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Elshaer A, Abraham NS. Management of Anticoagulant and Antiplatelet Agents in Acute Gastrointestinal Bleeding and Prevention of Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:205-216. [PMID: 38395479 DOI: 10.1016/j.giec.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Managing gastrointestinal bleeding in patients using antithrombotic agents remains challenging in clinical practice. This review article provides a comprehensive and evidence-based approach to managing acute antithrombotic-related gastrointestinal bleeding, focusing on the triage of patients, appropriate resuscitation, and timely endoscopy. The latest clinical practice guidelines are highlighted to guide decisions concerning the use of reversal agents, temporary interruption, and resumption of antithrombotic drugs. Additionally, preventive measures are discussed to lower the risk of future bleeding and minimize complications among patients prescribed antithrombotic drugs.
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Affiliation(s)
- Amany Elshaer
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Neena S Abraham
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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2
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Development of risk scores for early and late recurrence of colonic diverticular hemorrhage. Eur J Gastroenterol Hepatol 2023; 35:248-254. [PMID: 36708294 DOI: 10.1097/meg.0000000000002478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Colonic diverticular hemorrhage (CDH) often recurs. Although several studies have suggested that early rebleeding (ER) and late rebleeding (LR) should be treated independently, and several ER/LR risk factors have been identified, an integrated system for risk evaluation is still lacking. This study aimed to develop risk scores for early and late rebleeding of CDH. METHODS This two-center, retrospective cohort study included 218 patients between 2008 and 2021. ER and LR risk factors were identified using multivariate analysis, and risk scores were developed using the odds ratios of each risk factor. RESULTS The ER and LR rates were 32.6 and 25.7%, respectively. High heart rate on admission, early endoscopy from the visit, no bowel preparation and no endoscopic treatment were identified as risk factors for ER. On the other hand, LR risk factors included a history of hypertension and diabetes, early endoscopy from the visit, and the use of endoscopic clips. The ER risk score [area under the curve (AUC) = 0.71] was highly sensitive (90.3%) at a cutoff point of 6 and highly specific (98.0%) at a cutoff point of 15. The LR risk score (AUC = 0.70) was highly sensitive (91.1%) at a cutoff point of 2.6 and highly specific (88.3%) at a cutoff point of 7.1. CONCLUSIONS The ER and LR risk scores were established for the first time, and they can divide CDH patients based on their risk of rebleeding as well as provide clinicians with practical information about the CDH management.
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Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023; 118:208-231. [PMID: 36735555 DOI: 10.14309/ajg.0000000000002130] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.
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Aoki T, Yamada A, Niikura R, Nakada A, Suzuki N, Hayakawa Y, Hirata Y, Koike K, Fujishiro M. Efficacy of Early Video Capsule Endoscopy for Acute Overt Lower Gastrointestinal Bleeding with Colonic Diverticulosis: A Prospective Observational Study. Digestion 2022; 103:367-377. [PMID: 35772398 PMCID: PMC9501749 DOI: 10.1159/000525314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Although most patients with presumptive colonic diverticular bleeding (CDB) do not undergo a small bowel investigation in clinical practice, no prospective study supports this management. We evaluated the utility of early small bowel capsule endoscopy (CE) after negative colonoscopy results. METHODS This prospective study evaluated the diagnostic yield of early small bowel CE (≤3 days from visit) for consecutive patients with acute-onset hematochezia, when colonoscopy found colonic diverticulosis but did not identify the definite bleeding source (n = 51; presumptive CDB). As a matched control for comparing clinical outcomes, presumptive CDB patients without CE (n = 51) were retrospectively extracted. RESULTS On CE for the prospective cohort, the rates of total positive findings, P2 findings (high bleeding potential according to the P classification), and blood pooling in the colon were 57%, 12% (ulceration, 8%; angioectasia, 4%), and 24%, respectively. The rates of rebleeding within 30 and 365 days were 16% and 29% in the prospective cohort with CE, respectively, and were not significantly different from those in the retrospective cohort without CE (10% and 25%, respectively). In addition, thromboembolism and mortality within 30 and 365 days were not significantly different between those with and without CE. CONCLUSION Early CE detected a suspected small bowel bleeding source in 12% of acute-onset presumptive CDB patients but did not significantly improve major clinical outcomes. Therefore, routine CE is unnecessary for presumptive CDB patients after colonoscopy (UMIN000026676).
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Ochanomizu Surugadai Clinic, Tokyo, Japan,*Atsuo Yamada,
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Ayako Nakada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Nobumi Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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5
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Kim YS. [Diagnosis and Treatment of Colonic Diverticular Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 79:233-243. [PMID: 35746837 DOI: 10.4166/kjg.2022.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/29/2022] [Indexed: 06/15/2023]
Abstract
Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.
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Affiliation(s)
- You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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6
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肖 雪, 苏瑞亚·帕力哈提, 周 敏, 曾 煜, 杨 锦. [Lower Gastrointestinal Bleeding: Current State of Diagnosis and Treatment and Interpretation of the Clinical Guidelines]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2022; 53:367-374. [PMID: 35642140 PMCID: PMC10409430 DOI: 10.12182/20220560207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Indexed: 06/15/2023]
Abstract
Lower gastrointestinal bleeding (LGIB) is a common clinical emergency. However, most of the published findings on LGIB were of retrospective or observational studies, and the relevant clinical guidelines and consensuses were not published until quite recently. In clinical practice, LGIB treatment is not as standardized as the treatment of upper gastrointestinal bleeding. Herein, on the basis of the latest clinical research findings on and guidelines for LGIB, we summarized and analyzed the existent diagnosis and treatment of LGIB from the perspectives of patient assessment and endoscopic, interventional and medication treatment, intending to provide more references to support the clinical practice.
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Affiliation(s)
- 雪 肖
- 四川大学华西医院 消化内科 (成都 610041)Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 苏瑞亚·帕力哈提
- 四川大学华西医院 消化内科 (成都 610041)Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 敏 周
- 四川大学华西医院 消化内科 (成都 610041)Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 煜 曾
- 四川大学华西医院 消化内科 (成都 610041)Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 锦林 杨
- 四川大学华西医院 消化内科 (成都 610041)Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
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Sato Y, Yasuda H, Nakamoto Y, Kiyokawa H, Yamashita M, Matsuo Y, Maehata T, Yamamoto H, Itoh F. Risk Factors for Late Rebleeding of Colonic Diverticular Bleeding in Elderly Individuals. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:148-157. [PMID: 33937555 PMCID: PMC8084535 DOI: 10.23922/jarc.2020-081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
Objectives This study aimed to examine the clinical characteristics of colonic diverticular bleeding (CDB) in elderly individuals. Methods This retrospective case-control study was conducted at a single tertiary center. A total of 519 patients (356 men and 163 women; mean age of 73.1 ± 12.5 years) with CDB and hospitalized between January 2004 and May 2019 were analyzed. The subjects were divided into two groups: the elderly (274 individuals aged ≥75 years; mean age, 82.1 ± 5.3 years) and non-elderly (245 individuals aged <75 years; mean age, 63.0 ± 10.3 years) groups. Primary outcomes were early and late rebleeding rates, and secondary outcomes were the risk factors for late rebleeding in elderly individuals. Rebleeding occurring within 30 days of hospitalization was defined as early rebleeding, whereas rebleeding occurring after 31 days was defined as late rebleeding. Results The early rebleeding rates were 30.6% and 33.1% (p = 0.557) in the elderly and non-elderly groups, respectively. The late rebleeding rates were 42.3% and 30.6% (p = 0.005) in the elderly and non-elderly groups, respectively. The 3-year recurrence-free survival was 63.6% in the elderly group and 75.6% in the non-elderly group (log-rank test: p < 0.001). Multivariate analysis revealed the use of non-steroidal anti-inflammatory drugs (NSAIDs) [odds ratio (OR), 3.55], chronic kidney disease (OR, 2.89), and presence of bilateral diverticula (OR, 1.83) as the independent risk factors for late rebleeding in elderly individuals. Conclusions Elderly individuals with CDB require careful follow-up even after discharge. Furthermore, it is important to consider discontinuing NSAIDs to prevent rebleeding.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroshi Yasuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Yusuke Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hirofumi Kiyokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Yamashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Yasumasa Matsuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Tadateru Maehata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroyuki Yamamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Fumio Itoh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
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Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage. Can J Gastroenterol Hepatol 2020; 2020:3283940. [PMID: 32399458 PMCID: PMC7201635 DOI: 10.1155/2020/3283940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023] Open
Abstract
AIM This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. METHODS This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. RESULTS Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68-12.0, P < 0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23-7.53, P=0.016). CONCLUSIONS In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.
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9
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Abstract
Objective Colonic diverticular bleeding often recurs, and readmissions are common. The aim of this study was to identify predictors of colonic diverticular recurrent bleeding and readmission within 90 days. Methods Subjects comprised 144 patients diagnosed with colonic diverticular bleeding who received inpatient hospital care between January 2012 and June 2017. A retrospective comparative study was carried out regarding the clinical characteristics during the hospital stay by dividing the cases into 2 groups: patients with recurrent bleeding requiring readmission within 90 days (n=17) and patients without recurrent bleeding (n=127). Results A univariate analysis showed that recurrent bleeding and readmission were significantly more frequent among cases with hypovolemic shock on admission (p=0.009), blood transfusion during hospitalization (p=0.029), and hyperlipidemia (p=0.020) than among others. Shock on admission (odds ratio, 5.118; 95% confidence interval, 1.168-22.426, p=0.030) remained a significant predictor on a multivariate analysis. Conclusion Shock may predict recurrent colonic diverticular bleeding and readmission within 90 days. Careful and adequate endoscopic hemostasis is recommended for patients showing shock on admission.
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Affiliation(s)
- Tomoyuki Kitagawa
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Yasumi Katayama
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Ikuhiro Kobori
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Yo Fujimoto
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
| | - Masaya Tamano
- Department of Gastroenterology, Dokkyo Medical University Saitama Medical Center, Japan
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Wada M, Nishizawa T, Kato M, Hirai Y, Kinoshita S, Mori H, Nakazato Y, Fujimoto A, Kikuchi M, Uraoka T, Kanai T. Colonic diverticular bleeding and predictors of the length of hospitalization: An observational study. J Gastroenterol Hepatol 2019; 34:1351-1356. [PMID: 30636058 DOI: 10.1111/jgh.14603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM A significant percentage of patients with colonic diverticular bleeding (CDB) experience bleeding that is severe enough to necessitate prolonged hospitalization. Prolonged hospitalization causes deterioration in patients' quality of life, as well as difficulties with cost-effective utilization of medical resources, and is a financial burden to the society. Therefore, we investigated the factors associated with the length of hospitalization for the optimal management of patients hospitalized with CDB. METHODS This study included patients who were hospitalized for the treatment of CDB and underwent colonoscopy between July 2008 and February 2016. Logistic regression analysis was performed to investigate the association between the length of hospitalization and the patients' baseline characteristics, in-hospital procedures performed, and the clinical outcomes. RESULTS The study included 223 patients. Diabetes mellitus (odds ratio [OR] 3.4, P = 0.014) and blood transfusion (OR 3.1, P = 0.0006) were identified as risk factors for prolonged hospitalization (≥ 8 days). Urgent colonoscopy (OR 0.41, P = 0.0072) predicted a shorter length of hospitalization (≤ 7 days). The study also indicated that endoscopic treatment showed a stronger association with urgent colonoscopy (OR 7.8, P < 0.0001) than with elective colonoscopy and that urgent colonoscopy was not associated with an increased rate of adverse events or re-bleeding. CONCLUSIONS Compared with elective colonoscopy, urgent colonoscopy shortens the length of hospitalization in patients with CDB. Moreover, it is not associated with an increased rate of adverse events. Urgent colonoscopy may be impracticable in a few cases; however, if possible, aggressive urgent colonoscopy should be considered for the efficient management of the patient's hospital stay.
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Affiliation(s)
- Michiko Wada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology and Hepatology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshihiro Nakazato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Ai Fujimoto
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Predictors of gastrointestinal bleeding in older persons taking nonsteroidal anti-inflammatory drugs: Results from the FDA adverse events reporting system. J Am Assoc Nurse Pract 2019; 31:206-213. [PMID: 30589757 DOI: 10.1097/jxx.0000000000000130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Older adults continue to take nonsteroidal anti-inflammatory drugs (NSAIDs) to manage chronic pain. The study's purpose was to identify predictors of gastrointestinal (GI) bleeding in older adults taking NSAIDs. METHODS A secondary analysis of the 2016 Food and Drug Administration's Adverse Events Reporting System data was conducted with 1,347 cases aged 65 years and older with an NSAID as the primary suspect for an adverse drug event (ADE). Data included age, sex, NSAID, multiple NSAID use, rivaroxaban, warfarin, clopidogrel, cardiovascular drug (proxy for cardiovascular disease), diabetes drug (proxy for diabetes mellitus), and primary adverse drug response. CONCLUSIONS Aspirin was the primary suspect NSAID in 72.5% of cases. Rivaroxaban was taken in 67.9% of cases. Logistic regression was conducted to predict GI bleed versus other NSAID-related ADEs with age, sex, cardiovascular medication, diabetes medication, warfarin, clopidogrel, concurrent NSAID use, aspirin, and rivaroxaban as predictors. Aspirin, rivaroxaban, and concurrent NSAID were significant predictors of GI bleed. Gastrointestinal bleed risk versus other ADE risk increased by 39.77 times when taking aspirin, rivaroxaban, and another NSAIDs concurrently. IMPLICATIONS FOR PRACTICE Results support reduced NSAID use by older adults, especially aspirin, and avoidance of rivaroxaban in older persons taking NSAIDs.
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12
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Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019; 25:69-84. [PMID: 30643359 PMCID: PMC6328962 DOI: 10.3748/wjg.v25.i1.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/17/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, Tokyo 108-8639, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
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13
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Nagata N, Ishii N, Kaise M, Shimbo T, Sakurai T, Akiyama J, Uemura N. Long-term recurrent bleeding risk after endoscopic therapy for definitive colonic diverticular bleeding: band ligation versus clipping. Gastrointest Endosc 2018; 88:841-853.e4. [PMID: 30036505 DOI: 10.1016/j.gie.2018.07.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 07/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Very few prospective studies with over 100 samples have evaluated the long-term outcomes of endoscopic therapy for colonic diverticular bleeding (CDB). This study sought to elucidate the recurrent bleeding risk of endoscopic band ligation versus clipping for definitive CDB based on stigmata of recent hemorrhage (SRH). METHODS Patients emergently hospitalized for acute lower GI bleeding and examined by high-resolution colonoscopy were enrolled. Better visualization of SRH from a diverticulum was obtained using a water-jet device. Endoscopic band ligation or clipping was performed as first-line treatment, and patients were prospectively followed after discharge. RESULTS No statistical difference was found between the ligation (n = 61) and clipping (n = 47) groups in baseline characteristics or follow-up period. The probability of 1-year recurrent bleeding was 11.5% in the ligation group versus 37.0% in the clipping group (P = .018). No patients required surgery or experienced perforation. One patient in the ligation group experienced diverticulitis the next day. In patients with recurrent bleeding within 7 days, the recurrent bleeding site was the same diverticulum, and ulceration was found in the ligation group on repeat colonoscopy. In patients with recurrent bleeding after 2 months, repeat colonoscopy identified that the recurrent bleeding site was different, and scar formation was seen in the ligation group. The left side of the colon was an independent predictor for recurrent bleeding in the ligation group but not in the clipping group. CONCLUSIONS Band ligation for definitive CDB has better outcomes than clipping during long-term follow-up after endoscopic therapy, probably because of complete elimination of the diverticulum. CDB can recur at the same diverticulum in the short term but at a different diverticulum in the long term.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoki Ishii
- Gastroenterology Division, Koga Hospital, Koga, Japan; Gastroenterology Division, St. Luke's International Hospital, Tokyo, Japan
| | - Mitsuru Kaise
- Gastroenterology Division, Nippon Medical School, Tokyo, Japan
| | - Takuro Shimbo
- Department of Internal Medicine, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan; Department of Gastroentegology, The Jikei University School of Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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Vajravelu RK, Mamtani R, Scott FI, Waxman A, Lewis JD. Incidence, Risk Factors, and Clinical Effects of Recurrent Diverticular Hemorrhage: A Large Cohort Study. Gastroenterology 2018; 155:1416-1427. [PMID: 30056095 PMCID: PMC6219900 DOI: 10.1053/j.gastro.2018.07.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/12/2018] [Accepted: 07/22/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Although recurrent diverticular hemorrhage is common, its incidence and risk factors have not been measured outside of small institutional cohorts. We analyzed the incidence of and risk factors for recurrent diverticular hemorrhage and whether discontinuing anticoagulation after diverticular hemorrhage is associated with ischemic stroke. METHODS We performed a retrospective cohort study of patients enrolled in the OptumInsight Clinformatics database from 2000 through 2016. Incidence rates for initial and recurrent diverticular hemorrhage were calculated by identifying patients who had hospitalizations with a primary discharge diagnosis consistent with diverticular hemorrhage. The hazard ratios of second diverticular hemorrhage associated with anticoagulants or platelet aggregation inhibitors were calculated using Cox proportional hazards regression adjusted for demographics, comorbidities, and medication use. The hazard ratio for ischemic stroke among patients who discontinued anticoagulation after diverticular hemorrhage was calculated similarly. RESULTS In the cohort analyzed, 14,925 patients had an initial diverticular hemorrhage; 1368 of these patients had a second episode. The unstandardized incidence rates of initial and second diverticular hemorrhage were 10.9 per 100,000 person-years (95% confidence interval [CI] 10.7-11.0) and 3625.6 per 100,000 person-years (95% CI 3436.0-3823.0). Platelet aggregation inhibitors were associated with second episodes of diverticular hemorrhage (hazard ratio 1.47; 95% CI 1.15-1.88), whereas all classes of anticoagulation agents were not associated. Among patients with a potential indication for stroke prophylaxis, those who discontinued anticoagulation after the diverticular hemorrhage had an increased hazard of ischemic stroke (hazard ratio 1.93; 95% CI 1.17-3.19). CONCLUSIONS In this retrospective cohort study, platelet aggregation inhibitors, but not anticoagulants, were associated with recurrent diverticular hemorrhage. Discontinuing anticoagulation was associated with increased hazard for ischemic stroke.
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Affiliation(s)
- Ravy K Vajravelu
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ronac Mamtani
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank I Scott
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Adam Waxman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Wada M, Kato M, Hirai Y, Kubosawa Y, Sunata Y, Abe K, Hirata T, Takada Y, Banno S, Takatori Y, Kinoshita S, Mori H, Takabayashi K, Kikuchi M, Kikuchi M, Suzuki M, Kanai T, Uraoka T. Initial Management of Colonic Diverticular Bleeding: Observational Study. Digestion 2018; 98:41-47. [PMID: 29672291 DOI: 10.1159/000487264] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Although colonic diverticular bleeding (CDB) often ceases spontaneously, re-bleeding occurs in about 30%. Bleeding diverticulum can be treated directly by endoscopic hemostasis; however, it is difficult to perform colonoscopy in all cases with limited medical resource and certain risks. The aim of this study was to clarify who should undergo colonoscopy as well as appropriate methods of initial management in CDB patients. METHODS A total of 285 patients who were diagnosed as CDB and underwent colonoscopy from March 2004 to October 2015 were retrospectively analyzed. First, the association between re-bleeding and various factors including patients' background and initial management were analyzed. Second, the examination conditions that influenced bleeding point identification were analyzed. RESULTS Of 285 patients, 187 were men and 98 were women. Median age was 75 years, and the median observation period was 17.5 months. Re-bleeding was observed in 79 patients (28%). A history of CDB (OR 2.1, p = 0.0090) and chronic kidney disease (CKD; OR 2.3, p = 0.035) were risk factors, and bleeding point identification (OR 0.20, p = 0.0037) was a preventive factor for re-bleeding. Bleeding point identification significantly reduced approximately 80% of re-bleeding. Furthermore, extravasation on CT (OR 3.7, p = 0.031) and urgent colonoscopy (OR 5.3, p < 0.001) were predictors for identification of bleeding point. Compared to bleeding point identification of 11% in all patients who underwent colonoscopy, identification rate in those who had extravasation on CT and underwent urgent colonoscopy was as high as 70%. CONCLUSIONS Contrast-enhanced CT upon arrival is suggested, and patients with extravasation on CT would be good candidates for urgent colonoscopy, as well as patients who have a history of CDB and CKD.
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Affiliation(s)
- Michiko Wada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoko Kubosawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yukie Sunata
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Keiichiro Abe
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Tetsu Hirata
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshiaki Takada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Shigeo Banno
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yusaku Takatori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Kaoru Takabayashi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Miho Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masayuki Suzuki
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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16
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Abstract
Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.
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17
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Almadi MA, Barkun AN. Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:363-377. [PMID: 29933781 DOI: 10.1016/j.giec.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The approach to lower gastrointestinal bleeding (LGIB) has evolved over the last few years to incorporate a multidisciplinary management strategy. Although the causes of LGIB vary depending on the age and comorbid conditions of patients, the initial resuscitation and principles of optimizing patients' condition before endoscopic evaluation, when appropriate, are the cornerstones to clinical care. The role of risk stratification is to triage patients as well as to mobilize health care resources based on predicted outcomes. Individualized management according to patients' comorbid conditions has been a focus in most recent guidelines.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
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18
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Kinjo K, Matsui T, Hisabe T, Ishihara H, Kojima T, Chuman K, Yasukawa S, Beppu T, Koga A, Ishikawa S, Kishi M, Takatsu N, Hirai F, Yao K, Ueki T, Washio M. Risk factors for severity of colonic diverticular hemorrhage. Intest Res 2018; 16:458-466. [PMID: 30090045 PMCID: PMC6077309 DOI: 10.5217/ir.2018.16.3.458] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS Colonic diverticular hemorrhage (DH) was a rare disease until the 1990s, and its incidence has increased rapidly since 2000 in Japan. In recent years, colonic DH has been the most frequent cause of lower gastrointestinal bleeding (LGIB). Nearly all cases of DH are mild, with the bleeding often stopping spontaneously. Some cases, however, require surgery or arterial embolization. In this study, using a cohort at Fukuoka University Chikushi Hospital, we investigated factors associated with severe colonic DH. METHODS Among patients with LGIB who underwent colonoscopy at our hospital between 1995 and 2013, DH was identified in 273 patients. Among them, 62 patients (22.7%) were defined as having severe colonic DH according to recurrence of bleeding in a short period, and/or the necessity of transfusion, arterial embolization, or surgery. We then evaluated risk factors for severe DH among DH patients in this retrospective cohort. RESULTS Among the 273 patients with DH, use of non-steroidal anti-inflammatory drugs (NSAIDs) (odds ratio [OR], 2.801; 95% confidence interval [CI], 1.164-6.742), Charlson Risk Index (CRI) ≥2 (OR, 3.336; 95% CI, 1.154-7.353), right-sided colonic DH (OR, 3.873; 95% CI, 1.554-9.653), and symptoms of cerebral hypoperfusion (such as light-headedness, dizziness, or syncope) (OR, 2.926; 95% CI, 1.310-6.535) showed an increased risk of severe DH even after controlling for other factors. CONCLUSIONS Severe DH occurred in 23% of DH patients, and NSAID use, CRI ≥2, right-sided colonic DH, and symptoms of cerebral hypoperfusion are suggested to be predictors of severe DH.
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Affiliation(s)
- Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Takashi Hisabe
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Hiroshi Ishihara
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiki Kojima
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kenta Chuman
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Shigeyoshi Yasukawa
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Tsuyoshi Beppu
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Akihiro Koga
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Satoshi Ishikawa
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Masahiro Kishi
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Noritaka Takatsu
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Kenshi Yao
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Masakazu Washio
- Department of Community Health and Clinical Epidemiology, St. Mary's College, Kurume, Japan
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19
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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: 5] [Impact Index Per Article: 0.8] [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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20
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Niikura R, Nagata N, Doyama H, Ota R, Ishii N, Mabe K, Nishida T, Hikichi T, Sumiyama K, Nishikawa J, Uraoka T, Kiyotoki S, Fujishiro M, Koike K. Current state of practice for colonic diverticular bleeding in 37 hospitals in Japan: A multicenter questionnaire study. World J Gastrointest Endosc 2016; 8:785-794. [PMID: 28042393 PMCID: PMC5159677 DOI: 10.4253/wjge.v8.i20.785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 08/20/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To clarify the current state of practice for colonic diverticular bleeding (CDB) in Japan.
METHODS We conducted multicenter questionnaire surveys of the practice for CDB including clinical settings (8 questions), diagnoses (8 questions), treatments (7 questions), and outcomes (4 questions) in 37 hospitals across Japan. The answers were compared between hospitals with high and low number of inpatient beds to investigate which factor influenced the answers.
RESULTS Endoscopists at all 37 hospitals answered the questions, and the mean number of endoscopists at these hospitals was 12.7. Of all the hospitals, computed tomography was performed before colonoscopy in 67% of the hospitals. The rate of bowel preparation was 46.0%. Early colonoscopy was performed within 24 h in 43.2% of the hospitals. Of the hospitals, 83.8% performed clipping as first-line endoscopic therapy. More than half of the hospitals experienced less than 20% rebleeding events after endoscopic hemostasis. No significant difference was observed in the annual number of patients hospitalized for CDB between high- (≥ 700 beds) and low-volume hospitals. More emergency visits (P = 0.012) and endoscopists (P = 0.015), and less frequent participation of nursing staff in early colonoscopy (P = 0.045) were observed in the high-volume hospitals.
CONCLUSION Some practices unique to Japan were found, such as performing computed tomography before colonoscopy, no bowel preparation, and clipping as first-line therapy. Although, the number of staff differed, the practices for CDB were common irrespective of hospital size.
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21
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ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
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22
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Nagata N, Niikura R, Sakurai T, Shimbo T, Aoki T, Moriyasu S, Sekine K, Okubo H, Imbe K, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Safety and Effectiveness of Early Colonoscopy in Management of Acute Lower Gastrointestinal Bleeding on the Basis of Propensity Score Matching Analysis. Clin Gastroenterol Hepatol 2016; 14:558-64. [PMID: 26492844 DOI: 10.1016/j.cgh.2015.10.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/30/2015] [Accepted: 10/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated the safety and effectiveness of early colonoscopy (performed within 24 hours of hospital admission) for acute lower gastrointestinal bleeding (LGIB) vs elective colonoscopy (performed 24 hours after admission). METHODS We conducted a retrospective study by using a database of endoscopies performed at the National Center for Global Health and Medicine in Tokyo, Japan from January 2009 through December 2014. We analyzed data from 538 patients emergently hospitalized for acute LGIB. We used propensity score matching to adjust for differences between patients who underwent early colonoscopy vs elective colonoscopy. Outcomes included rates of adverse events during bowel preparation and colonoscopy procedures, stigmata of recent hemorrhage, endoscopic therapy, blood transfusion requirement, 30-day rebleeding and mortality, and length of hospital stay. RESULTS We selected 163 pairs of patients for analysis on the basis of propensity matching. We observed no significant differences between the early and elective colonoscopy groups in bowel preparation-related rates of adverse events (1.8% vs 1.2%, P = .652), colonoscopy-related rates of adverse events (none in either group), blood transfusion requirement (27.6% vs 27.6%, P = 1.000), or mortality (1.2% vs 0, P = .156). The early colonoscopy group had higher rates than the elective group for stigmata of recent hemorrhage (26.4% vs 9.2%, P < .001) and endoscopic therapy (25.8% vs 8.6%, P < .001), including clipping (17.8% vs 4.9%, P < .001), band ligation (6.1% vs 1.8%, P = .048), and rebleeding (13.5% vs 7.4%, P = .070). Patients in the early colonoscopy group stayed in the hospital for a shorter mean time (10 days) than patients in the elective colonoscopy group (13 days) (P < .001). CONCLUSIONS Early colonoscopy for patients with acute LGIB is safe, allows for endoscopic therapy because it identifies the bleeding source, and reduces hospital stay. However, compared with elective colonoscopy, early colonoscopy does not reduce mortality and may increase the risk for rebleeding.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Ryota Niikura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takuro Shimbo
- Clinical Research and Informatics, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Tomonori Aoki
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Koh Imbe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
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Cirocchi R, Grassi V, Cavaliere D, Renzi C, Tabola R, Poli G, Avenia S, Farinella E, Arezzo A, Vettoretto N, D'Andrea V, Binda GA, Fingerhut A. New Trends in Acute Management of Colonic Diverticular Bleeding: A Systematic Review. Medicine (Baltimore) 2015; 94:e1710. [PMID: 26554768 PMCID: PMC4915869 DOI: 10.1097/md.0000000000001710] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colonic diverticular disease is the most common cause of lower gastrointestinal bleeding. In the past, this condition was usually managed with urgent colectomy. Recently, the development of endoscopy and interventional radiology has led to a change in the management of colonic diverticular bleeding.The aim of this systematic review is to define the best treatment for colonic diverticular bleeding.A systematic bibliographic research was performed on the online databases for studies (randomized controlled trials [RCTs], observational trials, case series, and case reports) published between 2005 and 2014, concerning patients admitted with a diagnosis of diverticular bleeding according to the PRISMA methodology.The outcomes of interest were: diagnosis of diverticulosis as source of bleeding; incidence of self-limiting diverticular bleeding; management of non self-limiting bleeding (endoscopy, angiography, surgery); and recurrent diverticular bleeding.Fourteen studies were retrieved for analysis. No RCTs were found. Eleven non-randomized clinical controlled trials (NRCCTs) were included in this systematic review. In all studies, the definitive diagnosis of diverticular bleeding was always made by urgent colonoscopy. The colonic diverticular bleeding stopped spontaneously in over 80% of the patients, but a re-bleeding was not rare. Recently, interventional endoscopy and angiography became the first-line approach, thus relegating emergency colectomy to patients presenting with hemodynamic instability or as a second-line treatment after failure or complications of hemostasis with less invasive treatments.Colonoscopy is effective to diagnose diverticular bleeding. Nowadays, interventional endoscopy and angiographic treatment have gained a leading role and colectomy should only be entertained in case of failure of the former.
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Affiliation(s)
- Roberto Cirocchi
- From the Department of Digestive Surgery and Liver Unit, St Maria Hospital, Terni, Italy (RC, VG); Surgical Oncology, Forlì Hospital, Forlì, Italy (DC); Department of General and Oncologic Surgery, University of Perugia, St Maria Hospital, Perugia, Italy (CR); Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland (RT); Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy (GP); Department of Endocrine Surgery, University of Perugia, Perugia, Italy (SA); Department of Digestive Surgery, ULB-Hopital Erasme, Brussels, Belgium (EF); Department of Surgical Sciences, University of Torino, Torino, Italy (AA); Department of Surgery, Montichiari, Ospedali Civili Brescia, Italy (NV); Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy (VD); Department of Colorectal Surgery, Galliera Hospital, Genoa, Italy (GAB); and Surgical Research Unit, Medical University of Graz, Austria and First Department of Surgery, Hippokration Hospital, University of Athens Medical School, Athens, Greece (AF)
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24
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Nagata N, Niikura R, Aoki T, Moriyasu S, Sakurai T, Shimbo T, Sekine K, Okubo H, Watanabe K, Yokoi C, Akiyama J, Yanase M, Mizokami M, Fujimoto K, Uemura N. Risk factors for adverse in-hospital outcomes in acute colonic diverticular hemorrhage. World J Gastroenterol 2015; 21:10697-10703. [PMID: 26457031 PMCID: PMC4588093 DOI: 10.3748/wjg.v21.i37.10697] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/28/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the factors associated with transfusion, further bleeding, and prolonged length of stay.
METHODS: In total, 153 patients emergently hospitalized for diverticular bleeding who were examined by colonoscopy were prospectively enrolled. Patients in whom the bleeding source was identified received endoscopic treatment such as clipping or endoscopic ligation. After spontaneous cessation of bleeding with conservative treatment or hemostasis with endoscopic treatment, all patients were started on a liquid food diet and gradually progressed to a solid diet over 3 d, and were discharged. At enrollment, we assessed smoking, alcohol, medications [non-steroidal anti-inflammatory drugs (NSAIDs)], low-dose aspirin, and other antiplatelets, warfarin, acetaminophen, and oral corticosteroids), and co-morbidities [hypertension, diabetes mellitus, dyslipidemia, cerebro-cardiovascular disease, chronic liver disease, and chronic kidney disease (CKD)]. The in-hospital outcomes were need for transfusion, further bleeding after spontaneous cessation of hemorrhage, and length of hospital stay. The odds ratio (OR) for transfusion need, further bleeding, and prolonged length of stay were estimated by logistic regression analysis.
RESULTS: No patients required angiographic embolization or surgery. Stigmata of bleeding occurred in 18% of patients (27/153) and was treated by endoscopic procedures. During hospitalization, 40 patients (26%) received a median of 6 units of packed red blood cells. Multivariate analysis revealed that female sex (OR = 2.5, P = 0.02), warfarin use (OR = 9.3, P < 0.01), and CKD (OR = 5.9, P < 0.01) were independent risk factors for transfusion need. During hospitalization, 6 patients (3.9%) experienced further bleeding, and NSAID use (OR = 5.9, P = 0.04) and stigmata of bleeding (OR = 11, P < 0.01) were significant risk factors. Median length of hospital stay was 8 d. Multivariate analysis revealed that age > 70 years (OR = 2.1, P = 0.04) and NSAID use (OR = 2.7, P = 0.03) were independent risk factors for prolonged hospitalization (≥ 8 d).
CONCLUSION: In colonic diverticular bleeding, female sex, warfarin, and CKD increased the risk of transfusion requirement, while advanced age and NSAID increased the risk of prolonged hospitalization.
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25
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Nagata N, Sakamoto K, Arai T, Niikura R, Shimbo T, Shinozaki M, Aoki T, Sekine K, Okubo H, Watanabe K, Sakurai T, Yokoi C, Yanase M, Akiyama J, Noda M, Uemura N. Visceral fat accumulation affects risk of colonic diverticular hemorrhage. Int J Colorectal Dis 2015; 30:1399-406. [PMID: 26099321 DOI: 10.1007/s00384-015-2295-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/08/2023]
Abstract
PURPOSES Factors other than antithrombotic drugs associated with diverticular bleeding remain unknown. Visceral adiposity contributes to atherosclerosis and may affect arteriolar change at the diverticulum. We investigated whether visceral adipose tissue (VAT) measured by computed tomography (CT) is a risk factor for diverticular bleeding. METHODS A cohort of 283 patients (184 with asymptomatic diverticulosis and 99 with diverticular bleeding) undergoing colonoscopy and CT was analyzed. Associations between body mass index (BMI), VAT, subcutaneous adipose tissue (SAT), and diverticular bleeding were assessed by logistic regression models adjusted for age, gender, alcohol, smoking, diabetes mellitus, hypertension, dyslipidemia, chronic kidney disease, and antithrombotic drugs (nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, and other antiplatelet drugs). RESULTS In univariate analysis, hypertension, dyslipidemia, chronic kidney disease, and NSAIDs use, low-dose aspirin, non-aspirin antiplatelets, increasing BMI, and increasing VAT area were associated with diverticular bleeding. In multivariate analysis adjusted for confounding factors, VAT area (p = 0.021), but not BMI (p = 0.551) or SAT area (p = 0.635), was positively associated with diverticular bleeding. When BMI was considered simultaneously, VAT area remained positively associated with diverticular bleeding (p = 0.018). However, none of obesity indices including VAT area were associated with recurrence of diverticular bleeding or prolonged hospitalization. CONCLUSIONS This study presents new information on risk factors for diverticular bleeding. A large volume of visceral adipose tissue, but not BMI or SAT, appears to entail a risk for diverticular bleeding, after age, gender, metabolic factors, and antithrombotic drugs use adjustments.
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Affiliation(s)
- Naoyoshi Nagata
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Kayo Sakamoto
- Diagnostic Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tomohiro Arai
- Diagnostic Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Niikura
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Takuro Shimbo
- Department of Internal Medicine, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Masafumi Shinozaki
- Diagnostic Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tomonori Aoki
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Katsunori Sekine
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Hidetaka Okubo
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kazuhiro Watanabe
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Toshiyuki Sakurai
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Chizu Yokoi
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Mikio Yanase
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Junichi Akiyama
- Departments of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Mitsuhiko Noda
- Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
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