by multivariable mixed-effects and exact-matched logistic, linear regression, and accelerated-failure time models, respectively.
Results A total of 814,647 patients with LGIB were included. The most common etiology of LGIB was diverticular bleeding (49 %) and 45 % of patients underwent EC. Over the study period, there was no change in the trend of colonoscopy timing. Although admission with LGIB increased over the study period, the mortality rate decreased for patients undergoing colonoscopy. Independent predictors of mortality were age, surgery (colostomy/colectomy) during admission, intensive care unit admission, acute kidney injury, and blood transfusion requirement. Timing of colonoscopy was not associated with mortality benefit. However, cost of hospitalization was $ 1,946 lower and LOS was 1.6 days shorter with EC.
Conclusion Trends in colonoscopy timing in management of LGIB have not changed over the years. EC is associated with lower LOS and cost of hospitalization but it does not appear to improve inpatient mortality.
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Affiliation(s)
- Kalpit Devani
- Division of Gastroenterology and Liver Disease, Department of Internal Medicine, Prisma Health, University of South Carolina, Greenville, South Carolina, United States
| | - Dhruvil Radadiya
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Paris Charilaou
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Saint Peterʼs University Hospital/Rutgers – Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Tyler Aasen
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Chakradhar M. Reddy
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Mark Young
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee, United States
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Don C. Rockey
- Division of Gastroenterology, Department of Internal Medicine, Medical University of South Carolina, United States
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4
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Kherad O, Restellini S, Almadi M, Strate LL, Ménard C, Martel M, Roshan Afshar I, Sadr MS, Barkun AN. Systematic review with meta-analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding. Aliment Pharmacol Ther 2020; 52:774-788. [PMID: 32697886 DOI: 10.1111/apt.15925] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/29/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal timing of colonoscopy in acute lower gastrointestinal bleeding (LGIB) remains controversial. AIM To characterise the utility of early colonoscopy (within 24 hours) in managing acute LGIB. METHODS A systematic literature search to October 2019 identified fully published articles and abstracts of randomised controlled trials (RCTs) and observational studies with control groups assessing early colonoscopy in acute LGIB. The primary outcome was rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events. Odds ratios (ORs) and mean differences (MD) were calculated. RESULTS Of 1116 citations, 4 RCTs (466 patients) and 13 observational studies with elective colonoscopy (>24 hours) as control group (1 061 281 patients) were included. No differences in rebleeding were noted between early and elective colonoscopy groups among RCTs alone (OR = 1.70; 0.79; 3.64), or observational studies alone (OR = 1.20; 0.69; 2.09). No other significant between-group differences in outcomes were found when restricting the analysis to RCTs. Among observational studies only, early colonoscopy was associated with lower rates of all-cause mortality (OR = 0.86; 0.75; 0.98), surgery (OR = 0.52; 0.42; 0.64), blood transfusion (OR = 0.81; 0.75; 0.87), units of blood transfusion (MD = -4.30; -6.24; -2.36) and shorter LOS (MD = -1.70; -1.70; -1.70 days). CONCLUSION In contradistinction to observational studies, data from RCTs do not support a role for early colonoscopy in the routine management of acute LGIB with regards to the most important clinical outcomes. Further research is needed to better identify patients with high-risk LGIB who may benefit from early colonoscopy.
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Affiliation(s)
- Omar Kherad
- Division of Internal Medicine, Hôpital de la Tour and University of Geneva, Geneva, Switzerland
| | - Sophie Restellini
- Division of Gastro-enterology and Hepatology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.,Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Majid Almadi
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada.,Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
| | - Charles Ménard
- Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Ira Roshan Afshar
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Mohamad Seyed Sadr
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, QC, Canada
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5
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Urgent Versus Standard Colonoscopy for Management of Acute Lower Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Gastroenterol 2020; 54:493-502. [PMID: 32091447 DOI: 10.1097/mcg.0000000000001329] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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6
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Oguri N, Ikeya T, Kobayashi D, Yamamoto K, Yoshimoto T, Takasu A, Okamoto T, Shiratori Y, Okuyama S, Takagi K, Nakamura K, Fukuda K. Effectiveness of risk scoring systems in predicting endoscopic treatment in colonic diverticular bleeding. J Gastroenterol Hepatol 2020; 35:815-820. [PMID: 31677183 PMCID: PMC7318164 DOI: 10.1111/jgh.14901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS The identification of stigmata of recent hemorrhage (SRH) in colonic diverticular bleeding (CDB) enables an endoscopic treatment and can improve the clinical outcome. However, SRH identification rate remains low. This study aims to investigate whether NOBLADS and Strate scoring systems are useful for predicting SRH identification rate of CDB pre-procedurally via colonoscopy. METHODS In this single-center retrospective observational study, 302 patients who experienced their first episode of CDB from April 2008 to March 2018 were included. Patients were classified into SRH-positive and SRH-negative groups. The primary outcome was SRH identification rate. The secondary outcomes were active bleeding in SRH and early rebleeding rates. The usefulness of the NOBLADS and Strate scores as predicted values of SRH identification was evaluated using the area under the receiver operating characteristic curve. RESULTS There were 126 and 176 patients in the SRH-positive and SRH-negative groups, respectively. The area under the receiver operating characteristic curve for SRH identification using the NOBLADS score was 0.74 (95% confidence interval, 0.69-0.80) and that using the Strate score was 0.74 (95% confidence interval, 0.68-0.79). Active bleeding and early rebleeding rates increased according to each score. By setting the cut-off of the NOBLADS score to four points, treatment was possible in 70.2% (66/94) patients. Addition of extravasation at computed tomography to a NOBLADS score of ≧ 4 points allowed treatment of all patients (24/24). CONCLUSIONS Severity scoring in acute lower gastrointestinal bleeding was effective for predicting SRH identification in CDB. We suggest that combination of these scorings and CT findings could offer a new therapeutic strategy.
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Affiliation(s)
- Noriaki Oguri
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan,Department of Gastroenterology and HepatologyKyorin University HospitalTokyoJapan
| | - Takashi Ikeya
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Daiki Kobayashi
- Department of Epidemiology, Graduate School of Public HealthSt. Luke's International UniversityTokyoJapan
| | - Kazuki Yamamoto
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Takaaki Yoshimoto
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Ayaka Takasu
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Takeshi Okamoto
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | | | - Shuhei Okuyama
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Koichi Takagi
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
| | - Kenji Nakamura
- Department of GastroenterologyTokyo Dental College Ichikawa General HospitalChibaJapan
| | - Katsuyuki Fukuda
- Division of GastroenterologySt. Luke's International HospitalTokyoJapan
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7
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Zullo A, Gatta L, Vassallo R, Francesco VD, Manta R, Monica F, Fiorini G, Vaira D. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019; 32:541-553. [PMID: 31700230 PMCID: PMC6826076 DOI: 10.20524/aog.2019.0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)
| | - Luigi Gatta
- Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)
| | - Roberto Vassallo
- Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
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