Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 21, 2021; 27(19): 2353-2365
Published online May 21, 2021. doi: 10.3748/wjg.v27.i19.2353
Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease
Jiyoung Yoon, Dae Sung Kim, Ye-Jee Kim, Jin Wook Lee, Seung Wook Hong, Ha Won Hwang, Sung Wook Hwang, Sang Hyoung Park, Dong-Hoon Yang, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Suk-Kyun Yang
Jiyoung Yoon, Dae Sung Kim, Jin Wook Lee, Seung Wook Hong, Ha Won Hwang, Sung Wook Hwang, Sang Hyoung Park, Dong-Hoon Yang, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Suk-Kyun Yang, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
Ye-Jee Kim, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
Author contributions: Yoon J and Kim DS equally contributed to this article; Yoon J and Kim DS collected and analyzed data, and drafted the manuscript; Kim YJ supervised the research and contributed to analysis; Lee JW, Hong SW, Hwang HW, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, and Myung SJ were involved in study patient enrollment, data collection, and data analysis; Yang SK was involved in study design, supervision, and critical revision of the study; all authors read and approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of Asan Medical Center, No. 2020-0814.
Informed consent statement: The requirement for informed consent was waived by the Institutional Review Board considering the retrospective design of the study.
Conflict-of-interest statement: All authors have no conflict of interest related to the study.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Suk-Kyun Yang, PhD, Professor, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea. sky@amc.seoul.kr
Received: February 5, 2021
Peer-review started: February 5, 2021
First decision: February 27, 2021
Revised: March 5, 2021
Accepted: April 25, 2021
Article in press: April 25, 2021
Published online: May 21, 2021
Abstract
BACKGROUND

Acute severe lower gastrointestinal bleeding (LGIB) is an uncommon but challenging complication of Crohn’s disease (CD).

AIM

To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.

METHODS

A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center, a tertiary university hospital in Korea. Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB. A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.

RESULTS

Multivariable Cox regression analysis revealed that early use of thiopurines [hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.48; P < 0.001] and female sex (HR: 0.51, 95%CI: 0.27-0.94; P = 0.031) were significantly associated with a lower risk of acute severe LGIB. The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups (P = 0.139 and P = 0.769, respectively). The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group (22.1/100 vs 13.2/100 patient-years; P = 0.012). However, if hospitalizations due to bleeding episodes were excluded from the analysis, the hospitalization rate was not significantly different between the bleeding group and the matched non-bleeding group (14.5/100 vs 13.2/100 patient-years; P = 0.631).

CONCLUSION

Early use of thiopurines may reduce the risk of acute severe LGIB. History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Keywords: Gastrointestinal hemorrhage, Lower gastrointestinal tract, Crohn’s disease, Risk factors, Cohort studies, Clinical course

Core Tip: A retrospective cohort study was conducted to identify the predictors of acute severe lower gastrointestinal bleeding (LGIB) in Crohn’s disease (CD) and the impact of acute severe LGIB on the subsequent clinical course thereof. In multivariable analysis, early use of thiopurines and female sex were associated with a lower risk of acute severe LGIB. Moreover, matched analyses within the cohort demonstrated that the risks of behavioral progression, intestinal resection, and hospitalization due to non-bleeding causes did not significantly differ according to bleeding, which suggests that a history of acute severe LGIB may not have a significant prognostic value in CD.