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You HS, Kim DH, Cho SY, Park SY, Park CH, Kim HS, Choi SK. Risk factors for patients hospitalized with recurrent colon diverticular bleeding: a single center experience. Front Med (Lausanne) 2023; 10:1195051. [PMID: 38020084 PMCID: PMC10661954 DOI: 10.3389/fmed.2023.1195051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background/aims Colonic diverticular bleeding (CDB) is a common cause of acute lower gastrointestinal bleeding. Patients with CDB are at increased risk for recurrence. Here, we aimed to evaluate the clinical course of patients with CDB and identify risk factors for recurrent CDB (rCDB). Methods We included patients who were hospitalized at a single tertiary center for management of CDB between January 2005 and March 2020. A Cox proportional hazards regression analysis was performed to evaluate the risk factors of patients with rCDB as follows: model 1 adjusted by age, Charlson comorbidity index (CCI), and presence of bilateral colon diverticula; model 2 adjusted by age, CCI, and presence of left side colon diverticula; model 3 adjusted by age, CCI, and presence of sigmoid colon diverticula. Results Among 219 patients (mean age, 68.0 years; 55 females), 56 and 163 had definite and presumptive CDB, respectively. During the median period of 506 days, 62 patients (28.3%) experienced rCDB. CCI score ≥ 4 was independently associated with rCDB in models 1, 2 and 3 (all p < 0.05). Age ≥ 75 years was independently associated with rCDB in models 1 and 2 (both p < 0.05). The presence of bilateral colon and sigmoid colon diverticula were independently associated with rCDB in models 1 and 3, respectively (both p < 0.05). Conclusion rCDB frequently occurred at any time in patients with previous CDB. High CCI scores and distribution of colon diverticula were associated with rCDB. Clinicians should consider a possible rCDB for a patient considering age, comorbidity, and distribution of colon diverticula.
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Affiliation(s)
| | | | | | - Seon-Young Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | | | - Hyun-Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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2
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Sebastian SA, Co EL, Panthangi V, Bansal R, Narayanan V, Paudel S, Raja R, Padda I, Mohan BP. Colonic diverticular bleeding: An update on pathogenesis and management. Dis Mon 2023; 69:101543. [PMID: 36918300 DOI: 10.1016/j.disamonth.2023.101543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.
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Affiliation(s)
| | - Edzel Lorraine Co
- University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | | | - Radha Bansal
- Government Medical College & Hospital, Chandigarh, India
| | | | | | - Rabab Raja
- All Saints University School of Medicine, Dominica
| | - Inderbir Padda
- Richmond University Medical Center, Staten Island, New York, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah School of Medicine, Utah, USA
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3
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Sano T, Ishikawa T, Azumi M, Sato R, Jimbo R, Kobayashi Y, Sato T, Iwanaga A, Yokoyama J, Honma T. Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization. Medicine (Baltimore) 2023; 102:e35092. [PMID: 37713820 PMCID: PMC10508449 DOI: 10.1097/md.0000000000035092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/15/2023] [Indexed: 09/17/2023] Open
Abstract
This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.
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Affiliation(s)
- Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Jimbo
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toshifumi Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Junji Yokoyama
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
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4
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Seow-En I, Seow-Choen F. Warm water irrigation is useful for the identification of a bleeding colonic diverticulum. Clin Endosc 2023; 56:671-673. [PMID: 37524566 PMCID: PMC10565441 DOI: 10.5946/ce.2022.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/11/2022] [Indexed: 08/02/2023] Open
Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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5
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Guo X, Patel B, Han L, Van Alstine WG, Noblet JN, Chambers SD, Kassab GS. Novel patch biomaterial treatment for colon diverticulosis in swine model. Front Bioeng Biotechnol 2023; 11:1215362. [PMID: 37588135 PMCID: PMC10425590 DOI: 10.3389/fbioe.2023.1215362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023] Open
Abstract
Current leading managements for diverticular disease cannot prevent the recurrence of diverticulitis, bleeding and/or other complications. There is an immediate need for developing new minimal invasive therapeutic strategies to prevent and treat this disease. Through a biomechanical analysis of porcine colon with diverticular lesions, we proposed a novel adhesive patch concept aiming at mechanical reconstruction of the diseased colon wall. This study aims to evaluate the surgical feasibility (safety and efficacy) of pulmonary visceral pleura (PVP) patch therapy using a pig model of diverticulosis. Six female Yucatan miniature pigs underwent collagenase injection (CI) for the development of diverticular lesions. The lesions in each animal either received patch implantation (treated group, n = 40 for 6 pigs) or left intact (untreated group, n = 44 for 6 pigs). The normal colonic wall in each animal received patch implantation at two spots to serve as control (n = 12 for 6 pigs). After 3 months of observation, the performance and safety of the patch treatment were evaluated through macroscopic and histological examination. We found that 95% of pouch-like herniation of the mucosa was prevented from the colon wall with the treatment. The pouch diameter was significantly reduced in the treated group as compared to the untreated group (p < 0.001). The patch application caused a significant increase in the levels of collagen of the colon tissue as compared to the untreated and control groups (p < 0.001). No difference was found in the lymphocyte and macrophage inflammatory infiltrate between the groups. Our results suggest that patch treatment efficiently inhibits the diverticular pouch deformation and promotes the healing of the colon wall with a normal inflammatory response, which may minimize the risk of diverticulosis reoccurrence and complications over time.
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Affiliation(s)
- Xiaomei Guo
- California Medical Innovations Institute Inc, San Diego, CA, United States
| | - Bhavesh Patel
- California Medical Innovations Institute Inc, San Diego, CA, United States
| | - Ling Han
- California Medical Innovations Institute Inc, San Diego, CA, United States
| | | | | | | | - Ghassan S. Kassab
- California Medical Innovations Institute Inc, San Diego, CA, United States
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6
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Lee C, Orellana M, Benharash P, Hawkins A, Khan A, Lee H. The use of surgical intervention for lower gastrointestinal bleeding and its association with clinical outcomes and resource use. Surgery 2023; 173:1346-1351. [PMID: 37045623 DOI: 10.1016/j.surg.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND To assess the use of surgical intervention for lower gastrointestinal bleeding and evaluate its associated factors. METHODS The 2016 to 2019 National Inpatient Sample was queried to identify non-elective adult (≥18 years) hospitalizations for lower gastrointestinal bleeding. The International Classification of Diseases, 10th Revision, codes were used to ascertain patient characteristics, including signs of hemodynamic instability, potential lower gastrointestinal bleed source, and transfusion of blood products, as well as endoscopic, radiologic, and surgical intervention. Multivariable regression analyses were used to elucidate factors associated with operative management of lower gastrointestinal bleeding and evaluate its associated mortality, length of stay, and hospitalization costs. RESULTS Of an estimated 364,495 patients, 1.7% underwent an operation for lower gastrointestinal bleeding. Compared to those managed conservatively, patients who underwent surgical intervention more commonly had diverticular-related bleeding, signs of hypovolemia, and less frequently underwent endoscopic intervention. After the adjustment of patient and hospital characteristics, ischemic colitis (adjusted odds ratio 7.5, 95% confidence interval 1.8-30.9, ref: hemorrhoids), hemodynamic instability (adjusted odds ratio 1.7, 95% confidence interval 1.5-2.0), and angiographic embolization (adjusted odds ratio 4.9, 95% confidence interval 3.9-6.0, ref: no endoscopic/radiologic intervention) were associated with greater odds of surgical intervention. Additionally, surgical intervention portended greater odds of in-hospital mortality (adjusted odds ratio 6.2, 95% confidence interval 4.5-8.5), a longer length of stay (8.5 days, 95% confidence interval 8.0-9.0), and greater hospitalization cost ($29.1K, 95% confidence interval 26.7K-31.5K). CONCLUSION Operative management of lower gastrointestinal bleeding is rare and associated with significant morbidity and mortality compared to those managed conservatively. However, when surgical intervention is indicated, preoperative patient characteristics should be used to identify those at greater risk of an operation to facilitate early surgical consultation and inform expectations during the perioperative period.
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Affiliation(s)
- Cory Lee
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Manuel Orellana
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Alexander Hawkins
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Aimal Khan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
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7
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Hui JWQ, En JWQ, Lau J, Te Neng L, Wong SK. Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding. ANZ J Surg 2022; 92:3247-3252. [PMID: 36074650 DOI: 10.1111/ans.18023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUNDS Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. METHODS The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). RESULTS From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. CONCLUSION A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.
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Affiliation(s)
| | | | - Joel Lau
- NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Lau Te Neng
- Department of Radiology, Mount Elizabeth Novena Hospital, Singapore
| | - Soong Kuan Wong
- The Colorectal Clinic Pte Ltd, Mt Elizabeth Novena Hospital, Singapore, Singapore
- NUS Yong Loo Lin School of Medicine, Singapore, Singapore
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8
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Ganta N, Aknouk M, Alnabwani D, Nikiforov I, Bommu VJL, Patel V, Cheriyath P, Hollenbeak CS, Hamza A. Disparities in colonoscopy utilization for lower gastrointestinal bleeding in rural vs urban settings in the United States. World J Gastrointest Endosc 2022; 14:474-486. [PMID: 36158630 PMCID: PMC9453311 DOI: 10.4253/wjge.v14.i8.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Lower gastrointestinal bleeds (LGIB) is a very common inpatient condition in the United States. Gastrointestinal bleeds have a variety of presentations, from minor bleeding to severe hemorrhage and shock. Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB, there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings.
AIM To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals.
METHODS This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality. It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016. This study does not differentiate between acute and chronic LGIB and both are included in this study. The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds; the secondary outcome measures were in-hospital mortality, length of stay, and costs involved in those receiving colonoscopy for LGIB. Statistical analyses were all performed using STATA software. Logistic regression was used to analyze the utilization of colonoscopy and mortality, and a generalized linear model was used to analyze the length of stay and cost.
RESULTS Our study found that 37.9% of LGIB patients at rural hospitals compared to approximately 45.1% at urban hospitals received colonoscopy, (OR = 0.730, 95%CI: 0.705-0.7, P > 0.0001). After controlling for covariates, colonoscopies were found to have a protective association with lower in-hospital mortality (OR = 0.498, 95%CI: 0.446-0.557, P < 0.0001), but a longer length of stay by 0.72 d (95%CI: 0.677-0.759 d, P < 0.0001) and approximately $2199 in increased costs.
CONCLUSION Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals, patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality. In both settings, benefit came at a cost of extended stay, and higher total costs.
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Affiliation(s)
- Nagapratap Ganta
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Mina Aknouk
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Dina Alnabwani
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Ivan Nikiforov
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Veera Jayasree Latha Bommu
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Vraj Patel
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Pramil Cheriyath
- Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
| | - Christopher S Hollenbeak
- Penn State Milton S. Hershey Medical Center, 500 University Drive, University Park, PA 16802, United States
| | - Alan Hamza
- Department of Internal Medicine, Ocala Health, Ocala, FL 34471, United States
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Gerald A, McCandless M, Sheth A, Aihara H, Russo S. A Soft Sensor for Bleeding Detection in Colonoscopies. ADVANCED INTELLIGENT SYSTEMS (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2022; 4:2100254. [PMID: 35757581 PMCID: PMC9216226 DOI: 10.1002/aisy.202100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Colonoscopies allow surgeons to detect common diseases i.e. colorectal cancer, ulcers and other ailments. However, there is a risk of bleeding in the lower gastrointestinal (GI) tract while maneuvering endoscopes. This may be due to perforations, hemorrhaging, polyps, diverticuli or post-biopsy complications. Thus, it is essential for the surgeon to be able to detect bleeding at the site and evaluate the severity of blood leakage. This paper presents a soft sensor that can detect the presence of blood at the bleeding site during colonoscopies. The sensor consists of optical waveguides that interface with a microfluidic channel. Blood flow causes absorption and scattering of incident light that can be picked up by the optical sensing apparatus via light transmission through the waveguide. The surgeon can be alerted when bleeding occurs through a graphical user interface. The device is compact and measures only 1 mm thick. This allows the sensor to be circumferentially mounted onto a colonoscope at different locations. The sensor is able to record the presence of blood as an optical loss, rapidly detect the presence of blood in under 100 milliseconds as it enters the microchannel, and differentiate between gastric fluid and blood through changes in measured optical loss.
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Affiliation(s)
- Arincheyan Gerald
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Max McCandless
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Avani Sheth
- Department of Biomedical Engineering, Boston University, Boston, MA 02215, USA
| | - Hiroyuki Aihara
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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10
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Sato Y, Nakatsu-Inaba S, Matsuo Y, Yamashita M, Ikeda H, Yasuda H, Itoh F. Efficient Colonoscopic Identification of Colonic Bleeding Diverticulum Using Intradiverticular Water Injection with a Nontraumatic Tube. J Anus Rectum Colon 2021; 5:313-318. [PMID: 34395945 PMCID: PMC8321589 DOI: 10.23922/jarc.2021-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/20/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: The colonoscopic identification of stigmata of recent hemorrhage (SRH) in patients with colonic diverticular bleeding (CDB) is difficult. Factors that influence the identification of SRH in the diagnosis of CDB were investigated. Methods: This was a retrospective study of 487 early colonoscopy patients with acute lower gastrointestinal bleeding who were diagnosed with CDB. Comorbidities, medications, bowel preparation, use of a transparent cap, use of a water-jet scope, colonoscopy by an expert colonoscopist, and use of a nontraumatic (NT) tube were assessed. A multivariate analysis was used to estimate the odds ratio and 95% confidence interval. Results: Of the 487 colonoscopy patients diagnosed with CDB, 191 (39%) were definitively identified with SRH. The use of a transparent cap, a water-jet scope, an expert colonoscopist, and an NT tube were independent predictive factors for SRH on univariate analysis. A multivariable logistic regression model showed that colonoscopy by an expert colonoscopist and the use of an NT tube were predictive factors for SRH. Conclusions: Intradiverticular water injection with an NT tube by an expert colonoscopist is useful in identifying CDB, and may help achieve effective endoscopic hemostasis.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Satoko Nakatsu-Inaba
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Yasumasa Matsuo
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Masaki Yamashita
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Hiroki Ikeda
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Hiroshi Yasuda
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
| | - Fumio Itoh
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine
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11
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Carabotti M, Falangone F, Cuomo R, Annibale B. Role of Dietary Habits in the Prevention of Diverticular Disease Complications: A Systematic Review. Nutrients 2021; 13:nu13041288. [PMID: 33919755 PMCID: PMC8070710 DOI: 10.3390/nu13041288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 02/05/2023] Open
Abstract
Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the effect of dietary habits in the prevention of diverticula complications (i.e., acute diverticulitis and diverticula bleeding) in patients with diverticula disease. PubMed and Scopus databases were searched up to 19 January 2021, 330 records were identified, and 8 articles met the eligibility criteria and were subjected to data extraction. The quality of the studies was evaluated by the Newcastle-Ottawa quality assessment form. No study meets the criteria for being a high-quality study. A high intake of fiber was associated to a decreased risk of diverticulitis or hospitalization due to diverticular disease, with a protective effect for fruits and cereal fiber, but not for vegetable fiber; whereas, a high red meat consumption and a generally Western dietary pattern were associated with an increased risk of diverticulitis. Alcohol use seemed to be associated to diverticular bleeding, but not to recurrent diverticulitis or diverticular complications. Further high-quality studies are needed to better define these associations. It is mandatory to ascertain the role of dietary habits for the development of recurrent acute diverticulitis and diverticular bleeding.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, “Sant’Anna e San Sebastiano” Hospital Caserta, 81100 Caserta, Italy;
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
- Correspondence: ; Tel.: +39-06-33775695
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12
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Carabotti M, Morselli Labate AM, Cremon C, Cuomo R, Pace F, Andreozzi P, Falangone F, Barbara G, Annibale B. Distinguishing features between patients with acute diverticulitis and diverticular bleeding: Results from the REMAD registry. Dig Liver Dis 2021; 53:202-209. [PMID: 32553704 DOI: 10.1016/j.dld.2020.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, via di Grottarossa 1035-1039, 00189 Rome, Italy.
| | | | - Cesare Cremon
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Rosario Cuomo
- UOC Gastroenterologia AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Fabio Pace
- Head Complex Operating Unit of Gastroenterology, "Bolognini" Hospital, Seriate, Bergamo, Italy
| | | | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, via di Grottarossa 1035-1039, 00189 Rome, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, via di Grottarossa 1035-1039, 00189 Rome, Italy
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Lock JF, Galata C, Reißfelder C, Ritz JP, Schiedeck T, Germer CT. The Indications for and Timing of Surgery for Diverticular Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:591-596. [PMID: 33161943 DOI: 10.3238/arztebl.2020.0591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 11/14/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease. METHODS This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease. RESULTS Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails. CONCLUSION The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.
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Affiliation(s)
- Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christian Galata
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reißfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jörg-Peter Ritz
- Department of General and Visceral Surgery, Helios Klinikum Schwerin, Schwerin, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Klinikum Ludwigsburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
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Sato Y, Yasuda H, Nakamoto Y, Kiyokawa H, Yamashita M, Matsuo Y, Maehata T, Yamamoto H, Mimura H, Itoh F. Risk factors of interventional radiology/surgery for colonic diverticular bleeding. JGH OPEN 2021; 5:343-349. [PMID: 33732880 PMCID: PMC7936614 DOI: 10.1002/jgh3.12499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 01/23/2023]
Abstract
Background and Aim Colonic diverticular bleeding (CDB) stops spontaneously, but sometimes, excessive bleeding does not allow hemostasis and requires interventional radiology (IR)/surgery. We examined risk factors in patients who required IR/surgery for CDB and late recurrent bleeding rate after IR/surgery. Methods This retrospective case-control study was conducted at a tertiary center. We included 608 patients who required hospitalization for CDB. Patients were investigated for risk factors using logistic regression analysis. We also investigated early and late recurrent bleeding rates following IR/surgery. Results In 261 patients (42.9%), the bleeding source was identified, and endoscopic hemostasis was performed; 23 (3.8%) required IR/surgery. In multivariate analysis, shock state with a blood pressure of ≤90 mmHg (P < 0.001; odds ratio [OR], 20.1; 95% confidence interval [CI], 5.08-79.5), positive extravasation on contrast-enhanced computed tomography (P < 0.001; OR 9.5, 95% CI 2.85-31.4), two or more early recurrent bleeding episodes (P = 0.002; OR 7.4, 95% CI 2.14-25.4), and right colon as the source of bleeding (P = 0.023; OR 4.1, 95% CI 1.25-14.0) were independent risk factors requiring IR/surgery. Early recurrent bleeding was observed in 0% and 28.0% patients (P < 0.001) in the IR/surgery and no IR/surgery groups, respectively, whereas late recurrent bleeding rate was observed in 43.4% and 30.7% patients (P = 0.203) in the IR/surgery and no IR/surgery groups, respectively. Four patients who required surgery experienced late recurrent bleeding at a site different from the initial CDB. Conclusions Although IR/surgery is an effective hemostatic treatment wherein endoscopic treatment is unsuccessful, late recurrent bleeding cannot be prevented.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hiroshi Yasuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yusuke Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hirofumi Kiyokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Masaki Yamashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yasumasa Matsuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Tadateru Maehata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hiroyuki Yamamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hidefumi Mimura
- Department of Radiology St. Marianna University School of Medicine Kawasaki Japan
| | - Fumio Itoh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
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Adegboyega T, Rivadeneira D. Lower GI Bleeding: An Update on Incidences and Causes. Clin Colon Rectal Surg 2019; 33:28-34. [PMID: 31915423 DOI: 10.1055/s-0039-1695035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bleeding from the lower gastrointestinal tract represents a significant source of morbidity and mortality. The colon represents the vast majority of the location of bleeding with only a much smaller incidence occurring in the small intestine. The major causes of lower gastrointestinal bleeding (LGIB) are from diverticulosis, vascular malformations, and cancer. We discuss the incidence and causes of LGIB.
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Affiliation(s)
- Titilayo Adegboyega
- Department of Surgery, Donald and Barbara Zucker School of Medicine Hofstra University, Northwell Health System, New York
| | - David Rivadeneira
- Department of Surgery, Donald and Barbara Zucker School of Medicine Hofstra University, Northwell Health System, New York
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Rising Events and Improved Outcomes of Gastrointestinal Bleed With Shock in USA: A 12-year National Analysis. J Clin Gastroenterol 2019; 53:e194-e201. [PMID: 29369239 DOI: 10.1097/mcg.0000000000000995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock. METHODS We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products. RESULTS GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%). CONCLUSIONS GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.
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Schwenk W. [Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding]. Chirurg 2019; 90:621-630. [PMID: 30976892 DOI: 10.1007/s00104-019-0950-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Diverticular bleeding is a complication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The 99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.
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Affiliation(s)
- W Schwenk
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Städtisches Klinikum Solingen gGmbH, Gotenstraße 1, 42653, Solingen, Deutschland.
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18
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Haji A, Plastiras A, Ortenzi M, Gulati S, Emmanuel A, Hayee B. Elective endoscopic clipping for the treatment of symptomatic diverticular disease: a potential for 'cure'. Gut 2019; 68:582-584. [PMID: 29730604 DOI: 10.1136/gutjnl-2017-315509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/03/2018] [Accepted: 04/10/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Aris Plastiras
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Monica Ortenzi
- Department of Colorectal Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Shraddha Gulati
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew Emmanuel
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
| | - Bu'Hussain Hayee
- King's Institute of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
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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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20
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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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Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage. J Clin Gastroenterol 2019; 53:e75-e83. [PMID: 29356785 DOI: 10.1097/mcg.0000000000000988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
GOALS The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage. BACKGROUND Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula. STUDY We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test. RESULTS In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage. CONCLUSION CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.
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Morrison TC, Wells M, Fidler JL, Soto JA. Imaging Workup of Acute and Occult Lower Gastrointestinal Bleeding. Radiol Clin North Am 2018; 56:791-804. [PMID: 30119774 DOI: 10.1016/j.rcl.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Lower gastrointestinal bleeding is defined as occurring distal to the ligament of Treitz and presents as hematochezia, melena, or with anemia and positive fecal occult blood test. Imaging plays a pivotal role in the localization and treatment of lower gastrointestinal bleeds. Imaging tests in the workup of acute lower gastrointestinal bleeding include computed tomography (CT) angiography, nuclear medicine scintigraphy, and conventional catheter angiography. Catheter angiography can also be used to deliver treatment. Imaging tests in the workup of occult lower gastrointestinal bleeding include CT enterography and nuclear medicine Meckel scan.
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Affiliation(s)
- Trevor C Morrison
- Boston University Medical Center, 830 Harrison Avenue, FGH 3rd Floor, Boston, MA 02118, USA
| | - Michael Wells
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jorge A Soto
- Boston University Medical Center, 830 Harrison Avenue, FGH 3rd Floor, Boston, MA 02118, USA.
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Taylor SA. Is CT Useful as a First-Line Investigation in Colonic Diverticular Bleeding? Radiology 2018; 288:762-763. [PMID: 29893648 DOI: 10.1148/radiol.2018180643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Stuart A Taylor
- From the Centre for Medical Imaging, University College London, Charles Bell House, 43-45 Foley Street, London W1W 7TS, England
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Bleeding diverticulum of the colon treated with CT-guided percutaneous injection of epinephrine and cyanoacrylate. Radiol Case Rep 2018; 13:596-598. [PMID: 30073042 PMCID: PMC6069681 DOI: 10.1016/j.radcr.2018.02.030] [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] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/28/2018] [Indexed: 11/23/2022] Open
Abstract
Hematochezia may be a result of anatomic, vascular, inflammatory, infectious, or neoplastic diseases. Colonoscopic evaluation and therapy may be limited because of intermittent bleeding in the setting of numerous diverticula. This report describes a patient with diverticulosis who presented with hematochezia and hemodynamic instability with failed colonoscopic and arteriographic evaluations, and was treated with percutaneous transcolonic diverticular cyanoacrylate and epinephrine injection.
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Abstract
Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.
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Affiliation(s)
| | - Vikram Jala
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
| | | | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
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Diamantopoulou G, Konstantakis C, Kottorοu A, Skroubis G, Theocharis G, Theopistos V, Triantos C, Nikolopoulou V, Thomopoulos K. Acute Lower Gastrointestinal Bleeding: Characteristics and Clinical Outcome of Patients Treated With an Intensive Protocol. Gastroenterology Res 2018; 10:352-358. [PMID: 29317943 PMCID: PMC5755637 DOI: 10.14740/gr914w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 02/06/2023] Open
Abstract
Background In recent years major advances have been made in the management of patients with acute lower gastrointestinal bleeding. The aim of this study was to investigate the characteristics and clinical outcome of patients with acute lower gastrointestinal bleeding (ALGIB) treated with an intensive protocol. Methods We analyzed the medical records of 528 patients with ALGIB. All patients after hemodynamic stabilization underwent colonoscopy during the first 24 h of hospitalization and capsule enteroscopy when needed. Patients with massive ongoing bleeding underwent computed tomography angiography (CTA), and when active bleeding was detected embolization was immediately performed. Results The mean age of the patients was 70.2 ± 14.6 years and 271 (51.3%) of them were men. At least one comorbidity was present in 464 patients (87.9%), cardiovascular disease in 266 (50.4%), while 158 (30%) patients were on antiplatelet drugs and 96 (18.2%) on anticoagulants. The most common causes of bleeding were diverticulosis (19.7%) and ischemic colitis (19.3%). Thirty-six patients (6.9%) had small intestinal bleeding. In 117 patients (22.2%) active bleeding or recent bleeding stigmata were found and in 82 of them (92.1%) endoscopic hemostasis was applied. Embolization was performed in 10 (1.9%) and was successful in seven (70%) cases, while surgical hemostasis was required in only six (1.1%) cases. Forty-four (8.3%) patients had a rebleeding episode, and 13 patients died with an overall mortality of 2.5%. Conclusions Management of ALGIB based on an intensive protocol is safe and effective. The bleeding source can be identified in most cases with a favorable outcome.
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Affiliation(s)
| | | | - Anastasia Kottorοu
- Laboratory of Molecular Oncology, University Hospital of Patras, 26504 Rio, Greece
| | - Georgios Skroubis
- Department of Surgery, University Hospital of Patras, 26504 Rio, Greece
| | - Georgios Theocharis
- Department of Gastroenterology, University Hospital of Patras, 26504 Rio, Greece
| | - Vasileios Theopistos
- Department of Gastroenterology, University Hospital of Patras, 26504 Rio, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, 26504 Rio, Greece
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28
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Werner DJ, Manner H, Nguyen-Tat M, Kloeckner R, Kiesslich R, Abusalim N, Rey JW. Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature. United European Gastroenterol J 2017; 6:337-342. [PMID: 29774146 DOI: 10.1177/2050640617746299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
Abstract
Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.
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Affiliation(s)
- David J Werner
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Hendrik Manner
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Marc Nguyen-Tat
- First Department of Internal Medicine, University Medical Center, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz, Germany
| | - Ralf Kiesslich
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Nael Abusalim
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Johannes W Rey
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
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Oakland K, Isherwood J, Lahiff C, Goldsmith P, Desborough M, Colman KS, Guy R, Uberoi R, Murphy MF, East JE, Hopewell S, Jairath V. Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review. Endosc Int Open 2017; 5:E959-E973. [PMID: 28975147 PMCID: PMC5624283 DOI: 10.1055/s-0043-117958] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Investigations for lower gastrointestinal bleeding (LGIB) include flexible sigmoidoscopy, colonoscopy, computed tomographic angiography (CTA), and angiography. All may be used to direct endoscopic, radiological or surgical treatment, although their optimal use is unknown. The aims of this study were to determine the diagnostic and therapeutic yields of endoscopy, CTA, and angiography for managing LGIB, and their influence on rebleeding, transfusion, and hospital stay. PATIENTS AND METHODS A systematic search of MEDLINE, PubMed, EMBASE, and CENTRAL was undertaken to identify randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) published between 2000 and 12 November 2015 in patients hospitalized with LGIB. Separate meta-analyses were conducted, presented as pooled odds (ORs) or risk ratios (RR) with 95 % confidence intervals (CIs). RESULTS Two RCTs and 13 NRSIs were included, none of which examined flexible sigmoidoscopy, or compared endotherapy with embolization, or investigated the timing of CTA or angiography. Two NRSIs (57 - 223 participants) comparing colonoscopy and CTA were of insufficient quality for synthesis but showed no difference in diagnostic yields between the two interventions. One RCT and 4 NRSIs (779 participants) compared early colonoscopy (< 24 hours) with colonoscopy performed later; meta-analysis of the NRSIs demonstrated higher diagnostic and therapeutic yields with early colonoscopy (OR 1.86, 95 %CI 1.12 to 2.86, P = 0.004 and OR 3.08, 95 %CI 1.93 to 4.90, P < 0.001, respectively) and reduced length of stay (mean difference 2.64 days, 95 %CI 1.54 to 3.73), but no difference in transfusion or rebleeding. CONCLUSIONS In LGIB there is a paucity of high-quality evidence, although the limited studies on the timing of colonoscopy suggest increased rates of diagnosis and therapy with early colonoscopy.
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Affiliation(s)
| | - Jennifer Isherwood
- Department of General Surgery, Milton Keynes Hospital, Milton Keynes, United
Kingdom
| | - Conor Lahiff
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Petra Goldsmith
- Department of Transplantation, Royal Liverpool Hospital, Liverpool, United
Kingdom
| | | | | | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United
Kingdom
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals, Oxford,
United Kingdom
| | | | - James E. East
- Translational Gastroenterology Unit, University of Oxford, John Radcliffe
Hospital, Oxford, United Kingdom
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United
Kingdom
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London,
Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University Hospital,
London, Ontario, Canada
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30
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Naraynsingh V, Cawich SO, Hassranah D, Daniel F, Maharaj R, Harnarayan P. Segmental colectomy for bleeding diverticular disease guided by the PEEP test. Trop Doct 2017; 47:355-359. [PMID: 28764591 DOI: 10.1177/0049475517724690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many patients with massive lower gastrointestinal (GI) haemorrhage from diverticulosis are subjected to total colectomy when preoperative localisation is unavailable. We dissected colectomy specimens and noted that there was limited retrograde reflux in most of these cases. Therefore, we sought to assess the value of a positive endoluminal erythrocyte presence (PEEP) test (presence of fresh blood in the caecum) to direct segmental colectomies in 14 patients who required emergency operations for massive lower GI haemorrhage. Overall, 13 (93%) patients who had segmental colectomy guided by the PEEP test had successful control of bleeding. There was no mortality and a 14% postoperative morbidity after segmental resections guided by the PEEP test. One patient had persistent bleeding and required a completion colectomy on the third postoperative day. We propose that the PEEP test be added to the surgical armamentarium to guide segmental resection in the absence of localisation by conventional means. However, we advocate blind total colectomy if the PEEP test is equivocal and early completion colectomy if there is significant re-bleeding.
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Affiliation(s)
- Vijay Naraynsingh
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Shamir O Cawich
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Dale Hassranah
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Feisal Daniel
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Ravi Maharaj
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Patrick Harnarayan
- Consultant Surgeon, Department of Clinical Surgical Sciences, St Augustine Campus, University of the West Indies, St. Augustine, Trinidad & Tobago
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31
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Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, Murphy MF, Collins GS. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol 2017; 2:635-643. [PMID: 28651935 DOI: 10.1016/s2468-1253(17)30150-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/05/2017] [Accepted: 05/07/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute lower gastrointestinal bleeding is a common reason for emergency hospital admission, and identification of patients at low risk of harm, who are therefore suitable for outpatient investigation, is a clinical and research priority. We aimed to develop and externally validate a simple risk score to identify patients with lower gastrointestinal bleeding who could safely avoid hospital admission. METHODS We undertook model development with data from the National Comparative Audit of Lower Gastrointestinal Bleeding from 143 hospitals in the UK in 2015. Multivariable logistic regression modelling was used to identify predictors of safe discharge, defined as the absence of rebleeding, blood transfusion, therapeutic intervention, 28 day readmission, or death. The model was converted into a simplified risk scoring system and was externally validated in 288 patients admitted with lower gastrointestinal bleeding (184 safely discharged) from two UK hospitals (Charing Cross Hospital, London, and Hammersmith Hospital, London) that had not contributed data to the development cohort. We calculated C statistics for the new model and did a comparative assessment with six previously developed risk scores. FINDINGS Of 2336 prospectively identified admissions in the development cohort, 1599 (68%) were safely discharged. Age, sex, previous admission for lower gastrointestinal bleeding, rectal examination findings, heart rate, systolic blood pressure, and haemoglobin concentration strongly discriminated safe discharge in the development cohort (C statistic 0·84, 95% CI 0·82-0·86) and in the validation cohort (0·79, 0·73-0·84). Calibration plots showed the new risk score to have good calibration in the validation cohort. The score was better than the Rockall, Blatchford, Strate, BLEED, AIMS65, and NOBLADS scores in predicting safe discharge. A score of 8 or less predicts a 95% probability of safe discharge. INTERPRETATION We developed and validated a novel clinical prediction model with good discriminative performance to identify patients with lower gastrointestinal bleeding who are suitable for safe outpatient management, which has important economic and resource implications. FUNDING Bowel Disease Research Foundation and National Health Service Blood and Transplant.
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Affiliation(s)
- Kathryn Oakland
- National Health Service (NHS) Blood and Transplant, Oxford, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London, ON, Canada; Department of Medicine, University of Western Ontario, London, ON, Canada.
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Lakshmana Ayaru
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare, NHS Trust, London, UK
| | - Neil Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Mike F Murphy
- National Health Service (NHS) Blood and Transplant, Oxford, UK; Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK; Department of Transfusion Medicine, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Botnar Research Centre, Oxford, UK
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