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Wangrattanapranee P, Jensen DM, Khrucharoen U, Jensen ME. Patient Outcomes of Definitive Diverticular Hemorrhage After Colonoscopic, Medical, Surgical, or Embolization Treatment. Dig Dis Sci 2024; 69:538-551. [PMID: 38091175 DOI: 10.1007/s10620-023-08199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/15/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND There are few reports of clinical outcomes or the natural history of definitive diverticular hemorrhage (DDH). AIMS To describe 1-year clinical outcomes of patients with documented DDH treated with colonoscopic hemostasis, angioembolization, surgery, or medical treatment. METHODS DDH was diagnosed when active bleeding or other stigmata of hemorrhage were found in a colonic diverticulum during urgent colonoscopy or extravasation on angiography or red blood cell (RBC) scanning. This was a retrospective analysis of prospectively collected data of DDH patients from two referral centers between 1993 and 2022. Outcomes were compared for the four treatment groups. The Kaplan-Meier analysis was for time-to-first diverticular rebleed. RESULTS 162 patients with DDH were stratified based on their final treatment before discharge-104 colonoscopic hemostasis, 24 medical treatment alone, 19 colon surgery, and 15 angioembolization. There were no differences in baseline characteristics, except for a higher Glasgow-Blatchford score in the angioembolization group vs. the colonoscopic group. Post-treatment, the colonoscopic hemostasis group had the lowest rate of RBC transfusions and fewer hospital and ICU days compared to surgical and embolization groups. The medical group had significantly higher rates of rebleeding and reintervention. The surgical group had the highest postoperative complications. CONCLUSIONS Medically treated DDH patients had significantly higher 1-year rebleed and reintervention rates than the three other treatments. Those with colonoscopic hemostasis had significantly better clinical outcomes during the index hospitalization. Surgery and embolization are recommended as salvage therapies in case of failure of colonoscopic and medical treatments.
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Affiliation(s)
- Peerapol Wangrattanapranee
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- VA Hemostasis Research Unit and Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Dennis M Jensen
- VA Hemostasis Research Unit and Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases and Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA.
- VA Hemostasis GI Research Unit, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA.
| | - Usah Khrucharoen
- VA Hemostasis Research Unit and Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases and Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
- VA Hemostasis GI Research Unit, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA
| | - Mary Ellen Jensen
- VA Hemostasis Research Unit and Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases and Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
- VA Hemostasis GI Research Unit, VA Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, CA, 90073-1003, USA
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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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Uehara T, Matsumoto S, Tamura H, Kashiura M, Moriya T, Yamanaka K, Shinhata H, Sekine M, Miyatani H, Mashima H. Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study. PLoS One 2023; 18:e0289698. [PMID: 37611042 PMCID: PMC10446219 DOI: 10.1371/journal.pone.0289698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. METHODS We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. RESULTS The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. CONCLUSION We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.
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Affiliation(s)
- Takeshi Uehara
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Tamura
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masahiro Kashiura
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takashi Moriya
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kenichi Yamanaka
- Department of Gastroenterology, Saitama Citizens Medical Center, Saitama, Japan
| | - Hakuei Shinhata
- Department of Gastroenterology, Saitama Citizens Medical Center, Saitama, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Miyatani
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Gonai T, Toya Y, Kawasaki K, Yanai S, Akasaka R, Nakamura S, Matsumoto T. Risk factors of re‐bleeding within a year in colonic diverticular bleeding patients. DEN OPEN 2022; 2:e22. [PMID: 35310758 PMCID: PMC8828229 DOI: 10.1002/deo2.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023]
Abstract
Background/Aims Although colonic diverticular bleeding (CDB) is common, few reports have described the effects of antithrombotic agents (ATs) on CDB. This study aimed to clarify the risk factors of re‐bleeding within a year in CDB patients. Methods We retrospectively analyzed the risk of re‐bleeding in CDB patients. Among 324 patients who were hospitalized for acute lower gastrointestinal bleeding at our institution during the period from 2015 to 2019, we used 76 patients who were diagnosed as CDB. Risk factors for re‐bleeding were determined by Cox proportional hazard models. Results Of 76 patients analyzed, 32 were taking ATs, nine of whom were taking multiple agents. Twenty‐six patients re‐bled within a year. Compared with the patients without re‐bleeding, patients with re‐bleeding within a year had been treated by antithrombotic therapy more frequently (62% vs. 32%, p = 0.013). Cox proportional hazard model revealed that treatment with ATs (hazard ratio 3.89, 95% confidence interval 1.53–10.74, p = 0.004) was an independent risk factor for re‐bleeding within a year. Conclusion ATs were found to be an independent risk factor related to re‐bleeding within a year in patients with CDB.
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Affiliation(s)
- Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Keisuke Kawasaki
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Risaburo Akasaka
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
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5
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Longo S, Altobelli E, Castellini C, Vernia F, Valvano M, Magistroni M, Mancusi A, Viscido A, Ashktorab H, Latella G. Non-steroidal anti-inflammatory drugs and acetylsalicylic acid increase the risk of complications of diverticular disease: a meta-analysis of case-control and cohort studies. Int J Colorectal Dis 2022; 37:521-529. [PMID: 35094111 DOI: 10.1007/s00384-021-04088-1] [Citation(s) in RCA: 2] [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] [Accepted: 12/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The role of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid in the occurrence of diverticular bleeding (DB), complicated diverticulitis (CD), and acute diverticulitis (AD) is not yet defined. AIM Update a systematic review and meta-analyses of case-control and cohort studies to evaluate the association between NSAIDs or acetylsalicylic acid with DB, CD, or AD. METHODS The study included were identified through MEDLINE, Scopus, Web of Science, and Cochrane Library databases. Sizes were pooled across studies to obtain the overall effect size. A random-effects model was used to account for different sources of variation among studies. Odds ratio (OR) with 95% confidence interval (CI) was used as a measure of effect size. RESULTS Thirteen studies were included in the systematic review and meta-analysis. NSAIDs and acetylsalicylic acid use were associated with an increased risk of DB (OR: 6.90, 95% CI 3.86 to 12.35, P ˂ 0.00001, and OR 2.84, 95% CI 2.19 to 3.67, P < 0.00001, respectively). NSAIDs and acetylsalicylic acid use were also associated with increased risk of CD occurrence (OR 3.13, 95% CI 1.73 to 5.68, P = 0.0002, and OR 1.49, 95% CI 1.02 to 2.17, P = 0.04, respectively). The only study found about AD occurrence showed that NSAIDs use was not associated with AD and acetylsalicylic acid use had a low risk of AD. CONCLUSION NSAIDs and acetylsalicylic acid significantly increase the risk of DB and CD. Further studies are needed to clarify the role of NSAIDs and acetylsalicylic acid in AD. However, increasing evidence suggests caution in the use of such medications in patients with colonic diverticula.
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Affiliation(s)
- Salvatore Longo
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Emma Altobelli
- Epidemiology and Biostatistics Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Chiara Castellini
- Andrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Valvano
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Magistroni
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Mancusi
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angelo Viscido
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Hassan Ashktorab
- Department of Medicine, Gastroenterology Division and Cancer Center, Howard University, Washington, DC, USA
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
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6
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Gonai T, Toya Y, Kudara N, Abe K, Sawaguchi S, Fujiwara T, Eizuka M, Miura M, Urushikubo J, Yamada S, Yamaguchi S, Asakura K, Orikasa S, Matsumoto T. Risk factors for short-term re-bleeding in patients with colonic diverticular bleeding: a multicenter retrospective study. Scand J Gastroenterol 2022:1-6. [PMID: 35138982 DOI: 10.1080/00365521.2022.2035812] [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: 12/11/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Few studies have evaluated risk factors for short-term re-bleeding in patients with colonic diverticular bleeding (CDB). We aimed to reveal risk factors for re-bleeding within a month in patients with CDB. METHODS We retrospectively analyzed clinical course of patients with CDB diagnosed at 10 institutions between 2015 and 2019. Risk factors for re-bleeding within a month were assessed by Cox proportional hazards models. RESULTS Among 370 patients, 173 (47%) patients had been under the use of antithrombotic agents (ATs) and 34 (9%) experienced re-bleeding within a month. Multivariate analysis revealed that the use of ATs was an independent risk factor for re-bleeding within a month (HR 2.38, 95% CI 1.10-5.50, p = .028). Furthermore, use of multiple ATs and continuation of ATs were found to be independent risk factors for re-bleeding within a month (HR 3.88, 95% CI 1.49-10.00, p = .007 and HR 3.30, 95% CI 1.23-8.63, p = .019, respectively). Two of 370 patients, who discontinued ATs, developed thromboembolic event. CONCLUSIONS Use of ATs was an independent risk factor for short-term re-bleeding within a month in patients with CDB. This was especially the case for the use of multiple ATs and continuation of ATs. However, discontinuation of ATs may increase the thromboembolic events those patients.
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Affiliation(s)
- Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
- Department of Gastroenterology, Iwate Prefectural Kuji Hospital, Kuji, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
| | - Norihiko Kudara
- Department of Gastroenterology, Iwate Prefectural Ofunato Hospital, Ofunato, Japan
| | - Keinosuke Abe
- Department of Gastroenterology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | - Sera Sawaguchi
- Department of Gastroenterology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | - Takao Fujiwara
- Department of Gastroenterology, Morioka Red Cross Hospital, Morioka, Japan
| | - Makoto Eizuka
- Department of Gastroenterology, Hachinohe Red Cross Hospital, Hachinohe, Japan
| | - Manami Miura
- Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Japan
| | - Jun Urushikubo
- Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Japan
| | - Shun Yamada
- Department of Gastroenterology, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Satoko Yamaguchi
- Department of Gastroenterology, Kazuno Kosei Hospital, Kazuno, Japan
| | - Kensuke Asakura
- Department of Gastroenterology, Iwate Prefectural Kuji Hospital, Kuji, Japan
| | - Shunsuke Orikasa
- Department of Gastroenterology, Kitakami Saiseikai Hospital, Kitakami, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
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7
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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: 75] [Impact Index Per Article: 25.0] [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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8
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Sato Y, Yasuda H, Nakamoto Y, Kiyokawa H, Yamashita M, Matsuo Y, Maehata T, Yamamoto H, Itoh F. Risk Factors for Late Rebleeding of Colonic Diverticular Bleeding in Elderly Individuals. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:148-157. [PMID: 33937555 PMCID: PMC8084535 DOI: 10.23922/jarc.2020-081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
Objectives This study aimed to examine the clinical characteristics of colonic diverticular bleeding (CDB) in elderly individuals. Methods This retrospective case-control study was conducted at a single tertiary center. A total of 519 patients (356 men and 163 women; mean age of 73.1 ± 12.5 years) with CDB and hospitalized between January 2004 and May 2019 were analyzed. The subjects were divided into two groups: the elderly (274 individuals aged ≥75 years; mean age, 82.1 ± 5.3 years) and non-elderly (245 individuals aged <75 years; mean age, 63.0 ± 10.3 years) groups. Primary outcomes were early and late rebleeding rates, and secondary outcomes were the risk factors for late rebleeding in elderly individuals. Rebleeding occurring within 30 days of hospitalization was defined as early rebleeding, whereas rebleeding occurring after 31 days was defined as late rebleeding. Results The early rebleeding rates were 30.6% and 33.1% (p = 0.557) in the elderly and non-elderly groups, respectively. The late rebleeding rates were 42.3% and 30.6% (p = 0.005) in the elderly and non-elderly groups, respectively. The 3-year recurrence-free survival was 63.6% in the elderly group and 75.6% in the non-elderly group (log-rank test: p < 0.001). Multivariate analysis revealed the use of non-steroidal anti-inflammatory drugs (NSAIDs) [odds ratio (OR), 3.55], chronic kidney disease (OR, 2.89), and presence of bilateral diverticula (OR, 1.83) as the independent risk factors for late rebleeding in elderly individuals. Conclusions Elderly individuals with CDB require careful follow-up even after discharge. Furthermore, it is important to consider discontinuing NSAIDs to prevent rebleeding.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroshi Yasuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Yusuke Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hirofumi Kiyokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Yamashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Yasumasa Matsuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Tadateru Maehata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroyuki Yamamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Fumio Itoh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
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Nakahara R, Amano Y, Murakami D, Ogawa S, Ujihara T, Iwaki T, Katsuyama Y, Hayasaka K, Harada H, Tada Y, Yuki T, Miyaoka Y, Kushiyama Y, Fujishiro H, Ishihara S. Relationship between colonic diverticulosis and colon neoplasms in Japanese patients. Dig Endosc 2021; 33:418-424. [PMID: 32438477 DOI: 10.1111/den.13745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Colonic diverticulosis (CD) has been reported to be associated with presence of colon neoplasms (CNs) in Western patients, since most of the associated risk factors are common between them. However, such correlation has not been fully investigated in Asian patients. In this study, the association of CNs with CD was evaluated in a multicenter investigation. METHODS We enrolled 5633 patients who underwent both colonoscopy and esophagogastroduodenoscopy due to annual follow-up, screening for positive occult blood testing and abdominal symptoms between January 2016 and December 2017 at three institutions. The relationship between the presence of CNs and CD was investigated, and predictors for presence of CNs were determined by multivariate logistic analysis. RESULTS The enrolled patients consisted of 1799 (31.9%) with CD (average age 70.0 years, male 64.0%) and 3834 without CD (66.0 years, male 52.9%), with the prevalence of CNs in those groups 46.6% and 44.2%, respectively (P = 0.090). Predictors for early colon cancer were shown to be age (OR 1.02, 95% CI 1.01-1.04, P = 0.010), laxatives use (OR 1.76, 95% CI 1.17-2.64, P = 0.007), gastric neoplasms (OR 2.16, 95% CI 1.23-3.81, P = 0.008), and CD (OR 1.64, 95% CI 1.16-2.31, P = 0.005). Early colon cancer in the distal colon was most frequently detected in patients with right-sided CD (RR 2.50, P = 0.001). CONCLUSION In Japanese patients, early colon cancer was more frequently found in those with as compared to those without CD. The presence of CD may be an important indicator for an index colonoscopy examination to detect colon cancer. (Clinical-trial-registry: UMIN000038985).
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Affiliation(s)
- Ryotaro Nakahara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Yuji Amano
- Department of Endoscopy, New Tokyo Hospital, Chiba, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Sayaka Ogawa
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Tetsuro Ujihara
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Tomoyuki Iwaki
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | | | - Kenji Hayasaka
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Chiba, Japan
| | - Yasumasa Tada
- Department of Gastroenterology, Matsue Red Cross Hospital, Shimane, Japan
| | - Takafumi Yuki
- Department of Gastroenterology, Matsue Red Cross Hospital, Shimane, Japan
| | - Youichi Miyaoka
- Department of Endoscopy, Shimane Prefectural Central Hospital, Shimane, Japan
| | | | - Hirofumi Fujishiro
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Shunji Ishihara
- Department of Internal Medicine II, Faculty of Medicine, Shimane University, Shimane, Japan
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Alnzaer AA, Mohamedahmed AYY, Adam YA, Eltyiep E, Suliman SH. Presentation and anatomical distribution of diverticular disease in four hospitals in Sudan. Pan Afr Med J 2020; 36:64. [PMID: 32754291 PMCID: PMC7380871 DOI: 10.11604/pamj.2020.36.64.22987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/27/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction diverticular disease (DD) was thought to be more prevalent in the western countries, especially the white populations, but the recent increase in incidence among African and Asian population, was reported. Up to our knowledge, there is no previous study of DD in Sudan. Methods this is a descriptive cross-sectional study conducted at the department of endoscopy in four Sudanese hospitals in the period from October 2017 to February 2019. We included all patients who underwent colonoscopy during the study period. The main objective is to study the presentation and the anatomical pattern of diverticular disease among the Sudanese population. Results prevalence of DD in the included population was 7.5% (104/1393). The mean age was 66.4 ± 12.5 years with the percentage of males in our study is 77.1% and females were 22.9%. Presenting complains were: abdominal pain in all patients, constipation in 78.8% and rectal bleeding in 57.7%. Regarding anatomical distribution: 63.5% have left colonic DD, 19.2% in the right colon and 17.3% involving the entire colon. There was a significant correlation between the left side DD and following clinical presentations: mucus per-rectum (p = 0.015) and weight loss (p = 0.048). Other endoscopic findings of significance were internal pile in 21.2% and colo-rectal polyp in 15.4%. Conclusion the prevalence of DD in the included population, is 7.5% which is consistent with recent literature from the Middle East, Africa and Asia but still less than the prevalence in the western countries and left side colon is predominantly affected.
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Affiliation(s)
| | | | | | - Elmoiz Eltyiep
- General Surgery, Sudan Medical Specialization Board, Khartoum, Sudan
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11
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. Consenso mexicano sobre diagnóstico, prevención y tratamiento de la gastropatía y enteropatía por antiinflamatorios no esteroideos. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:190-206. [DOI: 10.1016/j.rgmx.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/27/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
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12
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. The Mexican consensus on the diagnosis, treatment, and prevention of NSAID-induced gastropathy and enteropathy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmxen.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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13
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Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage. Can J Gastroenterol Hepatol 2020; 2020:3283940. [PMID: 32399458 PMCID: PMC7201635 DOI: 10.1155/2020/3283940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
AIM This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. METHODS This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. RESULTS Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68-12.0, P < 0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23-7.53, P=0.016). CONCLUSIONS In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.
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14
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Abstract
Objective Colonic diverticular bleeding often recurs, and readmissions are common. The aim of this study was to identify predictors of colonic diverticular recurrent bleeding and readmission within 90 days. Methods Subjects comprised 144 patients diagnosed with colonic diverticular bleeding who received inpatient hospital care between January 2012 and June 2017. A retrospective comparative study was carried out regarding the clinical characteristics during the hospital stay by dividing the cases into 2 groups: patients with recurrent bleeding requiring readmission within 90 days (n=17) and patients without recurrent bleeding (n=127). Results A univariate analysis showed that recurrent bleeding and readmission were significantly more frequent among cases with hypovolemic shock on admission (p=0.009), blood transfusion during hospitalization (p=0.029), and hyperlipidemia (p=0.020) than among others. Shock on admission (odds ratio, 5.118; 95% confidence interval, 1.168-22.426, p=0.030) remained a significant predictor on a multivariate analysis. Conclusion Shock may predict recurrent colonic diverticular bleeding and readmission within 90 days. Careful and adequate endoscopic hemostasis is recommended for patients showing shock on admission.
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Affiliation(s)
- Tomoyuki Kitagawa
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Yasumi Katayama
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Ikuhiro Kobori
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Yo Fujimoto
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Masaya Tamano
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
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15
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Shafqet MA, Tonthat A, Esparragoza P, Toro B, Ehrlich AC, Friedenberg FK. Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram. Abdom Radiol (NY) 2019; 44:2632-2638. [PMID: 30949782 DOI: 10.1007/s00261-019-02005-3] [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: 11/24/2022]
Abstract
BACKGROUND Computed tomography angiography (CTA) is a diagnostic modality utilized in patients with suspected active lower gastrointestinal (GI) bleeding. CTA use in clinical practice is limited by the risk of contrast-induced nephropathy, and the loss of patients from direct physician observation while undergoing the test. Identifying clinical predictors of a positive result would be useful in guiding physician utilization of CTA studies. METHODS We performed a single-center retrospective study to determine which clinical predictors are associated with a positive CTA. Binary logistical regression modeling was used to identify the independent predictors and the results were expressed as adjusted odds ratios with corresponding 95% CI . RESULTS 262 patients met inclusion criteria and there were 61 (23.3%) positive CTA exams. In unadjusted analysis those who were CTA positive were more likely to require management in the intensive care unit (85.2% vs. 14.8%, p < 0.01) and being CTA positive was associated with a significantly increased in-hospital mortality (14.8% vs. 4.5%, p < 0.01). The use of a novel oral anticoagulant (NOAC) in the week prior to presentation was associated with a positive CTA after adjustment for confounders (adjusted odds ratio = 3.89; 95% CI 1.05-14.43). Similarly, the use of a non-steroidal anti-inflammatory drug (NSAID) was associated with a positive CTA (OR 2.36; 1.03-5.41). Only 8% of patients experienced contrast-induced nephropathy. CONCLUSION Use of either NOACs or NSAIDs in the previous week is independently associated with a positive CTA in the setting of acute lower GI bleeding. CTA exams appear to confer a low risk of contrast-induced nephropathy.
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Affiliation(s)
- Muhammad A Shafqet
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Alexander Tonthat
- School of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Paola Esparragoza
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Butros Toro
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Frank K Friedenberg
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
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Direct Oral Anticoagulant Use and Risk of Diverticular Hemorrhage: A Systematic Review of the Literature. Can J Gastroenterol Hepatol 2019; 2019:9851307. [PMID: 31316948 PMCID: PMC6604480 DOI: 10.1155/2019/9851307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/27/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anticoagulants carry a significant risk of gastrointestinal bleeding. With the increase in use and availability of direct oral anticoagulants ("DOACs") more data are available regarding the risks of these medications. With diverticular bleeds being common, and hospitalization associated with gastrointestinal bleed increasing 30-day mortality, it is paramount to better understand the potential risks of using DOACs in this population. METHODS A systematic review of the literature was undertaken, using the databases PubMed, EMBASE, Cochrane Library, and CINAHL. Two reviewers independently searched the literature, and initial screening was performed through title and abstract reading. Search terms included "direct" AND "anticoagulant" AND "diverticular bleed" OR "diverticular hemorrhage". The references of the selected studies were manually reviewed for any further relevant articles. RESULTS Literature search across the databases garnered 182 articles-157 unique abstracts after duplicate removal. Based on inclusion and exclusion criteria, 6 studies were deemed relevant. The selected studies' reference lists yielded no further relevant articles. DISCUSSION Across the 6 studies, the incidence of diverticular bleeding in patients using DOACs was extremely low. Of 23,990 patients taking DOACs identified from two separate institutions, only 60 were found to have diverticular hemorrhage. Similarly, among 15,056 patients with diverticular hemorrhage, only 246 (1.6%) among them were taking DOACs. Generally, the studies found no increased diverticular bleeding rate between patients taking DOACs and those who were taking other anticoagulants, such as warfarin, or the general population. The studies also did not find an increased risk of rebleeding with DOAC continuation. CONCLUSION The evidence suggests the risk of diverticular bleed among DOAC users is equivocal to those not taking DOACs, and the overall incidence of diverticular bleed in the DOAC population is low. As it stands, the risk of thrombotic events from not starting DOACs apparently outweighs the risk of diverticular bleed.
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17
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Okamoto N, Tominaga N, Sakata Y, Hara M, Yukimoto T, Tsuruta S, Yamanouchi K, Takeshita E, Matsunaga K, Ito Y, Miyahara K, Noda T, Yamaguchi D, Tsunada S, Tanaka Y, Kawakubo H, Tsuruoka N, Shimoda R, Ogata S, Fujimoto K. Lower Rebleeding Rate after Endoscopic Band Ligation than Endoscopic Clipping of the Same Colonic Diverticular Hemorrhagic Lesion: A Historical Multicenter Trial in Saga, Japan. Intern Med 2019; 58:633-638. [PMID: 30333407 PMCID: PMC6443565 DOI: 10.2169/internalmedicine.1473-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective This historical control study was performed to evaluate i) the rebleeding rate of bleeding colon diverticula treated with endoscopic band ligation (EBL) versus endoscopic clipping (EC) and ii) risk factors for rebleeding of diverticula initially treated by endoscopic hemostasis. Methods From January 2010 to December 2012, 68 patients were treated with EC, and from January 2013 to August 2016, 67 patients were treated with EBL. All patients in each group were followed up for one year to check for rebleeding. Results The rebleeding rate was lower in the EBL group (7 of 67, 10%) than in the EC group (21 of 68, 31%; p<0.01). This difference was mainly due to the lower rebleeding rate from the same hemorrhagic diverticulum initially treated by hemostasis (EBL: 4 of 67, 6%; EC: 15 of 68, 22%; p<0.01). The time span until rebleeding in the EBL group was ≤1 week. A multivariate analysis indicated that bleeding from the diverticula on the right side of the colon was a high-risk factor for rebleeding from the diverticula (odds ratio, 4.48; 95% confidence interval, 1.22-16.46; p=0.02). Conclusion The low rebleeding rate in the EBL group was attributed to the low degree of rebleeding from the same diverticulum, indicating that EBL was superior to EC in preventing rebleeding of an initially treated diverticulum.
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Affiliation(s)
- Norihiro Okamoto
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
- Department of Internal Medicine, Saga Medical School, Japan
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
| | | | - Megumi Hara
- Department of Preventive Medicine, Saga Medical School, Japan
| | - Takahiro Yukimoto
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
- Department of Internal Medicine, Saga Medical School, Japan
| | - Sanae Tsuruta
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
| | - Kohei Yamanouchi
- Department of Internal Medicine and Gastrointestinal Endoscopy, Takagi Hospital, Japan
| | - Eri Takeshita
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Keiji Matsunaga
- Department of Internal Medicine, Yuaikai Oda Hospital, Japan
| | - Yoichiro Ito
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Koichi Miyahara
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Takahiro Noda
- Department of Internal Medicine, Karatsu Red Cross Hospital, Japan
| | - Daisuke Yamaguchi
- Department of Internal Medicine, National Hospital Organization Ureshino Medical Center, Japan
| | - Seiji Tsunada
- Department of Internal Medicine, National Hospital Organization Ureshino Medical Center, Japan
| | - Yuichiro Tanaka
- Department of Internal Medicine, Imari Arita Kyoritsu Hospital, Japan
| | - Hiroharu Kawakubo
- Department of Internal Medicine, Imari Arita Kyoritsu Hospital, Japan
| | - Nanae Tsuruoka
- Department of Internal Medicine, Saga Medical School, Japan
| | - Ryo Shimoda
- Department of Internal Medicine, Saga Medical School, Japan
| | - Shinichi Ogata
- Department of Gastroenterology, Saga Medical Centre Koseikan, Japan
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Vajravelu RK, Mamtani R, Scott FI, Waxman A, Lewis JD. Incidence, Risk Factors, and Clinical Effects of Recurrent Diverticular Hemorrhage: A Large Cohort Study. Gastroenterology 2018; 155:1416-1427. [PMID: 30056095 PMCID: PMC6219900 DOI: 10.1053/j.gastro.2018.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/12/2018] [Accepted: 07/22/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Although recurrent diverticular hemorrhage is common, its incidence and risk factors have not been measured outside of small institutional cohorts. We analyzed the incidence of and risk factors for recurrent diverticular hemorrhage and whether discontinuing anticoagulation after diverticular hemorrhage is associated with ischemic stroke. METHODS We performed a retrospective cohort study of patients enrolled in the OptumInsight Clinformatics database from 2000 through 2016. Incidence rates for initial and recurrent diverticular hemorrhage were calculated by identifying patients who had hospitalizations with a primary discharge diagnosis consistent with diverticular hemorrhage. The hazard ratios of second diverticular hemorrhage associated with anticoagulants or platelet aggregation inhibitors were calculated using Cox proportional hazards regression adjusted for demographics, comorbidities, and medication use. The hazard ratio for ischemic stroke among patients who discontinued anticoagulation after diverticular hemorrhage was calculated similarly. RESULTS In the cohort analyzed, 14,925 patients had an initial diverticular hemorrhage; 1368 of these patients had a second episode. The unstandardized incidence rates of initial and second diverticular hemorrhage were 10.9 per 100,000 person-years (95% confidence interval [CI] 10.7-11.0) and 3625.6 per 100,000 person-years (95% CI 3436.0-3823.0). Platelet aggregation inhibitors were associated with second episodes of diverticular hemorrhage (hazard ratio 1.47; 95% CI 1.15-1.88), whereas all classes of anticoagulation agents were not associated. Among patients with a potential indication for stroke prophylaxis, those who discontinued anticoagulation after the diverticular hemorrhage had an increased hazard of ischemic stroke (hazard ratio 1.93; 95% CI 1.17-3.19). CONCLUSIONS In this retrospective cohort study, platelet aggregation inhibitors, but not anticoagulants, were associated with recurrent diverticular hemorrhage. Discontinuing anticoagulation was associated with increased hazard for ischemic stroke.
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Affiliation(s)
- Ravy K Vajravelu
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ronac Mamtani
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank I Scott
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Adam Waxman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Mǎrginean CO, Meliţ LE, Mǎrginean MO. Segmental Colitis Associated Diverticulosis-A Possible Diagnosis in Teenagers. Front Pediatr 2018; 6:168. [PMID: 29922640 PMCID: PMC5996823 DOI: 10.3389/fped.2018.00168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 05/21/2018] [Indexed: 01/19/2023] Open
Abstract
Segmental colitis associated with diverticulosis (SCAD) is manifested by active chronic inflammation of the colonic segments affected by diverticulosis, luminal-mucosal inflammation, independent of the presence of inflammation within and/or around the diverticula, and it usually spares the rectum. We present the case of a 15-year-old female admitted to our clinic due to lower digestive hemorrhage and abdominal pain in the previous week, associated with fever 1 day prior to admission. The patient had pallor, painful abdomen upon palpation, accelerated bowel movements, and macroscopic evidence of blood in the stools. Initial laboratory tests showed leukocytosis with neutrophilia, thrombocytosis, anemia, and elevated inflammatory biomarkers. Moreover, colonoscopy revealed multiple ulcerations, hemorrhage, and edema of the sigmoid colon; however, multiple orifices raised the suspicion of a colonic diverticulosis and this was later on confirmed through a barium enema. The histopathological examination pointed out signs of an active chronic inflammation and mucosal architectural changes associated with crypt abscesses, therefore suggesting the diagnosis of SCAD. The patient's prognosis was favorable; her condition improved following steroid and 5-aminosalicylate therapy, without any symptoms or recurrences at the 4 months follow-up. In conclusion, SCAD is a very rare disease entity that is usually confused with other inflammatory bowel conditions. Moreover, it has not been reported in the pediatric age group until now.
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Affiliation(s)
- Cristina O Mǎrginean
- Department of Pediatrics I, University of Medicine and Pharmacy of Tîrgu Mureş, Târgu Mureş, Romania
| | - Lorena E Meliţ
- Department of Pediatrics I, University of Medicine and Pharmacy of Tîrgu Mureş, Târgu Mureş, Romania
| | - Maria O Mǎrginean
- Department of Pediatrics I, University of Medicine and Pharmacy of Tîrgu Mureş, Târgu Mureş, Romania
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