Introduction

Although transcatheter arterial embolization (TAE) has been reported to be effective for colonic diverticular bleeding, the patient outcomes of TAE have not been fully elucidated. The present study was conducted to investigate the patient characteristics and outcomes of TAE for colonic diverticular bleeding.

Aims & Methods

We enrolled 50 patients who were performed transcatheter angiography among 294 patients diagnosed as colonic diverticular bleeding by colonoscopy and abdominal CT, and were required for hospitalization from August 2012 to January 2021. Their clinical characteristics and outcomes of TAE were determined according to medical records retrospectively.

Results

The mean age of all 50 patients (44 males and 6 females) was 68 (45-86) years. History of cardiovascular disease in 15 patients, cerebrovascular disease in 7, renal disease in 4, hepatic disease in 5, hypertension in 27, diabetes mellitus in 5, and dyslipidemia in 10. The reasons for transcatheter angiography were rebleeding after colonoscopy in 21 cases (42%), shock vital in 13 cases (26%), extravasation on CT in 4 cases (8%), difficulty in stopping bleeding by endoscopy in 4 cases (8%), and rebleeding after angiography in 7 cases (14%). TAE was performed in 30 of 50 patients (60%). 7 of 50 patients (14%) were performed transcatheter angiography twice, of which 3 patients successfully performed TAE on the second time, 2 patients successfully performed TAE both times. The reasons for unsuccessful TAE were all negative extravasation on transcatheter angiography, and there were no cases in which TAE was technically impossible. In a comparison of 30 successful TAE cases and 20 unsuccessful TAE cases, the mean time from the appearance of hematochezia to transcatheter angiography (9.8 vs. 12.75 h; P=0.413), the rate of extravasation on CT before transcatheter angiography (56% vs. 45%; P=0.419) were not significantly different between the two groups. On the other hand, the rate of early rebleeding within 30 days was significantly lower in patients with successful TAE (13% vs. 60%, P = 0.001).

Conclusion

In cases of colonic diverticular bleeding, transcatheter angiography can be safely performed even when the patient's circulation is unstable. Moreover, the early rebleeding rate was significantly reduced in cases of successful TAE. However, the early rebleeding rate was high in patients who did not receive successful TAE, this should be considered as a future subject.

Introduction

Although the number of patients with diverticular hemorrhage in the colon has been increasing in recent years, it remains controversial whether emergency colonoscopy is effective for patient outcomes. We developed a new protocol to avoid emergency colonoscopic procedures at night (22:00-05:00), in which colonoscopy were performed within 8, 12, or 24 hours after the patient's arrival, as determined by the presence or absence of extravasation on contrast-enhanced computerized tomography and history of shock at the time of arrival. We have been applying the new protocol for lower gastrointestinal bleeding since the end of 2021. In addition, the endoscopic band ligation method has beenstandardized as the first choice for hemostasis when stigmata of recent hemorrhage (SRH) was identified. The purpose of this study was to verify the effectiveness of the new protocol.

Aims & Methods

Among patients diagnosed as diverticular hemorrhage at Nippon Medical School Hospital, we evaluated clinical outcomes including SRH identification rate, the rebleeding rate after 30 days of hemostasis, the period of hospitalization, and the rate for the hemostasis method after identifying SRH. Each clinical outcome factor afterapplying the protocol (January 2022 to December 2022) was compared with those before the protocol was established (January 2020 to December 2021). The chi-square or Fisher’s exact test was used to compare categorical variables. Mann-Whitney U test was used to compare continuous variables.

Results

Among 93 cases diagnosed as diverticular hemorrhage during the new protocol was in operation, 79 cases followed the protocol and 74 cases underwent endoscopy. Among 191 cases diagnosed as diverticular hemorrhage before new protocol was in operation, 175 cases underwent endoscopy. After the new protocol was in operation, the number of emergency endoscopies at night (22 pm - 5 am) tended to decrease (before, 7.4% vs. after, 4.1%; P=0.41) although the difference was not significant. Both the SRH identification rate (before, 18.3% vs. after, 17.6%; P = 0.90) and the rebleeding rate after 30 days of hemostasis (8.0% vs. 6.8%; P = 0.74) was comparable between two groups. The period of hospitalization was significantly shortened by 1 day after the new protocol was in operation (P = 0.02). The rate for the hemostasis method after identifying SRH using clip/EBL was 8.4%/13% before the new protocol compared with 7.5%/9.7% after the new protocol.

Conclusion

Even when emergency colonoscopic procedures for colonic diverticular hemorrhage were not performed during nighttime whenever possible according to the protocol, similar clinical outcomes were observed by setting up detailed protocols according to the different situations.
There are no different patient outcomes observed even when emergency colonoscopic procedures for colonic diverticular hemorrhage were not performed during nighttime.
Our new protocol has validity to avoid nighttime colonoscopy as much as possible.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB) and often requires blood transfusion. There are several studies regarding the use of restrictive blood transfusion for acute upper gastrointestinal bleeding, but there is only one previous study regarding the use of restrictive blood transfusion for ALGIB [1]. Therefore, the efficacy of restrictive blood transfusion for CDB remains unclear.

Aims & Methods

This study sought to elucidate the association between the restrictive blood transfusion strategy and the clinical outcomes in patients with CDB. We retrospectively analyzed 475 patients who were urgently hospitalized for CBD and received blood transfusions at two facilities between November 2013 and December 2021. Transfusion strategy was defined as the restrictive group when patients received transfusion for hemoglobin (Hb) ≤ 7 g/dl, and the liberal group when patients received for Hb > 7 g/dl. The hemoglobin cut-off value for restrictive blood transfusion was determined based on a prior randomized clinical trial regarding UGIB [2]. Rebleeding within 30-days, mortality within 30-days, and composite outcome within 30-days were evaluated. The composite outcome comprised the following endpoints: rebleeding, need for surgery or IVR for hemostasis, and mortality within 30 days. We also investigated medical costs during hospitalization. Logistic regression analysis was performed to calculate the odds ratios (OR) with 95% confidence interval (CI) to analyze associations between restrictive transfusion strategy and outcomes.

Results

Of 475 patients, 184 (38.7%) (124 males, 60 females, mean age 76.5±11.5 years) patients received blood transfusion. The mean hemoglobin levels at the time of transfusion in the restrictive and liberal groups were 6.3±0.6 g/dl and 8.2±1.2 g/dl, In the restrictive and liberal group, rebleeding within 30-days was 53.9% and 45.3% (P = 0.24), the mortality within 30-days was 1.1% and 0% (P = 0.30), the composite outcome within 30-days was 56.1% and 52.6% (P = 0.63), respectively. After adjusting for potential confounders, multivariate analysis revealed that restrictive transfusion strategy not associated with decreased rebleeding risk within 30-days, (P = 0.42 ; odds ratio [OR], 1.3), whereas endoscopic hemostasis significantly associated with decreased rebleeding risk (P < 0.01 ; OR 0.2). There was no statistically significant difference in total medical costs between the two groups (P = 0.68).

Conclusion

There were no statistically significant differences in rebleeding within 30-days, mortality within 30-days, and compositeoutcome within 30-days between the restrictive and liberal blood transfusion strategies. Restrictive blood transfusion may be a reasonable therapeutic strategy for patients with CDB, except for patients in which shock status cannot be withdrawn. However, further evidence is needed to advocated the efficacy of restrictive transfusion strategies for lower gastrointestinal bleeding.

References

[1] Kherad O, Restellini S, Martel M, Sey M, Murphy MF, Oakland K, et al. Outcomes following restrictive or free red blood cell transfusion in patients with lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2019 Apr;49(7):919–25.
[2] Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11–21.

Introduction

The global incidence of early-onset colorectal cancer is rising at an alarming rate, underscoring the urgent need for effective preventive and therapeutic strategies. While age-associated molecular and pathological alterations have been reported, the immunological landscape—particularly the roles of distinct T cell subtypes in anti-tumor immunity—remains poorly characterized in early-onset colorectal tumor, especially in endoscopically resected colorectal tumors.
In this study, we investigated the association between T cell subtype densities—specifically CD3+, CD4+, CD8+, and FOXP3+ T cells—and clinicopathological features, with a particular focus on tumors arising in younger individuals. Early-onset colorectal tumors were defined as those diagnosed before the age of 50, whereas later-onset tumors were defined as those diagnosed at age 50 or older.

Aims & Methods

This study aimed to evaluate the relationship between T cell subtypes and the clinicopathological features of early-onset colorectal tumors. We utilized a molecular pathology database comprising 169 cases of colorectal cancer and adenoma, analyzing a total of 306 colorectal lesions. Among these, 214 lesions were classified as early-onset tumors and had been resected via endoscopic techniques—including cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection—at Nippon Medical School Hospital in Japan between February 2017 and January 2020.
Formalin-fixed paraffin-embedded (FFPE) tissue blocks were collected, and immunohistochemical staining for CD3, CD4, CD8, and FOXP3 was conducted. The densities of CD3+, CD4+, CD8+, and FOXP3+ cells were quantified within tumor, stromal, and normal tissue regions. Depending on lesion size, one to five fields of view (median: five) were selected and imaged at 200x magnification using a BZX800 fluorescence microscope (KEYENCE). Automated image analysis was employed to determine the average number of each T cell subtype. Quantification within stromal and normal regions was restricted to specimens with sufficiently large resected tissue to include these areas in addition to tumor tissue. Clinicopathological variables were assessed retrospectively. Statistical analyses included the chi-square test for categorical variables, Spearman’s rank correlation for assessing associations, the Mann–Whitney U test for comparison of continuous variables, and the Kruskal–Wallis test for comparisons across three or more groups.

Results

Tumor locations were distributed as follows: 126 cases (41%) in the proximal colon, 142 cases (47%) in the distal colon, and 37 cases (12%) in the rectum. Compared with later-onset colorectal tumors, early-onset tumors had significantly lower numbers of CD3+, CD4+, and CD8+ T cells (all P <0.001). In contrast, no significant difference was observed in the number of FOXP3+ T cells between the two groups.
Additionally, the densities of CD3+, CD4+, and CD8+ T cells decreased with increasing tumor diameter (all P <0.001). The distributions of CD3+, CD8+, and FOXP3+ T cells also differed significantly by tumor location (P = 0.040, 0.006, and 0.013, respectively).

Conclusion

Analysis of endoscopically resected specimens suggests that anti-tumor immune responses mediated by T cells may vary depending on age of onset, tumor size, and tumor location. These findings highlight the need for further research to identify subsets of early-onset colorectal tumors that may require more intensive surveillance following endoscopic resection, based on their immunological profiles.

Introduction

Acute hemorrhagic rectal ulcer (AHRU) is one of the most common diseases in elderly patients with underlying medical conditions and often results in serious outcomes. Although AHRU is a potentially life-threatening disease, its characteristics and clinical course are not fully elucidated.

Aims & Methods

We aimed to clarify the clinical characteristics of patients with acute hemorrhagic rectal ulcer. We enrolled consecutive 68 AHRU patients admitting to Nippon Medical School Hospital from September 2015 to December 2022, and their clinical characteristics and outcomes were determined according to medical records retrospectively.

Results

Clinical characteristics of AHRU patients were as follows: mean age 79; including 33 males and 35 females.
31 patients (46%) had a performance status (PS) of 3 or more. Comorbidities were cardiovascular disease in 24 patients, chronic renal failure (eGFR<30 for more than 3 months) in 12 patients, cerebrovascular disease in 14 patients, chronic hepatitis and cirrhosis in 2 patients, hypertension in 33 patients, diabetes in 22 patients, and dyslipidemia in 21 patients. Medications were antiplatelet agents in 27 patients, anticoagulants in 18 patients, NSAIDs in 7 patients, and steroids in 6 patients. 24 of 68 patients (38%) underwent endoscopic hemostasis (clip in 15 cases, hemostatic forceps in 9 cases, and combined clip and HSE injection in 1 case), interventional radiology in 1 case, and transanal suture in 4 cases. Rebleeding was observed in 16 of 68 patients (24%). Rebleeding after endoscopic hemostasis was observed in 7 of 24 patients (29%), of which 3 patients performed emergency colonoscopy after rebleeding. Of the 68 patients who required blood transfusion during hospitalization, 50 patients (74%) had a mean transfusion volume of 10.6 units (2-50). 13 (19%) of the 68 patients died during hospitalization due to exacerbation of their comorbidities.

Conclusion

AHRU was more common in elderly patients with comorbidities and lowered PS. Patients with AHRU who was required for endoscopic hemostasis was associated with frequent rebleeding, and some patients were led to severe outcome due to their complications or exacerbation of comorbidities. Therefore, management of patients with AHRU should focus on not only controlling the local bleeding but also managing their comorbidities and complications.

Introduction

The incidence of early-onset colorectal cancer has been increasing worldwide, and action is urgently needed to address this problem. Although we have previously reported age-related changes with respect to molecular pathology, the vast majority remains unknown regarding the clinicopathologic characteristics of early-onset colorectal cancers and adenomas, especially those resected by endoscopic approaches. In this study, we defined early-onset colorectal tumors as adenoma and carcinoma diagnosed age at 40 or under. The aim of this study was to examine the clinicopathologic characteristics of endoscopically resected early-onset colorectal tumors compared with later-onset colorectal tumors diagnosed at age 40 or older.

Aims & Methods

We examined the clinicopathological characteristics of endoscopically resected colorectal adenomas and carcinomas in 1,005 patients with 2,367 lesions including early-onset colorectal carcinoma/adenoma (159 lesions in 96 consecutive cases from January 2010 to December 2020), late-onset colorectal carcinoma (183 lesions in 90 cases from January 2010 to December 2020), and late-onset adenoma (2,025 lesions in 819 consecutive cases from January 2020 to July 2020) endoscopically resected at the Nippon Medical School Hospital. The chi-square test was used to compare categorical variables, and the Mann-Whitney U test was used to compare continuous variables.

Results

Median age (quartiles) and sex (female/male) of cases were 37 (34-38), 34 (35%) / 62 (65%) in the early-onset tumor group; and 55 (46-72), 277 (30%) / 632 (70%) in the late-onset tumor group, respectively. The distribution rate of tumor location was 49 cases (31%) for proximal colon, 97 (61%) for distal colon, 13 (8.2%) for rectum in the early-onset group; and 1085 (49%), 899 (41%), 83 (10%) in the later-onset group, respectively. Macroscopic types were classified into Ip for 46 cases (29%), Is and Isp for 100 (63%), II for 13 (8.2%) in the early-onset group; and 278 (13%), 1574 (71%), 356 (16%) in the late-onset group, respectively. Histological types were classified into tubular adenocarcinoma or papillary carcinoma for 14 cases (8.8%), high-grade tubular adenoma (TA) for 36 (23%), low-grade TA for 97 (61%), sessile serrated lesion or traditional serrated adenoma for 12 (7.5%) in the early-onset tumor group; and 183 (8.3%), 281 (13%), 1655 (75%), 89(4%), respectively. Compared with the later-onset colorectal tumors, a higher rate of left-sided tumor location and macroscopic type Ip was observed in the early-onset colorectal tumor (p <0.001, respectively). When limited to adenoma lesions, the rate of high-grade was significantly higher in the early-onset colorectal adenomas than those in the later-onset colorectal adenomas.

Conclusion

Regarding tumor location and macroscopic type, unique clinicopathological features were observed in early-onset colorectal tumors compared with later-onset colorectal tumors. Further studies are needed to investigate the association between early-onset colorectal cancer and adenomas stratified by the method by tumor resection.