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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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Zhao Y, Chee MYM, Sultana R, Tan WJ. Safe discharge for patients admitted for lower gastrointestinal bleeding (LGITB): derivation and validation of a novel scoring system. BMC Gastroenterol 2023; 23:349. [PMID: 37814216 PMCID: PMC10561471 DOI: 10.1186/s12876-023-02950-w] [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: 04/07/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023] Open
Abstract
AIM Bleeding from the lower gastrointestinal tract (LGITB) is a common clinical presentation. Recent guidelines have recommended for incorporation of clinical risk assessment tools in the management for LGITB. We derived and validated a novel clinical scoring system to predict safe discharge after LGITB admission, and compared it to other published scoring systems in current literature. METHODS A retrospective cohort of 798 patients with LGITB from August 2018 to March 2021 was included in the derivation cohort. Multivariate binary logistic regression was performed to identify significant clinical variables predictive of safe discharge. A clinical scoring system was developed based on the results, and validated on a prospective cohort of 312 consecutive patients with LGITB from April 2021 to March 2022. The performance of the novel scoring system was compared to other LGITB clinical risk assessment scores via area under the receiver operating characteristics curve (AUROC) analysis. RESULTS Variables predictive of safe discharge included the following; absence of previous LGITB admission, absence of ischemic heart disease, absence of blood on digital rectal examination, absence of dizziness or syncope at presentation and the systolic blood pressure and haemoglobin levels at presentation. The novel score had an AUROC of 0.907. A cut-off point of 4 provided a sensitivity of 41.9%, specificity of 97.5%, positive predictive value of 96.4% and negative predictive value of 51.5% for prediction of safe discharge. The score performs comparably to the Oakland score. CONCLUSION The novel LGITB clinical risk score has good predictive performance for safe discharge in patients admitted for LGITB.
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Affiliation(s)
- Yue Zhao
- Ministry of Health Holdings, 110 Sengkang E Way, Singapore, 544886, Singapore.
| | | | | | - Winson Jianhong Tan
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore.
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3
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Talemal L, Yaratha K, Monahan BV, Yu D, Lu X, Poggio JL. Seasonal Variations and Factors that Influence Diverticular Bleeding in the United States of America. J Res Health Sci 2023; 23:e00577. [PMID: 37571948 PMCID: PMC10422131 DOI: 10.34172/jrhs.2023.112] [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: 03/22/2023] [Revised: 04/21/2023] [Accepted: 05/13/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Seasonal variation in hospitalizations for diverticulitis has a sinusoidal pattern, peaking in summer. Little is known about seasonal, regional trends, and risk factors associated with hospital admissions regarding diverticular bleeding in the United States. STUDY DESIGN Cross-sectional population database review using the healthcare cost and utilization project's national inpatient sample. METHODS Patients that had diagnoses of diverticulitis with bleeding or diverticulosis with bleeding admitted from January 1, 2015, through December 31, 2017, were identified and stratified by month and season. Then, the potential effects of region, age, gender, race, and patient risk factors on seasonal admissions for diverticular bleeding were explored, and data were analyzed in SAS and presented in Excel using chi-square and Kruskal-Wallis for categorical and continuous variables, respectively. RESULTS Of the 54191 hospitalized cases for diverticular bleeding, the peak and the lowest seasons were spring and summer (25.5% vs. 24.2%, P<0.0001). A significant seasonal pattern in comorbidities was also identified, and those with diabetes (P<0.0001), hypertension (HTN) (P<0.0001), obesity (P<0.0001), and those on anticoagulants (P=0.016) all had more bleeding events in the spring. This was noted across US regions, gender, race, and age. Eventually, the southern region had the most admissions for diverticular bleeding at 40.9% (P<0.0001). CONCLUSION A better understanding of these seasonal and regional trends may provide a mechanism to identify a potential trigger for diverticular bleeding events. This helps identify individuals at greatest risk for hospitalization, as well as prepare hospitals to allocate supplies appropriately during the seasons.
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Affiliation(s)
- Lindsay Talemal
- Temple University, Lewis Katz School of Medicine, Philadelphia, PA, USA
| | | | - Brian V. Monahan
- Temple University Hospital, Department of Surgery, Philadelphia, PA, USA
| | - Daohai Yu
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Xiaoning Lu
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Juan Lucas Poggio
- Temple University Hospital, Department of Surgery, Philadelphia, PA, USA
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4
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Gastrointestinal Emergencies in the ICU. Crit Care Nurs Q 2023; 46:35-47. [DOI: 10.1097/cnq.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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5
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ARI D, ERDOĞAN Ç, YÜKSEL M, YEŞİL B, TURAN GÖKÇE D, BACAKSIZ F, KAYAÇETİN E. Using the Charlson comorbidity index as a prognostic factor of lower gastrointestinal system bleeding: the experience of a tertiary center. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1178982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Lesions in the gastroinestinal (GI) tract that are distal to the Treitz ligament are what cause the lower gastrointestinal bleeding (LGB) system. The purpose of this study was to investigate and compare the Charlson Comorbidity Index (CCI), mortality rates, length of hospital stays, need for intensive care, need for blood products, and surgical rates in patients with acute LGB.
Material and Method: Retrospective research was done on patients who had lower GI bleeding and had been seen in our gastroenterology clinic between 2015 and 2021. We looked into the impact of CCI on patients' follow-up after LGB.
Results: The mean age of the 210 patients who had lower GI bleeding was 67.70±13.67 years. For all of the patients, the median CCI value was 4.00. (2.00-5.00). While 16 study participants (group 1) passed away, 194 participants (group 2) were released from the hospital. The variance in the median CCI values between the two groups was statistically significant (p>0.001). The results of a multivariate logistic regression analysis revealed that CCI was a reliable predictor of mortality (p>0.001).
Conclusion: It was found that CCI was an accurate predictor of mortality. CCI ought to be regarded as a crucial factor in the treatment of patients who are bleeding from their lower gastrointestinal tract.
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Affiliation(s)
- Derya ARI
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Çağdaş ERDOĞAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Mahmut YÜKSEL
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | | | - Dilara TURAN GÖKÇE
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
| | - Ferhat BACAKSIZ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, DİYARBAKIR GAZİ YAŞARGİL SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Ertuğrul KAYAÇETİN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ
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6
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Mirza MH, Nzewi E. A rare case of small bowel arteriovenous malformation presenting as obscure gastrointestinal bleeding. J Surg Case Rep 2022; 2022:rjac278. [PMID: 35712612 PMCID: PMC9197310 DOI: 10.1093/jscr/rjac278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/19/2022] [Indexed: 11/14/2022] Open
Abstract
Lower gastrointestinal (GI) bleeding (LGIB) is a common surgical condition, which is frequently encountered in the emergency department. The most common origin of LGIB is from the colo-rectal region. However, in majority of cases where no apparent bleeding source is identified, small bowel is the area of concern. Here, we report an uncommon cause of small bowel bleeding that manifested as LGIB. A 63-year-old woman presented to emergency department with 2-day history of dark red rectal bleeding. The upper and lower GI endoscopy did not reveal any source of bleeding. Due to the ongoing blood loss, the hemoglobin level dropped significantly, necessitating blood transfusion. Subsequently, an emergency computed tomography mesenteric angiogram was performed, which showed extravasation of contrast into the distal ileum. She underwent a laparotomy where an arteriovenous malformation of the ileum was noticed. A limited ileal resection was performed, followed by primary anastomosis. She recovered well post-operatively with no further bleeding.
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Affiliation(s)
| | - Emeka Nzewi
- Department of Surgery , Cavan General Hospital, Cavan, Ireland
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7
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Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review with Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:2534975. [PMID: 34513750 PMCID: PMC8429023 DOI: 10.1155/2021/2534975] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/17/2021] [Indexed: 12/22/2022] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) has been reported to affect the gastrointestinal system with a variety of symptoms, including bleeding. The prevalence of bleeding in these patients remains unclear. The aim of this meta-analysis is to estimate the rate of gastrointestinal bleeding in COVID-19 patients and its association with mortality. MEDLINE and Embase were searched through December 20, 2020. Studies reporting COVID-19 patients with and without gastrointestinal bleeding were included. Estimated prevalence with 95% confidence intervals (CI) was pooled; heterogeneity was expressed as I 2. Metaregression analysis was performed to assess the impact of confounding covariates. Ten studies met the inclusion criteria and were included in the analysis. A total of 91887 COVID-19 patients were considered, of whom 534 reported gastrointestinal bleeding (0.6%) [409 (76.6%) upper and 121 (22.7%) lower gastrointestinal bleeding (UGIB and LGIB, resp.)]. The overall pooled gastrointestinal bleeding rate was 5% [95% CI 2-8], with high heterogeneity (I 2 99.2%); "small study effect" was observed using the Egger test (p=0.049). After removing two outlier studies, the pooled bleeding rate was 2% [95% CI 0-4], with high heterogeneity (I 2 99.2%), and no "small study effect" (p=0.257). The pooled UGIB rate was 1% (95% CI 0-3, I 2 98.6%, p=0.214), whereas the pooled LGIB rate was 1% (95% CI 0-2, I 2 64.7%, p=0.919). Metaregression analysis showed that overall estimates on gastrointestinal bleeding were affected by studies reporting different sources of bleeding. No significant association between gastrointestinal bleeding and mortality was found. In this meta-analysis of published studies, individuals with COVID-19 were found to be at risk for gastrointestinal bleeding, especially upper gastrointestinal bleeding.
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8
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Karuppasamy K, Kapoor BS, Fidelman N, Abujudeh H, Bartel TB, Caplin DM, Cash BD, Citron SJ, Farsad K, Gajjar AH, Guimaraes MS, Gupta A, Higgins M, Marin D, Patel PJ, Pietryga JA, Rochon PJ, Stadtlander KS, Suranyi PS, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update. J Am Coll Radiol 2021; 18:S139-S152. [PMID: 33958109 DOI: 10.1016/j.jacr.2021.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | | | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, Chair, Committee on Practice Parameters Interventional Radiology, American College of Radiology, Program Director, Interventional Radiology Residency, Zucker School of Medicine NSLIJ
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | | | - Khashayar Farsad
- Oregon Health and Science University, Portland, Oregon, Vice Chair, Department of Interventional Radiology, Oregon Health & Science University
| | - Aakash H Gajjar
- PRiSMA Proctology Surgical Medicine & Associates, Houston, Texas, American College of Surgeons
| | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Paul J Rochon
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | - Pal S Suranyi
- Medical University of South Carolina, Charleston, South Carolina
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9
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Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese. Dig Dis Sci 2021; 66:823-831. [PMID: 32285322 DOI: 10.1007/s10620-020-06253-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese. METHODS Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis. RESULTS There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 103/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively). CONCLUSIONS The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese.
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10
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Bhattacharjee HK, Nariampalli Karthyarth M, Suhani S, Goyal A, Das NR, Sharma R, Parshad R. Laparoscopic total mesorectal excision for rectal venous malformation: A case report with a brief literature review. Asian J Endosc Surg 2021; 14:85-89. [PMID: 32548901 DOI: 10.1111/ases.12808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
Abstract
Rectal vascular malformation is a rare disease on which few reports have been published. Here, we report the case of a 38-year-old woman who presented with severe weakness, dyspnea, and recurrent episodes of rectal bleeding. Her colonoscopy showed an extensive pigmented lesion in the lower rectum. CT angiography showed diffuse circumferential wall thickening of the rectum, perirectal fat stranding, tiny round foci of calcification, and no arterial feeders. Multiphasic MRI confirmed the diagnosis. The patient underwent a total mesorectal excision with hand-sewn coloanal anastomosis. The venous malformation was confined to the mesorectal tissue. The avascular plane between the ectodermal and mesodermal tissue was well maintained. Blood loss was 200 mL. The patient has had no recurrence of disease in the 18 months since surgery. Although total mesorectal excision is described for rectal cancer, it may be indicated for benign disease like rectal vascular malformation to achieve complete removal of the disease and to minimize intraoperative blood loss.
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Affiliation(s)
- Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | | | - Suhani Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radio-Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar R Das
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radio-Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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11
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Yi WS, Garg G, Sava JA. Localization and Definitive Control of Lower Gastrointestinal Bleeding with Angiography and Embolization. Am Surg 2020. [DOI: 10.1177/000313481307900426] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angiography has long been a mainstay of lower gastrointestinal bleeding localization. More recently, angioembolism has been used therapeutically for bleeding control, but there are limited data on its efficacy. This study was designed to evaluate the efficacy of angiography and embolization for localizing and treating lower gastrointestinal bleeding as well evaluate the occurrence of bowel ischemia after embolization. This study is a retrospective descriptive review of all patients undergoing mesenteric angiography at a tertiary hospital over an eight-year period. Clinical data were recorded including patient demographics, causes of bleeding, procedures, and outcomes. Patients were excluded if the cause of bleeding was upper gastrointestinal bleeding or the medical record was missing data. Localization and definitive control of bleeding was the primary end point. One hundred fifty-nine angiograms were performed on 152 patients. Mean age was 72 years. Angiographic localization was successful in 23.7 per cent of patients. Although embolization after angiographic localization achieved definitive control of bleeding in 50 per cent of patients, the success rate was only 8.6 per cent of all patients who had angiography. One patient developed postembolization ischemia requiring laparotomy. Angiographic localization of lower gastrointestinal bleeding is successful in only 23.7 per cent of patients. Definitive hemostasis through embolization was successful in only 8.6 per cent of patients who underwent angiography for lower gastrointestinal bleeding.
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Affiliation(s)
| | - Gaurav Garg
- From Washington Hospital Center, Washington, DC
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12
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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13
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Gastrointestinal Air Motion Artifact Which Can Be Mistaken for Active Gastrointestinal Bleeding in Multidetector Computed Tomography: Phantom and Clinical Study. J Comput Assist Tomogr 2020; 44:145-152. [PMID: 31939896 DOI: 10.1097/rct.0000000000000972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We investigated the computed tomographic characteristics of gastrointestinal air motion artifact (GIAMA), which can be misinterpreted as active gastrointestinal bleeding. METHODS We simulated GIAMA using 3 types of air-ball phantoms (air-ball in water, air-ball in oil, air-water-ball in oil) and a bovine intestine in oil phantom. We also performed a retrospective clinical review of precontrast abdominal computed tomography images of 76 patients to investigate the frequency, location, shape, and maximum density of hyperdense GIAMA. RESULTS In phantom studies, air motion artifacts appeared as dark and bright streak artifacts at the borders of a moving air-ball and water or oil. In the clinical study, hyperdense GIAMA was visualized in 60 (79.0%) of 76 patients. The small intestine was most commonly affected (46.4%), and the intramural type had the highest frequency (58.0%). CONCLUSION Knowing the radiologic features of GIAMA can assists radiologists in identifying active gastrointestinal bleeding sites accurately.
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Albadawi H, Altun I, Hu J, Zhang Z, Panda A, Kim H, Khademhosseini A, Oklu R. Nanocomposite Hydrogel with Tantalum Microparticles for Rapid Endovascular Hemostasis. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 8:2003327. [PMID: 33437588 PMCID: PMC7788497 DOI: 10.1002/advs.202003327] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Indexed: 05/09/2023]
Abstract
Endovascular embolization to treat vascular hemorrhage involves pushing coil-shaped metal wires into the artery repeatedly until they are densely packed to slow the blood flow and clot. However, coil embolization is associated with high rebleeding rates, unpredictable economics and, most importantly, they rely on the patient's ability to make a clot. These issues are exacerbated when the patient is anticoagulated or coagulopathic. A novel bioengineered tantalum-loaded nanocomposite hydrogel for gel embolic material (Ta-GEM) that can be rapidly delivered using clinical catheters for instant hemostasis regardless of the coagulopathic state is reported. Ta-GEM formulation is visible by most of the clinically available imaging modalities including ultrasound, computed tomography, magnetic resonance imaging, and fluoroscopy without significant artifact. In addition, Ta-GEM can be retrieved, allowing temporary vascular occlusion, and it can be used to rescue cases of failed coil embolization. Ta-GEM occlusion of first-order arteries such as the renal artery and iliac artery in a swine model is found to be safe and durable; by 28 days, 75% of the injected Ta-GEM in the arterial lumen is replaced by dense connective tissue. Altogether, this study demonstrates that Ta-GEM has many advantages over the current technologies and has potential applications in clinical practice.
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Affiliation(s)
- Hassan Albadawi
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
| | - Izzet Altun
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
| | - Jingjie Hu
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
| | - Zefu Zhang
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
| | - Anshuman Panda
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
| | - Han‐Jun Kim
- Terasaki Institute for Biomedical InnovationLos AngelesCA90024USA
| | | | - Rahmi Oklu
- Minimally Invasive Therapeutics LaboratoryDepartment of Vascular and Interventional RadiologyMayo ClinicPhoenixAZ85054USA
- Terasaki Institute for Biomedical InnovationLos AngelesCA90024USA
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15
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Jawaid S, Marya NB, Hicks M, Marshall C, Bhattacharya K, Cave D. Prospective cost analysis of early video capsule endoscopy versus standard of care in non-hematemesis gastrointestinal bleeding: a non-inferiority study. J Med Econ 2020; 23:10-16. [PMID: 31578113 DOI: 10.1080/13696998.2019.1675671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and aim: A non-inferiority cost analysis was performed to assess if the early capsule approach would incur higher costs than the standard of care approach in patients presenting with non-hematemesis gastrointestinal bleeding.Methods: A prospective non-inferiority cost analysis was performed on patients receiving either an early video capsule as the first diagnostic procedure or an endoscopic procedure as determined by gastroenterology staff that were not involved in the study. Primary outcome was total direct costs incurred in both groups.Results: Forty-five patients and 42 patients were enrolled into the early capsule and standard of care arms, respectively. There was no difference in total direct cost per inpatient case in both groups ($7,362 vs $7,148, p = 0.77 [CI = -2,285-2,315, equivalent margin = -$3,100]). Localization of a bleeding source after the first diagnostic procedure was identified more frequently in the early capsule group (69.2% vs 27.9%, p = 0.0003). If patients were discharged after their last non-diagnostic evaluation, then length of stay could be decreased by 50% in both groups (58.5 to 31.6 h, p = 0.02 in the early capsule group and 69.4 to 39.2 h in the standard of care group p = 0.001). Projections indicate the fastest a patient with non-diagnostic evaluations could be discharged is 0.88 days in the early capsule group vs 1.63 days in the standard of care group (p = 0.0005).Discussion: In patients with non-hematemesis bleeding, video capsule endoscopy may be a more efficient diagnostic approach than the standard of care approach, since it detects bleeding significantly more often without an increase in healthcare costs.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Neil B Marya
- Division of Gastroenterology, Department of Internal Medicine, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Michelle Hicks
- Department of Financial Reporting, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Christopher Marshall
- Division of Gastroenterology, Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kanishka Bhattacharya
- Division of Gastroenterology, Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Cave
- Division of Gastroenterology, Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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WITHDRAWN: Etiology of lower gastrointestinal bleeding in Sulaimani governorate-Kurdistan region-Iraq-retrospective cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Jiménez CE, Randial L, Quiroga F. Manejo endovascular de la hemorragia digestiva, experiencia del Hospital Universitario Clínica San Rafael. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La hemorragia digestiva ocasiona el 2 % de las hospitalizaciones; se clasifica en alta o baja, la primera se presenta en el 80 % de casos. Después de la estabilización hemodinámica, se determinan la causa y el tratamiento mediante la endoscopia; no obstante, esta falla en 10 a 20 % de los casos, y del 15 al 20 % requieren cirugía mayor, con una mortalidad de más del 40 %. El tratamiento para la hemorragia digestiva mediante la formación de émbolos de los vasos mesentéricos, es una conducta bien establecida, produce buenos resultados, evita la cirugía y disminuye la morbimortalidad. Objetivos. Determinar la indicación y el éxito del tratamiento endovascular para la hemorragia digestiva en nuestra institución. Materiales y métodos. estudio retrospectivo y descriptivo, se incluyeron 10 pacientes que requirieron la urgente formación de émbolos por falla o imposibilidad del manejo endoscópico, y que presentaban gran riesgo quirúrgico y anestésico con la técnica abierta. Se evaluaron la causa de la hemorragia, la arteria comprometida, los hallazgos angiográficos, la hemoglobina antes y después de la formación de los émbolos, la reincidencia de la hemorragia, las complicaciones, la necesidad de intervención quirúrgica, la eficacia del procedimiento y la mortalidad a 30 días. Resultados. Todos los pacientes se intervinieron por vía endovascular, para la oclusión selectiva de las arterias comprometidas. La hemorragia se controló en todos ellos. Se presentaron dos muertes tempranas (<30 días) no asociadas con el procedimiento. No hubo complicaciones secundarias a la formación de los émbolos o al acceso percutáneo y, tampoco, necesidad de cirugías mayores posteriores para controlar la hemorragia. Conclusión. Los métodos endovasculares para controlar la hemorragia digestiva son eficaces, no se acompañan de complicaciones, y disminuyen la morbimortalidad y la necesidad de cirugías mayores. Se requieren estudios con mayor número de pacientes para lograr un mayor grado de certeza.
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18
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Ahmed HO, Ahmed SH. Etiology of lower gastrointestinal bleeding in Sulaimani governorate-Kurdistan region-Iraq- retrospective cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Barium Enema for Treatment for Diverticular Bleeding. ACG Case Rep J 2018; 5:e71. [PMID: 30280111 PMCID: PMC6160609 DOI: 10.14309/crj.2018.71] [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: 10/08/2017] [Accepted: 07/17/2018] [Indexed: 11/18/2022] Open
Abstract
Diverticula of the colon are the most common cause of lower gastrointestinal bleeding in adults. In cases of persistent loss of blood or severe acute hemorrhage, treatment is required. However, if these modern intervention techniques are inadequate, surgical resection of the colon may be required. Diverticular bleeding often concerns patients with a high surgical risk, so a less invasive treatment is preferable. A forgotten but excellent treatment, namely that of the obsolete barium contrast enema to staunch diverticular bleeding, is the focus of this case series. We describe 3 patients who were successfully treated with barium enema.
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Lee HH, Oh JS, Park JM, Chun HJ, Kim TH, Cheung DY, Lee BI, Cho YS, Choi MG. Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography. Scand J Gastroenterol 2018; 53:1089-1096. [PMID: 30354855 DOI: 10.1080/00365521.2018.1501512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Colonoscopy is preferred for treatment of lower gastrointestinal bleeding (LGIB). However, several conditions such as poor bowel preparation can cause endoscopic failure, leading to surgery or transcatheter therapy as alternative options. We aimed to assess the efficacy and safety of transcatheter arterial embolization (TAE) for LGIB in patients with endoscopic failure. METHODS Between January 2005 and June 2015, 93 consecutive patients with acute LGIB underwent visceral angiography at three academic hospitals. Among them, a total of 52 patients were treated with TAE for LGIB and analyzed. Technical success, complications and 30-day rebleeding and mortality after TAE were investigated retrospectively in patients with and without localization of LGIB. RESULTS Technical success of TAE was achieved in all patients. After TAE, 30-day rebleeding and mortality rate were 27% (14/52) and 29% (15/52), respectively. TAE was performed without localizing bleeding site in 32 of 52 patients (62%). Between patients with and without localized bleeding site, there were no significant differences in 30-day rebleeding rate (25% vs. 28%) and mortality rate (15% vs. 38%). Causes of death were mostly unrelated to bleeding. Only two cases of bowel infarction occurred after TAE in patients without bleeding site localization. Rebleeding could be predicted if the patient received more than six units of packed red blood cell transfusion before TAE in multivariate analysis. CONCLUSIONS TAE can be an effective treatment for LGIB even without localizing bleeding site.
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Affiliation(s)
- Han Hee Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Jung Suk Oh
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Jae Myung Park
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Ho Jong Chun
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Tae Ho Kim
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Dae Young Cheung
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Bo-In Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Young-Seok Cho
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Myung-Gyu Choi
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
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Banister T, Spiking J, Ayaru L. Discharge of patients with an acute upper gastrointestinal bleed from the emergency department using an extended Glasgow-Blatchford Score. BMJ Open Gastroenterol 2018; 5:e000225. [PMID: 30233807 PMCID: PMC6135483 DOI: 10.1136/bmjgast-2018-000225] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To use an extended Glasgow-Blatchford Score (GBS) cut-off of ≤1 to aid discharge of patients presenting with acute upper gastrointestinal bleeding (AUGIB) from emergency departments. BACKGROUND The GBS accurately predicts the need for intervention and death in AUGIB, and a cut-off of 0 is recommended to identify patients for discharge without endoscopy. However, this cut-off is limited by identifying a low percentage of low-risk patients. Extension of the cut-off to ≤1 or ≤2 has been proposed to increase this proportion, but there is controversy as to the optimal cut-off and little data on performance in routine clinical practice. METHODS Dual-centre study in which patients with AUGIB and GBS ≤1 were discharged from the emergency department without endoscopy unless there was another reason for admission. Retrospective analysis of associated adverse outcome defined as a 30-day combined endpoint of blood transfusion, intervention or death. RESULTS 569 patients presented with AUGIB from 2015 to 2018. 146 (25.7%) had a GBS ≤1 (70, GBS=0; 76, GBS=1). Of these, 103 (70.5%) were managed as outpatients, and none had an adverse outcome. GBS ≤1 had a negative predictive value=100% and the GBS had an area under receiver operator characteristic (AUROC)=0.89 (95% CI 0.86 to 0.91) in predicting adverse outcomes. In 2008-2009, prior to risk scoring (n=432), 6.5% of patients presenting with AUGIB were discharged safely from the emergency department in comparison with 18.1% (p<0.001) in this cohort. A GBS cut-off ≤2 was associated with an adverse outcome in 8% of cases. CONCLUSION GBS of ≤1 is the optimal cut-off for the discharge of patients with an AUGIB from the emergency department.
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Affiliation(s)
- Thomas Banister
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
| | - Josesph Spiking
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
| | - Lakshmana Ayaru
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
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22
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Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation. Gastrointest Endosc Clin N Am 2018; 28:379-390. [PMID: 29933782 DOI: 10.1016/j.giec.2018.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.
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23
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Mohammed Ilyas MI, Szilagy EJ. Management of Diverticular Bleeding: Evaluation, Stabilization, Intervention, and Recurrence of Bleeding and Indications for Resection after Control of Bleeding. Clin Colon Rectal Surg 2018; 31:243-250. [PMID: 29942215 DOI: 10.1055/s-0037-1607963] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.
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Affiliation(s)
| | - Eric J Szilagy
- Department of Colon and Rectal Surgery, West Bloomfield Hospital, Henry Ford Health System, Detroit, Michigan
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24
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Khodadoostan M, Shavakhi A, Padidarnia R, Shavakhi A, Ahmadian M. Full colonoscopy in patients under 50 years old with lower gastrointestinal bleeding. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2018; 23:45. [PMID: 29937907 PMCID: PMC5996571 DOI: 10.4103/jrms.jrms_531_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 08/01/2017] [Accepted: 03/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Lower gastrointestinal (GI) bleeding is a common clinical problem in young patients. The management of this disease in patients is challenging. The aim of this study is to compare sigmoidoscopy with full colonoscopy in these patients. MATERIALS AND METHODS In this cross-sectional study, 120 eligible patients under 50 years old with acute rectal bleeding were enrolled. After cleaning the colon, initially the patients underwent sigmoidoscopy. Pain, the comfort of the test by physician and patient, duration of the procedure, and pathologic findings were recorded. The procedure continued until the splenic flexure passed in the ileocecal valve, and this stage was considered as proximal colonoscopy. Pain, easy performance by physician and the patient, duration of procedure, and pathologic findings were recorded in this stage too. The variables in the two stages were compared with each other. RESULTS There were 66 women (55%) and 54 men (45%) and the mean of age was 41 ± 7.9 years. Proximal colonoscopy from splenic flexure to reach cecum was relatively easier for the physician and the patient than sigmoidoscopy (P < 0.001). Furthermore, the time spent to carry out proximal colonoscopy was less than the time taken for sigmoidoscopy (P < 0.001). Pathologic findings recorded in full colonoscopy were more than sigmoidoscopy (P < 0.001). Therefore, full colonoscopy that includes sigmoidoscopy and proximal colonoscopy is relatively easier than sigmoidoscopy for patients, and it also proves more advantageous than sigmoidoscopy for physicians to perform in Iranian patients because of more tortuous and elongated sigmoid colon in these patients. CONCLUSION It is advised to perform full colonoscopy than sigmoidoscopy in young patients with lower GI bleeding.
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Affiliation(s)
- Mahsa Khodadoostan
- Department of Gastroenterology and Hepatology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Shavakhi
- Department of Gastroenterology and Hepatology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reihaneh Padidarnia
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Shavakhi
- Department of Internal Medicine, Shahrekord University of Medical, Shahrekord, Iran
| | - Mehdi Ahmadian
- Department of Gastroenterology and Hepatology, Isfahan University of Medical Sciences, Isfahan, Iran
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25
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Hágendorn R, Farkas N, Vincze Á, Gyöngyi Z, Csupor D, Bajor J, Erőss B, Csécsei P, Vasas A, Szakács Z, Szapáry L, Hegyi P, Mikó A. Chronic kidney disease severely deteriorates the outcome of gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2017; 23:8415-8425. [PMID: 29308001 PMCID: PMC5743512 DOI: 10.3748/wjg.v23.i47.8415] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/23/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To understand the influence of chronic kidney disease (CKD) on mortality, need for transfusion and rebleeding in gastrointestinal (GI) bleeding patients. METHODS A systematic search was conducted in three databases for studies on GI bleeding patients with CKD or end-stage renal disease (ESRD) with data on outcomes of mortality, transfusion requirement, rebleeding rate and length of hospitalization (LOH). Calculations were performed with Comprehensive Meta-Analysis software using the random effects model. Heterogeneity was tested by using Cochrane's Q and I2 statistics. Mean difference (MD) and OR (odds ratio) were calculated. RESULTS 1063 articles (EMBASE: 589; PubMed: 459; Cochrane: 15) were found in total. 5 retrospective articles and 1 prospective study were available for analysis. These 6 articles contained data on 406035 patients, of whom 51315 had impaired renal function. The analysis showed a higher mortality in the CKD group (OR = 1.786, 95%CI: 1.689-1.888, P < 0.001) and the ESRD group (OR = 2.530, 95%CI: 1.386-4.616, P = 0.002), and a rebleeding rate (OR = 2.510, 95%CI: 1.521-4.144, P < 0.001) in patients with impaired renal function. CKD patients required more unit red blood cell transfusion (MD = 1.863, 95%CI: 0.812-2.915, P < 0.001) and spent more time in hospital (MD = 13.245, 95%CI: 6.886-19.623, P < 0.001) than the controls. CONCLUSION ESRD increases mortality, need for transfusion, rebleeding rate and LOH among GI bleeding patients. Prospective patient registries and observational clinical trials are crucially needed.
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Affiliation(s)
- Roland Hágendorn
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs 7624, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, University of Pécs, Pécs 7624, Hungary
| | - Dezső Csupor
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Judit Bajor
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs 7624, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Péter Csécsei
- Department of Neurology, University of Pécs, Pécs 7623, Hungary
| | - Andrea Vasas
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - László Szapáry
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, University of Pécs, Pécs 7624, Hungary
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Hundeshagen G, Kramer GC, Ribeiro NM, Salter M, Koutrouvelis AK, Li H, Solanki D, Indrikovs A, Seeton R, Henkel SN, Kinsky MP. Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage. Crit Care Med 2017; 45:e1068-e1074. [PMID: 28682837 PMCID: PMC5600681 DOI: 10.1097/ccm.0000000000002593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation. DESIGN Experimental human hemorrhage and resuscitation. SETTING Clinical research laboratory. SUBJECTS Healthy volunteers. INTERVENTIONS Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency. MEASUREMENTS AND MAIN RESULTS All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: -0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration. CONCLUSIONS We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - George C. Kramer
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Nicole M. Ribeiro
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael Salter
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Aristides K. Koutrouvelis
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Husong Li
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Daneshvari Solanki
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Alexander Indrikovs
- Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Hofstra Northwell School of Medicine, Department of Pathology, 500 Hofstra Blvd, Hempstead, NY 11549
| | - Roger Seeton
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Sheryl N Henkel
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael P Kinsky
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
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Ng KS, Nassar N, Soares D, Stewart P, Gladman MA. Acute lower gastrointestinal haemorrhage: outcomes and risk factors for intervention in 949 emergency cases. Int J Colorectal Dis 2017; 32:1327-1335. [PMID: 28712008 DOI: 10.1007/s00384-017-2844-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Outcomes of acute lower gastrointestinal haemorrhage (ALGIH) are mostly derived from studies performed in the sub-acute/elective rather than the emergency department (ED) setting. The aims of this study were to determine the incidence and outcomes of patients presenting to a tertiary hospital ED with ALGIH and to identify associated clinicopathological risk factors. METHOD A retrospective observational cohort study of consecutive patients presenting with ALGIH to a tertiary hospital ED was performed. Primary outcome measures included mortality and hospital (including high dependency [HDU]) admission. Secondary outcome measures included rates of (i) blood transfusion, (ii) radiological/endoscopic investigation(s) and (iii) therapeutic intervention. RESULTS ALGIH accounted for 949 (512 M, mean age 62.3 years) of 130,262 (0.73%) ED presentations, of which 285 patients (30.1%) were on anti-platelet/coagulant therapy. There were five deaths (0.5%). Hospital admission was required in 498 patients (52.5%), of which 19 (3.8%) required HDU monitoring. Hospital admission was twice as likely in males and four times more likely in patients >75 years old and those taking multiple anti-platelet/coagulant therapy (P < 0.05). Blood product transfusion was required in 172 patients (34.5%), specialist investigations in 230 (46.2%) and therapeutic intervention in 51 (10.2%) (surgery in 24 [4.8%]; endoscopic haemostasis in 20 [4.0%] and angiographic embolisation in 9 [1.8%] patients). CONCLUSION ALGIH accounts for 1% of all ED presentations, with half requiring hospital admission. Mortality and surgical intervention rates are low and although most patients can be managed supportively, access to interventional radiology/endoscopy is important.
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Affiliation(s)
- Kheng-Seong Ng
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Deanne Soares
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Patrick Stewart
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Marc A Gladman
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia. .,Adelaide Medical School, Faculty of Health & Medical Sciences, The University of Adelaide, Medical School South, Frome Road, Adelaide, 5005, Australia.
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Abstract
Many colorectal carcinomas will present emergently with issues such as obstruction, perforation, and bleeding. Emergency surgery is associated with poor short- and long-term outcomes. For abnormality localizing to the colon proximal to the splenic flexure, surgical management with hemicolectomy is often a safe and appropriate approach. Obstructions are more common in the distal colon, however, where there is an evolving spectrum of surgical and nonsurgical options, most notably by the development of endoluminal stents. Perforation and bleeding are managed similarly to benign causes, as malignancy may be only part of a differential diagnosis at the time of an operation.
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Ruhnke GW, Manning WG, Rubin DT, Meltzer DO. The Drivers of Discretionary Utilization: Clinical History Versus Physician Supply. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:703-708. [PMID: 28441679 PMCID: PMC5407298 DOI: 10.1097/acm.0000000000001500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB). METHOD Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression. RESULTS EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54). CONCLUSIONS Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.
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Affiliation(s)
- Gregory W Ruhnke
- G.W. Ruhnke is assistant professor, Section of Hospital Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois.W.G. Manning was professor, Department of Health Studies, and professor, Public Policy Studies and Public Health Sciences, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois.D.T. Rubin is professor of medicine and section chief, Gastroenterology, Hepatology and Nutrition, Department of Medicine, Pritzker School of Medicine, University of Chicago Medicine, Chicago, Illinois.D.O. Meltzer is section chief, Hospital Medicine, Fanny L. Pritzker Professor of Medicine, and director, Center for Health and the Social Sciences, Pritzker School of Medicine, and professor, Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois
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Celik M. Efficacy of early endoscopy and colonoscopy in very elderly patients with gastrointestinal bleeding. Pak J Med Sci 2017; 33:187-190. [PMID: 28367197 PMCID: PMC5368306 DOI: 10.12669/pjms.331.11616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We aimed to determine the efficacy and safety of early (within the first 24 hour from application) endoscopy and colonoscopy in very elderly patients with GIS bleeding. METHODS In this study, 95 patients were included who underwent early endoscopy with the pre-diagnosis of upper GIS bleeding or endoscopy-colonoscopy with the pre-diagnosis of lower GIS bleeding between 2012 and 2016. Endoscopy and colonoscopy procedures were compared in terms of the development of complications, tolerance of procedure, detection of bleeding site, and rate of therapeutic interventions performed for bleeding. In addition, the adequacy of colonoscopy preparation was evaluated. RESULTS There was no significant difference between endoscopy and colonoscopy on procedural complication (2.1% vs 2.8%) and tolerance rates (81% vs 74.2), (p>0.05). The bleeding site was detected during endoscopy in 34(56.6%) patients, and an endoscopic intervention was required for 15(25%) of these patients. The bleeding site was detected during colonoscopy in 12(34.3%) patients, and an endoscopic intervention was performed for two (5.7%) patients (p<0.05). In addition, the colonoscopy procedure was suboptimal in 26 of 35 patients (74.2%) because of poor preparations. CONCLUSION Early endoscopy and colonoscopy are safe and well tolerated in very elderly patients with GIS bleeding. Upper GIS endoscopy in this patient population enables the detection of the bleeding site and an endoscopic intervention for the bleeding. However, colonoscopy is insufficient for detecting bleeding sites, and colonoscopic treatment of bleeding sites is difficult because of poor or no preparation in this patient population.
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Affiliation(s)
- Mustafa Celik
- Mustafa Celik, Department of Gastroenterology, Pamukkale University Training and Research Hospital, Denizli; Turkey
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Clerc D, Grass F, Schäfer M, Denys A, Demartines N, Hübner M. Lower gastrointestinal bleeding-Computed Tomographic Angiography, Colonoscopy or both? World J Emerg Surg 2017; 12:1. [PMID: 28070213 PMCID: PMC5215140 DOI: 10.1186/s13017-016-0112-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 12/14/2016] [Indexed: 01/14/2023] Open
Abstract
Background Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control. Methods Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control. Results Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery. Conclusions Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.
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Affiliation(s)
- Daniel Clerc
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Fabian Grass
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alban Denys
- Department of Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Accuracy of 99mTechnetium-labeled RBC Scintigraphy and MDCT With Gastrointestinal Bleed Protocol for Detection and Localization of Source of Acute Lower Gastrointestinal Bleeding. J Clin Gastroenterol 2016; 50:754-60. [PMID: 26646804 DOI: 10.1097/mcg.0000000000000462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute lower gastrointestinal bleeding (LGIB) is a major cause of morbidity and mortality. Multidetector row computed tomography (CT) with gastrointestinal (GI) bleed protocol is a novel diagnostic technique for detecting and localizing LGIB. Being rapid and noninvasive, it may be useful as a first-line modality to investigate cases of acute LGIB. GOALS To assess and compare diagnostic accuracy of (99M)Technetium (Tc)-labeled red blood cell (RBC) scintigraphy and multidetector row CT with GI bleed protocol for detection and localization of source of acute LGIB. STUDY Requirement of informed consent was waived for this retrospective study. Seventy-six patients had undergone either RBC scintigraphy, CT with GI bleed protocol, or both, followed by conventional angiography for evaluation of acute persistent LGIB between January 2010 and February 2014 at our institution. Accuracy of both modalities was assessed using conventional angiography as reference standard and compared using the 2-tailed, Fisher exact test. A P-value of <0.05 was considered statistically significant. RESULTS Fifty-one, 20, and 5 patients had undergone RBC scintigraphy only, CT with GI bleed protocol only, and both modalities, respectively. Fourteen of 25 patients in the CT group had angiographic evidence of active bleeding as compared with 32 of 56 patients in the scintigraphy group. CT with GI bleed protocol had higher accuracy (96%) than (99M)Tc-labeled RBC scintigraphy (55.4%, P<0.001). CONCLUSIONS CT with GI bleed protocol was more accurate in detecting and localizing the source of acute LGIB as compared with (99M)Tc-labeled RBC scintigraphy.
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Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics. Dig Dis Sci 2016; 61:2732-40. [PMID: 27286877 PMCID: PMC5602600 DOI: 10.1007/s10620-016-4198-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 05/10/2016] [Indexed: 12/09/2022]
Abstract
BACKGROUND The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. METHODS In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. RESULTS Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01-5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively. CONCLUSIONS Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.
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Malignant Polyp in a Colonic Diverticulum: a Rare Cause of Diverticular Hemorrhage. J Gastrointest Cancer 2016; 43 Suppl 1:S104-7. [PMID: 21952946 DOI: 10.1007/s12029-011-9327-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy. AJR Am J Roentgenol 2016; 207:578-84. [PMID: 27303989 DOI: 10.2214/ajr.15.15714] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Lower gastrointestinal hemorrhage is a common cause of hospitalization and has substantial associated morbidity and financial cost. CT angiography (CTA) is emerging as an alternative to (99m)Tc-labeled RBC scintigraphy (RBC scintigraphy) for the localization of acute lower gastrointestinal bleeding (LGIB); however, data on comparative efficacy are scant. The aim of this study was to assess the utility of CTA compared with RBC scintigraphy in the overall evaluation and management of acute LGIB. MATERIALS AND METHODS We retrospectively reviewed images from all CTA examinations performed for suspected acute LGIB at our tertiary care hospital from January 2010 through November 2011. The comparison group was determined by retrospective review of twice the number of RBC scintigraphic scans consecutively obtained from June 2008 to November 2011 for the same indication. All CTA and RBC scintigraphic scans were reviewed for accurate localization of the site and source of suspected active LGIB. RESULTS In total, 45 CTA and 90 RBC scintigraphic examinations were performed during the study period. Seventeen (38%) CTA scans showed active gastrointestinal bleeding compared with 34 (38%) RBC scintigraphic scans (p = 1.000). However, the site of bleeding was accurately localized on 24 (53%) CTA scans. This proportion was significantly greater than the proportion localized on RBC scintigraphic scans (27 [30%]) (p = 0.008). There were no significant differences between the two groups in average hospital length of stay, blood transfusion requirement, incidence of acute kidney injury, or in-hospital mortality. CONCLUSION Both CTA and RBC scintigraphy can be used to identify active bleeding in 38% of cases. However, the site of bleeding is localized with CTA in a significantly higher proportion of studies.
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Abstract
Lower gastrointestinal bleeding (LGIB) is a frequent reason for hospitalization especially in the elderly. Patients with LGIB are frequently admitted to the intensive care unit and may require transfusion of packed red blood cells and other blood products especially in the setting of coagulopathy. Colonoscopy is often performed to localize the source of bleeding and to provide therapeutic measures. LGIB may present as an acute life-threatening event or as a chronic insidious condition manifesting as iron deficiency anemia and positivity for fecal occult blood. This article discusses the presentation, diagnosis, and management of LGIB with a focus on conditions that present with acute blood loss.
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Affiliation(s)
- Emad Qayed
- Grady Memorial Hospital, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, USA
| | - Gaurav Dagar
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53188, USA
| | - Rahul S Nanchal
- Critical Care Fellowship Program, Medical Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Chong V, Hill AG, MacCormick AD. Accurate triage of lower gastrointestinal bleed (LGIB) - A cohort study. Int J Surg 2015; 25:19-23. [PMID: 26612527 DOI: 10.1016/j.ijsu.2015.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/17/2015] [Accepted: 11/01/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Acute lower gastrointestinal bleeding (LGIB) is a common acute presenting complaint to hospital. Unlike upper gastrointestinal bleeding, the diagnostic and therapeutic approach is not well-standardised. Intensive monitoring and urgent interventions are essential for patients with severe LGIB. The aim of this study is to investigate factors that predict severe LGIB and develop a clinical predictor tool to accurately triage LGIB in the emergency department of a busy metropolitan teaching hospital. METHODS We retrospectively identified all adult patients who presented to Middlemore Hospital Emergency Department with LGIB over a one year period. We recorded demographic variables, Charlson Co-morbidities Index, use of anticoagulation, examination findings, vital signs on arrival, laboratory test results, treatment plans and further investigations results. We then identified a subgroup of patients who suffered severe LGIB. RESULTS A total of 668 patients presented with an initial triage diagnosis of LGIB. 83 of these patients (20%) developed severe LGIB. Binary logistic regression analysis identified four independent risk factors for severe LGIB: use of aspirin, history of collapse, haemoglobin on presentation of less than 100 mg/dl and albumin of less than 38 g/l. CONCLUSIONS We have developed a clinical prediction tool for severe LGIB in our population with a negative predictive value (NPV) of 88% and a positive predictive value (PPV) of 44% respectively. We aim to validate the clinical prediction tool in a further cohort to ensure stability of the multivariate model.
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Affiliation(s)
- Vincent Chong
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand.
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Hanna RF, Browne WF, Khanna LG, Prince MR, Hecht EM. Gadofosveset trisodium–enhanced MR angiography for detection of lower gastrointestinal bleeding. Clin Imaging 2015; 39:1052-5. [PMID: 26355018 DOI: 10.1016/j.clinimag.2015.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/16/2015] [Accepted: 07/30/2015] [Indexed: 12/24/2022]
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Frazee EN, Leedahl DD, Kashani KB. Key Controversies in Colloid and Crystalloid Fluid Utilization. Hosp Pharm 2015; 50:446-53. [PMID: 26405334 DOI: 10.1310/hpj5006-446] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades - the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.
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Affiliation(s)
- Erin N Frazee
- Hospital Pharmacy Services, Mayo Clinic , Rochester, Minnesota
| | - David D Leedahl
- Hospital Pharmacy Services, Sanford Health , Fargo, North Dakota
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota ; Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota
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Dar IA, Dar WR, Khan MA, Kasana BA, Sofi NU, Hussain M, Arshad F, Wani MA, Latief M, Sodhi JS. Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a Tertiary Care Hospital in India: A retro-prospective study. JOURNAL OF DIGESTIVE ENDOSCOPY 2015. [DOI: 10.4103/0976-5042.165697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Introduction: Lower gastrointestinal bleeding (LGIB) is one of the leading causes for hospital admissions in gastroenterology wards all over the world. Patients usually present with hematochezia or bloody diarrhea. Colonoscopy is usually the initial diagnostic intervention followed by other more sophisticated tests. Bleeding may stop spontaneously, but evaluation is important because patients may harbor a sinister lesion like cancer. Aim of the Study: To determine the various etiologies, clinical presentations, a diagnostic test used and treatments received by LGIB patients admitted in our department. Materials and Methods: A total of 300 cases were studied which included 180 retrospective cases and 120 prospective cases. For retrospective cases, all the information was obtained by analyzing their case records while as prospective patients were managed as per a predefined protocol and details of various investigations and treatments documented. Results: Most commonly affected was elderly population (>60 years), constituting 40% (120/300) of studied population. Males constituted 59% (177/300) and females 41% (123/300). The most common clinical presentation of LGIB in our patients was hematochezia (63.6%, 191/300). Growth/polyp was the most common finding on colonoscopic examination seen in 29.3% (n = 88) patients. Inflammatory lesions were seen in 77 out of 239 (25.7%) patients. Wireless capsule endoscopy was positive in 13 out of 24 patients (54%). Computed tomography (CT) enterography showed positive results in 6 out of 25 (24%) cases. Red blood cell scan was done in seven patients while as CT angiography in in four patients. Therapeutic endoscopy was successful in 115 out of 239 patients with positive colonoscopy, polypectomy was the commonest procedure performed. Medical management was carried out in 34.6% patients. Surgical treatment was offered to 21% patients. Conclusion: Colonoscopy is the initial and most common investigation used in the evaluation of GI bleed. A polyp is the most common diagnosis while as polypectomy the most common therapeutic procedure.
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Affiliation(s)
- Imtiyaz Ahmad Dar
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Waseem Raja Dar
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Mushtaq Ahmad Khan
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Basharat Ahmad Kasana
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Najeeb Ullah Sofi
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Moomin Hussain
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Faheem Arshad
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Manzoor Ahmad Wani
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
| | - Muzamil Latief
- Department of Medicine, Oncology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir
| | - Jaswinder Singh Sodhi
- Department of Medicine, Gastroenterology Division, Shere Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India
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Ahmed O, Jilani D, Sheth S, Giger M, Funaki B. Long-term results of microcoil embolization for colonic haemorrhage: how common is rebleeding? Br J Radiol 2015; 88:20150203. [PMID: 25927678 DOI: 10.1259/bjr.20150203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the long-term results of patients undergoing transcatheter coil embolization for the treatment of acute colonic haemorrhage. METHODS Patients undergoing angiography for suspected colonic bleeding between January 2002 and December 2012 were reviewed (average age, 60 years; 38.4% male). Baseline, procedural and outcome parameters were recorded following the Society of Interventional Radiology guidelines. Primary outcome measures included early (<30 days) and delayed (>30 days) rebleeding events and adverse procedure-related complication. Average follow-up time was 996 days (median, 232 days; range, 30-3663 days). RESULTS One or multiple sites of bleeding were identified in 40 cases. Coil embolization was performed in 39 patients, 26 (66.7%, 26/39) of whom were treated successfully without technical/clinical failure (n = 12) or loss to follow-up (n = 1). Three patients (11.5%, 3/26) rebled in the early period within 30 days; one patient went on to hemicolectomy. Four patients (15.3%, 4/26) experienced delayed rebleeding after 30 days; two of whom also underwent hemicolectomy. No major complication occurred. One minor complication of short segment arterial dissection was seen in the clinical failure group. One case of asymptomatic ischaemia was identified on a patient undergoing pre-operative colonoscopy for elective bowel resection. No instances of ischaemic stricture were seen. All-cause mortality of successfully treated and all patients at 1 year was 31% (8/26) and 30% (12/40), respectively. CONCLUSION Transcatheter coil embolization is a durable treatment option with a technical and clinical success rate of 67% in the setting of acute colonic haemorrhage. A modest level of rebleeding was seen among successfully treated patients in both the early and delayed periods; in the majority of patients, embolization proved to be definitive therapy. ADVANCES IN KNOWLEDGE Transcatheter coil embolization is a durable and potentially definitive therapy in the management of acute colonic haemorrhage.
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Affiliation(s)
- O Ahmed
- Department of Radiology, University of Chicago Hospitals, Chicago, IL, USA
| | - D Jilani
- Department of Radiology, University of Chicago Hospitals, Chicago, IL, USA
| | - S Sheth
- Department of Radiology, University of Chicago Hospitals, Chicago, IL, USA
| | - M Giger
- Department of Radiology, University of Chicago Hospitals, Chicago, IL, USA
| | - B Funaki
- Department of Radiology, University of Chicago Hospitals, Chicago, IL, USA
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Nishimura N, Matsueda K, Hamaguchi K, Shimodate Y, Doi A, Mouri Y, Yamamoto H. Clinical features and endoscopic findings in patients with actively bleeding colonic angiodysplasia. Indian J Gastroenterol 2015; 34:73-6. [PMID: 25772855 DOI: 10.1007/s12664-015-0536-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/04/2015] [Indexed: 02/04/2023]
Abstract
Colonic angiodysplasia (AGD) is an important cause of lower gastrointestinal bleeding. However, most episodes of bleeding from colonic AGD stop spontaneously. To date, few data are available regarding the endoscopic findings of bleeding colonic AGD. In order to clarify the clinical features and endoscopic findings of actively bleeding colonic AGD, we conducted a retrospective study of patients treated with colonoscopy at our hospital. From November 2006 to March 2013 inclusive, 32,586 colonoscopies were performed at this hospital, among which 13 patients with bleeding colonic AGD were enrolled in the current study. The mean age was 84 years (range: 69-90 years). All patients had chronic heart disease and were currently using anticoagulant and/or antiplatelet drugs. Sites of bleeding AGD were localized in the left colon in two patients (15 %) and in the right colon in the remaining patients (85 %). A total of 77 % of the lesions (10/13) were 1-2 mm in size and two lesions were 4 mm in size; only one lesion was larger than 5 mm. Endoscopic treatment resulted in a therapeutic success rate of 100 %, and no recurrence of bleeding was observed in 85 % of the patients (11/13) after treatment. During the study period, two patients presented with bleeding from residual AGD and underwent endoscopic treatment. In the present study, most sites of bleeding colonic AGD were very small, termed "micro-angiodysplasia", and targeted endoscopic treatment for actively bleeding AGD was found to be effective and safe. It is essential that physicians consider the potential for actively bleeding colonic AGD, especially "micro-angiodysplasia", when performing colonoscopy in elderly patients with a history of cardiovascular disease and/or treatment with anticoagulant or antiplatelet therapy.
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Affiliation(s)
- Naoyuki Nishimura
- Department of Gastroenterology, Kurashiki Central Hospital, Miwa, Kurashiki, Okayama, 710-8602, Japan,
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Abstract
PURPOSE OF REVIEW Diverticular disease is the most commonly reported finding at the time of colonoscopy and one of the most common gastrointestinal indications for hospitalization. Much of our previous understanding of diverticular disease has recently been challenged. RECENT FINDINGS There is emerging evidence that the long-accepted hypothesis of diverticulosis as a consequence of fiber deficiency may be more complex than commonly thought, with recent evidence suggesting that high-fiber diet and frequent bowel movements are associated with a greater and not lower prevalence of diverticular disease. There is also emerging support for the concept of low-grade inflammation in symptomatic uncomplicated diverticular disease (SUDD), and the role of anti-inflammatory treatment with mesalamine is being actively investigated. Additionally, elective 'prophylactic' surgery after diverticulitis, previously considered after a second confirmed diverticulitis episode, is being increasingly deferred. SUMMARY The pathogenesis of diverticular disease is likely multifactorial and complex. More studies are needed to evaluate the role of fiber in the pathogenesis and treatment of diverticular disease. The search for an effective medical therapy for SUDD and to prevent recurrent diverticulitis is being actively investigated. The efficacy of mesalamine does not appear to be strong data supported.
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Kim BSM, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol 2014; 5:467-478. [PMID: 25400991 PMCID: PMC4231512 DOI: 10.4291/wjgp.v5.i4.467] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/15/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is not apparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia. Obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine. Accurate clinical diagnosis is crucial and guides definitive investigations and interventions. This review summarizes the overall diagnostic approach to gastrointestinal bleeding and provides a practical guide for clinicians.
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Xu XQ, Hong T, Li BL, Liu W. Active gastrointestinal diverticulum bleeding diagnosed by computed tomography angiography. World J Gastroenterol 2014; 20:13620-13624. [PMID: 25309094 PMCID: PMC4188915 DOI: 10.3748/wjg.v20.i37.13620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/29/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
A diverticulum is a bulging sack in any portion of the gastrointestinal tract. Small intestine diverticular disease is much less common than colonic diverticular disease. The most common symptoms include non-specific epigastric pain and a bloating sensation. Major complications include diverticulitis, gastrointestinal bleeding, acute perforation, intestinal obstruction, intestinal perforation, localized abscess, malabsorption, anemia, volvulus and bacterial overgrowth. We report one case of massive jejunal diverticula bleeding and one case of massive colonic diverticula bleeding, both diagnosed by acute abdominal computed tomography angiography and treated successfully by surgery.
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Nuclear medicine and the emergency department patient: an illustrative case-based approach. Radiol Med 2014; 120:158-70. [PMID: 25115293 DOI: 10.1007/s11547-014-0451-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 06/16/2014] [Indexed: 12/07/2022]
Abstract
Radiologists are familiar with the use of radiographs, computed tomography, magnetic resonance imaging and ultrasound in the acute clinical setting. However, there are some specific clinical scenarios which may be found in nuclear medicine imaging problem-solving tools. These clinical scenarios and imaging techniques are less frequent, and the referring clinician from the emergency department may not consider these alternatives. It is important for the radiologist to be aware of these techniques to be able to guide the clinician to use those tools, which may result in optimal patient care. In this article, we will discuss those nuclear medicine studies which have application in the setting of an emergency radiology practice.
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Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis. J Gastroenterol 2014; 49:992-1000. [PMID: 24221694 DOI: 10.1007/s00535-013-0905-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 10/20/2013] [Indexed: 02/07/2023]
Abstract
Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.
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Ramaswamy RS, Choi HW, Mouser HC, Narsinh KH, McCammack KC, Treesit T, Kinney TB. Role of interventional radiology in the management of acute gastrointestinal bleeding. World J Radiol 2014; 6:82-92. [PMID: 24778770 PMCID: PMC4000612 DOI: 10.4329/wjr.v6.i4.82] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/20/2014] [Accepted: 03/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute gastrointestinal bleeding (GIB) can lead to significant morbidity and mortality without appropriate treatment. There are numerous causes of acute GIB including but not limited to infection, vascular anomalies, inflammatory diseases, trauma, and malignancy. The diagnostic and therapeutic approach of GIB depends on its location, severity, and etiology. The role of interventional radiology becomes vital in patients whose GIB remains resistant to medical and endoscopic treatment. Radiology offers diagnostic imaging studies and endovascular therapeutic interventions that can be performed promptly and effectively with successful outcomes. Computed tomography angiography and nuclear scintigraphy can localize the source of bleeding and provide essential information for the interventional radiologist to guide therapeutic management with endovascular angiography and transcatheter embolization. This review article provides insight into the essential role of Interventional Radiology in the management of acute GIB.
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Abstract
INTRODUCTION Colorectal cancer (CRC) is a common type of malignancy encountered in the United States. A significant proportion of patients with CRC will seek emergency medical care during the course of their illness and treatment. BACKGROUND Emergent presentations can be the result of either local tumor invasion, regional progression, or therapeutic techniques. Specific complications of CRC which present emergently include rectal bleeding, abdominal pain, and bowel obstruction. Less common issues encountered include malignant ascites, neutropenic enterocolitis, and radiation enteropathy. CONCLUSION The care of CRC patients in the setting of an acute severe illness typically requires the joint efforts of the emergency medical team in consultation with surgical, medical, and radiation oncology. A high degree of suspicion for the typical and atypical complications of CRC is important for all clinicians who are responsible for the care of these patients.
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