Introduction

Recurrence of colonic diverticular bleeding (CDB) can occur both in the short term and long term. The right and left sides of the colon are embryologically and hemodynamically different; thus, different rebleeding rates are expected depending on whether the diverticula are located in the right or left side of the colon. However, only few reports have specifically investigated the difference in CDB rebleeding rates between the right-sided and left-sided diverticula.

Aims & Methods

We aimed to compare the rebleeding rates in CDB between cases with right-sided and left-sided diverticula. Among the patients who underwent colonoscopy (CS) for hematochezia, and were admitted to our hospital between February 2009 and January 2022, 275 consecutive CDB patients (182 men and 93 women, mean age: 71 years) were included in the study, after excluding patients with diverticula in both sides of the colon. The diagnosis of CDB was made by CS, and the location of the diverticula was evaluated using CS and computed tomography. The right-sided group (n=167) was defined as patients with diverticula only in the right colon, and the left-sided group (n=108) was defined as patients with diverticula only in the left colon. Endoscopic treatment was indicated when stigmata of recent hemorrhage was identified during colonoscopic examination. Rebleeding was defined as significant amounts of fresh, bloody, or wine-colored stool after discharge. The cumulative rebleeding rate after discharge was compared in both groups by the Kaplan–Meier curve, using the log-rank test. The hazard ratios adjusted for age, sex, body mass index (BMI), and background factors were calculated using the Cox proportional hazards model.

Results

A total of 119 definitive CDB cases and 156 presumptive CDB cases were included in this study. Cases that underwent surgical resection of the colon during follow-up were not included in the study. Endoscopic treatment was performed in 118 patients. The median follow-up after discharge was 26 months (interquartile range: 4–55 months), and rebleeding occurred in 75 patients (27%). Cumulative rebleeding rates in the right-sided group over 1, 3, and 5 years were 18%, 26%, and 38%, while those in the left-sided group were 13%, 15%, and 23%, respectively, with significantly more rebleeding observed in the right-sided group (P = 0.002). The hazard ratio, adjusted for age, sex, BMI, and background factors, namely, alcohol consumption, performance status, white blood cell count on admission, heart failure, non-steroidal anti-inflammatory drug use, low-dose aspirin use, and endoscopic treatment, was 1.87 (95% confidence interval: 1.04–3.36).

Conclusion

After discharge from the hospital, CDB from the right-sided colon is more likely to recur than that from the left-sided colon.

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

Piecemeal endoscopic mucosal resection (pEMR) is a widely used technique for the removal of colonic lesions. Despite its effectiveness, recurrence remains a significant concern in clinical practice. Identifying factors associated with recurrence is essential for improving patient outcomes and guiding post-procedure treatment strategies. The Sydney EMR Recurrence Tool (SERT) provides a standardized method for assessing recurrence risk and identifying key factors contributing to recurrence (1).

Aims & Methods

This study aimed to evaluate the factors associated with recurrence in patients with colonic lesions ≥20 mm treated with piecemeal endoscopic mucosal resection (pEMR) and who had endoscopic follow-up. Specifically, we aimed to identify the prognostic factors using Kaplan-Meier survival analysis, log-rank tests, and multivariate Cox regression. We retrospectively analyzed data from 63 patients who underwent pEMR for colonic lesions ≥20 mm between 2021 and 2024 at a single tertiary center in Italy. The Kaplan-Meier method was used to evaluate time to recurrence based on the presence of high-grade dysplasia (HGD), right colon lesions, granular laterally spreading tumor (LST) type, and lesion size. Log-rank tests were employed to compare survival distributions between these groups. Multivariate Cox regression was used to identify independent predictors of recurrence. A p-value <0.05 was considered statistically significant.

Results

The mean age of the 63 patients was 67.6 ± 9.9 years, and the mean lesion size was 30.4 mm ± 10.6. After a mean follow-up of 7 months, the overall recurrence rate was 23.8% (15/63 patients). In univariate analysis, HGD and lesion size were the only variables associated with a higher risk of recurrence. After multivariable adjustment, only HGD was independently associated with a higher risk of recurrence (HR 5.73, 95% CI, 1.16–28.28; p = 0.03).

Conclusion

Our study highlights that high-grade dysplasia (HGD) is a significant predictor of recurrence in colonic lesions treated with pEMR, while lesion size and location did not show a significant correlation with recurrence. These findings emphasize the importance of close follow-up for patients with a diagnosis of HGD and suggest that the use of targeted surveillance strategies may improve patient outcomes after pEMR.

References

1) Tate DJ, Desomer L, Klein A, Brown G, Hourigan LF, Lee EY, Moss A, Ormonde D, Raftopoulos S, Singh R, Williams SJ, Zanati S, Byth K, Bourke MJ. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc. 2017 Mar;85(3):647-656.e6.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB). In a recent Japanese multicenter retrospective cohort study, 63.6% of patients with ALGIB were ultimately diagnosed with CDB [1]. It has also been reported that CDB in ALGIB is reportedly more severe than in other entities [2, 3]. However, few reports have demonstrated the efficacy and safety of bowel preparation for patients undergoing urgent colonoscopy.

Aims & Methods

We aim to clarify choice a of bowel preparation for urgent colonoscopy in patients with colonic diverticular bleeding. In a multicenter retrospective cohort study at 10 institutions, we analyzed the endoscopic findings and clinical course of patients diagnosed with CDB who underwent urgent colonoscopy within 24 hours after admission. Bowel preparation consisted of oral consumption of 1 to 2 L of polyethylene glycol lavage (PEL); enemas were not used. We compared those CDB patients who underwent PEL (PEL group) with a control group who did not undergo PEL (non-PEL group) before and after propensity score matching. For the matching, we selected variables known at the time of hospital admission (i.e. age, sex, comorbidities, medications, performance status, and laboratory data). The primary endpoint of the study was length of hospital stay, and secondary endpoints included blood transfusion requirements, rebleeding rates, endoscopic findings, and complications.

Results

242 patients were enrolled in this study. The median age was 76 years, and 60.7% of patients were men (n = 147). Approximately half of the patients underwent bowel preparation with PEL prior to urgent colonoscopy (n = 129). We compared with clinical findings between the PEL and non-PEL groups. The length of hospital stay was shorter in the PEL group (8.0 ± 5.1 days vs 10.9 ± 5.8 days; mean ± SD; P < 0.001). Further, the PEL group was significantly younger (72.2 ± 12.1 vs 75.4 ± 13.1; mean ± SD; P = 0.036), had fewer patients with hypertension (62.0% vs 75.2%; P = 0.027) and malignant neoplasm (1.6% vs 10.6%; P = 0.002), and had better performance statuses (86.1% vs 76.1%; P = 0.047). Patients in the PEL group received fewer blood transfusions (25.6% vs 44.3%; P = 0.002), had a higher rate of cecal completion (88.3% vs 49.6%; P < 0.001), and shorter endoscopic observation times (20.8 ± 16.2 min vs 29.9 ± 24.8 min; mean ± SD; P = 0.006). After propensity score matching, there were 91 patients each in PEL group and in non-PEL group. PEL group had a significantly shorter hospital stay (7.9 ± 4.6 days vs 10.7 ± 5.8 days; mean ± SD; P < 0.001), a higher cecum completion rate (87.8% vs 48.3%; P < 0.001), and a shorter endoscopic observation time (20.7 ± 16.8 min vs 28.9 ± 24.1 min; mean ± SD; P = 0.031) than non-PEL group. There were no significant differences in blood transfusion requirements, rebleeding rates, identification of SRH, need for endoscopic hemostatic treatment, or complication rates.

Conclusion

In patients with CDB, urgent colonoscopy under PEL resulted in shorter hospital stays, higher cecal completion rates, and shorter endoscopic observation time in urgent colonoscopy. The safety of urgent colonoscopy with PEL was comparable to colonoscopy without PEL. These results suggest that PEL is preferrable for urgent colonoscopy in patients with CDB.

References

1. Nagata N, Kobayashi K, Yamauchi A, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study. Am J Gastroenterol 2021; 116: 2222-2234.
2. Aoki T, Nagata N, Shimbo T, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2.
3. Xavier SA, Machado FJ, Magalhães JT, et al. Acute lower gastrointestinal bleeding: are STRATE and BLEED scores valid in clinical practice? Colorectal Dis 2019; 21: 357-364.

Introduction

Although the recommended method of an initial examination of hematochezia is colonoscopy, computed-enhanced CT (CECT) is an appealing diagnostic modality for the same disorder, because it has a superior ability of detecting active bleeding and it is widely available, fast, and minimally invasive. In many centers, CECT has already become an established method for characterizing the location of hematochezia. However, its impact on clinical courses of patients with colon diverticular bleeding is fully known. We conducted this study to assess them on the basis of single-center experience in Japan.

Aims & Methods

Consecutive 370 patients with colon diverticular bleeding from April 2002 to January 2023 were enrolled. Diagnosis of colon diverticular bleeding was based on total colonoscopy. Patients were divided into two groups who underwent initial examinations via CECT and colonoscopy. 
Patient attributes, clinical data, and outcomes (length of hospital stay, re-bleeding rate, blood transfusion units and 30 days survival rate) were retrospectively analyzed. The patient characteristics and outcomes were compared between two groups using χ2 test or Fisher’s exact test.

Results

279 patients were men (75.4%). The average age was 70.0(30-94) years old.  Initial CECT was performed to 204 patients (Group A) (54.9%) and remaining 166(group B).  
Patients in group A were more likely to have cerebrovascular disorder.
Findings for other characteristics were similar between two groups. 
In Group A, CECT revealed extravasation in 110 patients (53.9%). 
Emergent colonoscopy was performed in 118 patients (extravasation positive 100: negative 18) and found bleeding point in 46 patients (extravasation positive 43: negative 3). 
In Group B, emergent colonoscopy was performed in 70 patients and found bleeding point in 19(27.1%) patients. 
Patients in group A required more blood transfusion units than group B significantly (3.36 ± 6.28 units in group A vs. 1.53 ± 2.96 units in Group B, p=0.001).
No significant difference was observed in terms of length of hospital stay (10.64 ± 7.11 days in group A vs.9.95 ± 5.37 days in Group B ,p=0.32) , recurrent bleeding rate (23.6 % in group A vs. 23.4 % in Group B, OR 1.016 ,p=1) , and 30 days survival rate (99.5% in Group A vs. 100 % in Group B, OR 1.005 ,p=1)

Conclusion

Emergent colonoscopy, subsequent to initial CECT which revealed extravasation, can detect bleeding point more efficiently in patients with colon diverticular bleeding. But, CECT did not improve clinical outcomes of these patients in this study.

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.