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Kim KO. Recent updates on classification and unsolved issues of diverticular disease: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:252-260. [PMID: 39209318 PMCID: PMC11534408 DOI: 10.12701/jyms.2024.00542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 06/26/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
Recently, a paradigm shift has occurred in the classification of diverticular disease and the understanding of its pathogenesis. Diverticular disease is now defined as a variety of clinically significant conditions such as diverticulitis, diverticular bleeding, symptomatic uncomplicated diverticular disease, and segmental colitis associated with diverticulosis. Low-grade inflammation, visceral hypersensitivity, abnormal intestinal motility, and genetic factors have emerged as the key contributors to the pathogenesis of diverticular disease. Routine antibiotic use is no longer recommended for all cases of diverticulitis, and simple recurrence is not an indication for surgical treatment. Early colonoscopy with proper preparation is recommended for the treatment of diverticular bleeding, although recent studies have not shown significant efficacy in preventing recurrence. The roles of dietary fiber, nonabsorbable antibiotics, 5-aminosalicylates, and probiotics in the prevention of diverticular disease are controversial and require further investigation.
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Affiliation(s)
- Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Fusco S, Bauer ME, Schempf U, Stüker D, Blumenstock G, Malek NP, Werner CR, Wichmann D. Analysis of Predictors and Risk Factors of Postpolypectomy Syndrome. Diagnostics (Basel) 2024; 14:127. [PMID: 38248004 PMCID: PMC10814321 DOI: 10.3390/diagnostics14020127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/26/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND AIMS Postpolypectomy syndrome (PPS) is a relevant adverse event that can appear after polypectomy. Several publications mention postpolypectomy syndrome using different criteria to define it. The aim of this study is to detect potential risk factors and predictors for developing PPS and to define the main criteria of PPS. METHODS In this retrospective monocentric study, 475 out of 966 patients who underwent colonoscopy with polypectomy from October 2015 to June 2020 were included. The main criterion of PPS is defined as the development of postinterventional abdominal pain lasting more than six hours. RESULTS A total of 9.7% of the patients developed PPS, which was defined as local abdominal pain around the polypectomy area after six hours. A total of 8.6% of the study population had abdominal pain within six hours postintervention. A total of 3.7% had an isolated triad of fever, leukocytosis, and increased CRP in the absence of abdominal pain. Increased CRP combined with an elevated temperature over 37.5 °C seems to be a positive predictor for developing PPS. Four independent risk factors could be detected: serrated polyp morphology, polypoid configurated adenomas, polyp localization in the cecum, and the absence of intraepithelial neoplasia. CONCLUSIONS Four independent risk factors for developing PPS were detected. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology. As expected, the increasing use of cold snare polypectomies will reduce the incidence of this syndrome. Key summary: Our monocentric study on 966 patients detected four independent risk factors for developing PPS: pedunculated polyp, resected polyps in the cecum, absence of IEN, and serrated polyp morphology. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology.
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Affiliation(s)
- Stefano Fusco
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Michelle E. Bauer
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Ulrike Schempf
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Dietmar Stüker
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology, Eberhard-Karls-University, 72076 Tübingen, Germany
| | - Nisar P. Malek
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Christoph R. Werner
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
| | - Dörte Wichmann
- Department of Internal Medicine I, Section of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital of Tübingen, 72076 Tübingen, Germany (U.S.); (N.P.M.); (C.R.W.); (D.W.)
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Sano T, Ishikawa T, Azumi M, Sato R, Jimbo R, Kobayashi Y, Sato T, Iwanaga A, Yokoyama J, Honma T. Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization. Medicine (Baltimore) 2023; 102:e35092. [PMID: 37713820 PMCID: PMC10508449 DOI: 10.1097/md.0000000000035092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/15/2023] [Indexed: 09/17/2023] Open
Abstract
This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.
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Affiliation(s)
- Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Jimbo
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toshifumi Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Junji Yokoyama
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
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Bhatia M, Mattoo A. Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends. Cureus 2023; 15:e43158. [PMID: 37565180 PMCID: PMC10410187 DOI: 10.7759/cureus.43158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 08/12/2023] Open
Abstract
Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.
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Affiliation(s)
- Mohit Bhatia
- Surgery Department, Princess Royal University Hospital, King's College, Orpington, GBR
| | - Aastha Mattoo
- Emergency Department, Princess Royal University Hospital, King's College, Orpington, GBR
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Chang CY, Hsu TY, He GY, Shih HM, Wu SH, Huang FW, Chen PC, Tsai WC. Utility of monocyte distribution width in the differential diagnosis between simple and complicated diverticulitis: a retrospective cohort study. BMC Gastroenterol 2023; 23:96. [PMID: 36977993 PMCID: PMC10047462 DOI: 10.1186/s12876-023-02736-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis. METHODS This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher's exact test. The Mann-Whitney U test was used for continuous variables. Multivariable regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases. RESULTS Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784-0.956); CRP, 0.800 (95% CI, 0.707-0.892); NLR, 0.724 (95% CI, 0.616-0.832); PLR, 0.662 (95% CI, 0.525-0.798); and WBC, 0.679 (95% CI, 0.563-0.795). When the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively. CONCLUSIONS A large MDW was a significant and independent predictor of complicated diverticulitis. The optimal cutoff value for MDW is 20.38 as it exhibits maximum sensitivity and specificity for distinguishing between simple and complicated diverticulitis The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.
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Affiliation(s)
- Chang-Yuan Chang
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tai-Yi Hsu
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Guan-Yi He
- Department of Dermatology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hong-Mo Shih
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Shih-Hao Wu
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Exercise Health Science, National Taiwan University of Sport, Taichung, Taiwan
| | - Fen-Wei Huang
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Pei-Chun Chen
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, No. 100, Sec. 1, Jingmao Rd., Beitun Dist., Taichung City, 406040, Taiwan.
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Hui JWQ, En JWQ, Lau J, Te Neng L, Wong SK. Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding. ANZ J Surg 2022; 92:3247-3252. [PMID: 36074650 DOI: 10.1111/ans.18023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUNDS Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. METHODS The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). RESULTS From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. CONCLUSION A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.
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Affiliation(s)
| | | | - Joel Lau
- NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Lau Te Neng
- Department of Radiology, Mount Elizabeth Novena Hospital, Singapore
| | - Soong Kuan Wong
- The Colorectal Clinic Pte Ltd, Mt Elizabeth Novena Hospital, Singapore, Singapore
- NUS Yong Loo Lin School of Medicine, Singapore, Singapore
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Nozawa Y, Michimoto K, Ashida H, Baba A, Fukuda T, Ojiri H. Inferior vena cava diameter on CT angiography predicts mesenteric angiography positive for extravasation in colonic diverticular bleeding. LA RADIOLOGIA MEDICA 2022; 127:1412-1419. [PMID: 36208385 DOI: 10.1007/s11547-022-01564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/24/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Transcatheter arterial embolization (TAE) for colonic diverticular bleeding (CDB), an established procedure for hemostasis, is sometimes complicated by spontaneous hemostasis and unclear bleeding site on angiography despite active arterial bleeding on preoperative computed tomography angiography (CTA). Therefore, to investigate and increase the feasibility of TAE, this retrospective study evaluates the clinical and radiological features related to positive extravasation on angiography. MATERIAL AND METHODS Sixty CDB patients with extravasation on CTA underwent TAE between January 2011 and February 2021 and were divided into extravasation-positive (P-group; n = 25) and -negative groups (N-group; n = 35) based on the superior or inferior mesenteric angiography. Patient characteristics, laboratory findings, the diameter of the inferior vena cava (IVCD), the diameter of superior and inferior mesenteric veins, and technical outcomes were evaluated. RESULTS TAE was successful in 24 patients in the P-group (96%) and 14 in the N-group (40%) (p < 0.001). Univariate analysis revealed "usage of anticoagulant" (p < 0.05) and "larger IVCD (p < 0.05) on preoperative CTA" to be significant predictors of positive extravasation. In the multivariate analysis, IVCD remained significant with an adjusted odds ratio of 1.17. The IVCD cutoff value was 13.6 mm (area under the curve = 0.72, sensitivity = 84.0%, specificity = 54.3%). There were no significant differences in other parameters. CONCLUSION Measurement of IVCD in CDB with the cutoff value of 13.6 mm can be a simple and useful indicator to predict the detectability of extravasation following TAE procedures.
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Affiliation(s)
- Yosuke Nozawa
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan.
| | - Kenkichi Michimoto
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Hirokazu Ashida
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Akira Baba
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Takeshi Fukuda
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, Jikei University Hospital, Jikei University, 3-19-18, Nishishinbashi, Minato-ku, Tokyo, Japan
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Okada T, Mikamo T, Nakashima A, Yanagitani A, Tanaka K, Isomoto H. Construction of a Model for Predicting the Severity of Diverticular Bleeding in an Elderly Population. Intern Med 2022; 61:2247-2253. [PMID: 35022353 PMCID: PMC9424098 DOI: 10.2169/internalmedicine.8761-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective To identify the risk factors for severe diverticular bleeding in an elderly population. Methods Using a comprehensive computerized hospital database, severe and non-severe diverticular bleeding cases were compared for 19 factors: the age, sex, body mass index, comorbid conditions (hypertension, cardiovascular disease, cerebrovascular disease, and chronic renal failure, including those undergoing dialysis), history of diverticular bleeding, use of low-dose aspirin, use of antiplatelet agent besides aspirin, use of anticoagulant agent, use of prednisolone, use of non-steroidal anti-inflammatory drugs, use of cyclooxygenase-2 selective inhibitors, changes in vital signs, hypoalbuminemia, bilateral diverticula, identification of bleeding lesion, and rebleeding. Severe bleeding was defined as the need for blood transfusion, emergency surgery, or vascular embolization. Patients A total of 258 patients were admitted for lower gastrointestinal bleeding between August 2010 and July 2020, among whom 120 patients over 65 years old diagnosed with diverticular bleeding were included in this study. Results Fifty-one patients (43%) had severe diverticular bleeding. Independent risk factors for severe diverticular bleeding were as follows: change in vital signs [odds ratio (OR), 5.23; 95% confidence interval (CI), 1.9-14.4; p=0.0014], hypoalbuminemia (OR, 12.3; 95% CI, 1.97-77.3; p=0.0073), bilateral diverticula (OR, 3.47; 95% CI, 1.33-9.02; p=0.011), and rebleeding (OR, 5.92; 95% CI, 2.21-15.8; p<0.001). The area under the receiver operating characteristic curve was 0.79 after cross validation. Conclusion Severe diverticular bleeding in elderly population may be predicted by changes in their vital signs, hypoalbuminemia, bilateral diverticula, and rebleeding.
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Affiliation(s)
| | | | | | | | | | - Hajime Isomoto
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Japan
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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: 0.3] [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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10
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Bahin FF, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Farzan Fahrtash Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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Eckmann JD, Shaukat A. Updates in the understanding and management of diverticular disease. Curr Opin Gastroenterol 2022; 38:48-54. [PMID: 34619712 DOI: 10.1097/mog.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Diverticulosis leads to significant morbidity and mortality and is increasing in prevalence worldwide. In this paper, we review the clinical features, diagnosis, and management of diverticular disorders, followed by a discussion of recent updates and changes in the clinical approach to diverticular disease. RECENT FINDINGS Recent literature suggests that antibiotics are likely not necessary for low-risk patients with acute uncomplicated diverticulitis, and not all patients with recurrent diverticulitis require colectomy. Dietary restrictions do not prevent recurrent diverticulitis. Visceral hypersensitivity is increasingly being recognized as a cause of persistent abdominal pain after acute diverticulitis and should be considered along with chronic smoldering diverticulitis, segmental colitis associated with diverticula, and symptomatic uncomplicated diverticular disease. SUMMARY Clinicians should be aware that traditionally held assumptions regarding the prevention and management of diverticular disorders have recently been called into question and should adjust their clinical practice accordingly.
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Affiliation(s)
- Jason D Eckmann
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Division of Gastroenterology NYU Langone, New York, New York, USA
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12
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Papa A, Vetrone LM, Nakajima A, Yamada E. Prevalence of Diverticulosis and Diverticular Disease. COLONIC DIVERTICULAR DISEASE 2022:3-12. [DOI: 10.1007/978-3-030-93761-4_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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13
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Sato Y, Yasuda H, Nakamoto Y, Kiyokawa H, Yamashita M, Matsuo Y, Maehata T, Yamamoto H, Mimura H, Itoh F. Risk factors of interventional radiology/surgery for colonic diverticular bleeding. JGH OPEN 2021; 5:343-349. [PMID: 33732880 PMCID: PMC7936614 DOI: 10.1002/jgh3.12499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 01/23/2023]
Abstract
Background and Aim Colonic diverticular bleeding (CDB) stops spontaneously, but sometimes, excessive bleeding does not allow hemostasis and requires interventional radiology (IR)/surgery. We examined risk factors in patients who required IR/surgery for CDB and late recurrent bleeding rate after IR/surgery. Methods This retrospective case-control study was conducted at a tertiary center. We included 608 patients who required hospitalization for CDB. Patients were investigated for risk factors using logistic regression analysis. We also investigated early and late recurrent bleeding rates following IR/surgery. Results In 261 patients (42.9%), the bleeding source was identified, and endoscopic hemostasis was performed; 23 (3.8%) required IR/surgery. In multivariate analysis, shock state with a blood pressure of ≤90 mmHg (P < 0.001; odds ratio [OR], 20.1; 95% confidence interval [CI], 5.08-79.5), positive extravasation on contrast-enhanced computed tomography (P < 0.001; OR 9.5, 95% CI 2.85-31.4), two or more early recurrent bleeding episodes (P = 0.002; OR 7.4, 95% CI 2.14-25.4), and right colon as the source of bleeding (P = 0.023; OR 4.1, 95% CI 1.25-14.0) were independent risk factors requiring IR/surgery. Early recurrent bleeding was observed in 0% and 28.0% patients (P < 0.001) in the IR/surgery and no IR/surgery groups, respectively, whereas late recurrent bleeding rate was observed in 43.4% and 30.7% patients (P = 0.203) in the IR/surgery and no IR/surgery groups, respectively. Four patients who required surgery experienced late recurrent bleeding at a site different from the initial CDB. Conclusions Although IR/surgery is an effective hemostatic treatment wherein endoscopic treatment is unsuccessful, late recurrent bleeding cannot be prevented.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hiroshi Yasuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yusuke Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hirofumi Kiyokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Masaki Yamashita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yasumasa Matsuo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Tadateru Maehata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hiroyuki Yamamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hidefumi Mimura
- Department of Radiology St. Marianna University School of Medicine Kawasaki Japan
| | - Fumio Itoh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
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Imaeda H, Hibi T. The Burden of Diverticular Disease and Its Complications: West versus East. Inflamm Intest Dis 2018; 3:61-68. [PMID: 30733949 PMCID: PMC6361582 DOI: 10.1159/000492178] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 07/17/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Colonic diverticulosis is prevalent and increasing not only in Western but also in Asian countries. Diverticulosis can be complicated by diverticulitis and diverticular bleeding. Diverticular disease is a burdensome digestive disease, because it is a major cause of hospital admissions and is associated with significant health-care costs. SUMMARY The incidence of diverticulosis increases with age. Most cases of diverticulosis in Western countries involve the left side of the colon, while diverticulosis is predominantly present on the right side of the colon in Asian countries. The incidence of diverticulitis also increases with age. Diverticulitis is predominantly located on the left side of the colon in Western countries, while it is predominantly located on the right side of the colon in Asian countries. The overall complication rate is higher in left-sided than in right-sided diverticulitis. The incidence of diverticular bleeding also increases with age. The right colon is the source of diverticular bleeding in more than 50% of patients in Western countries. In Asian countries, age greater than 70 years and both-sided diverticulosis increase the bleeding risk. KEY MESSAGES In Western countries, diverticulosis and diverticulitis are predominantly located on the left side of the colon, whereas they are predominantly present on the right side of the colon in Asian countries. Diverticular bleeding is predominantly located on the right side in Western countries, and both-sided diverticulosis increases the risk of bleeding in Asian countries. Diverticular disease with complications requires admission and operation; moreover, it recurs frequently. Therefore, diverticular disease is associated with a significant economic burden in terms of health-care costs and resource utilization.
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Affiliation(s)
- Hiroyuki Imaeda
- Department of Gastroenterology, Saitama Medical University, Saitama, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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15
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Ng JL, Marican M, Mathew R. Topical haemostatic powder as a novel endoscopic therapy for severe colonic diverticular bleeding. ANZ J Surg 2018; 89:E56-E60. [DOI: 10.1111/ans.14895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/28/2018] [Accepted: 09/03/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Jia Lin Ng
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
| | - Musfirah Marican
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
| | - Ronnie Mathew
- Department of Colorectal Surgery; Singapore General Hospital; Singapore
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16
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Mizuki A, Tatemichi M, Nagata H. Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed! Inflamm Intest Dis 2018; 3:100-106. [PMID: 30733954 DOI: 10.1159/000490387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background/Summary Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is "preferable." Key Messages This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.
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Affiliation(s)
- Akira Mizuki
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
| | - Masayuki Tatemichi
- Department of Community Health, Tokai University School of Medicine, Isehara, Japan
| | - Hiroshi Nagata
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
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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: 0.7] [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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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: 23] [Impact Index Per Article: 3.3] [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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19
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Abstract
Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.
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Affiliation(s)
| | - Vikram Jala
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
| | | | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
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20
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Arimoto J, Higurashi T, Kato S, Fuyuki A, Ohkubo H, Nonaka T, Yamaguchi Y, Ashikari K, Chiba H, Goto S, Taguri M, Sakaguchi T, Atsukawa K, Nakajima A. Risk factors for post-colorectal endoscopic submucosal dissection (ESD) coagulation syndrome: a multicenter, prospective, observational study. Endosc Int Open 2018; 6. [PMID: 29527556 PMCID: PMC5842075 DOI: 10.1055/s-0044-101451] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Colorectal cancer (CRC) is one of the most common neoplasms and endoscopic submucosal dissection (ESD) is an effective treatment for early-stage CRC. However, it has been observed that patients undergoing ESD often complain of pain, even if ESD has been successfully performed. Risk factors for such pain still remain unknown. The aim of this study was to explore the risk factors for post-colorectal ESD coagulation syndrome (PECS). PATIENTS AND METHODS This was a prospective multicenter observational trial (UMIN000016781) conducted in 106 of 223 patients who underwent ESD between March 2015 and April 2016. We investigated age, sex, tumor location, ESD operation time, lesion size, duration of hospitalization, and frequency of PECS. We defined PECS as local abdominal pain (evaluated on a visual analogue scale) in the region corresponding to the site of the ESD that occurred within 4 days of the procedure. RESULTS PECS occurred in 15/106 (14.2 %), and 10 were women ( P = 0.01, OR: 7.74 [1.6 - 36.4]), 7 had lesions in the cecum ( P < 0.001, OR: 20.6 [3.7 - 115.2]), and 9 in whom ESD operation time was > 90 min ( P = 0.002, OR: 10.3 [2.4 - 44.6]). Frequency of deviation from the prescribed clinical path was significantly higher (47 % [7/15] vs. 2 % [2/91], P < 0.001, OR: 38.9 [6.9 - 219.6]), and hospital stay was significantly longer in the PECS group. . CONCLUSIONS Female gender, location of lesion in the cecum, and ESD operation time > 90 minutes were significant risk factors independent of PECS. These findings are important to management of PECS. .
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Affiliation(s)
- Jun Arimoto
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Akiko Fuyuki
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Hidenori Ohkubo
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takashi Nonaka
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Critical Care, Yokohama City University School of Medicine, Yokohama, Japan
| | - Keiichi Ashikari
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | - Shungo Goto
- Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Japan
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takashi Sakaguchi
- Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Japan
| | - Kazuhiro Atsukawa
- Department of Gastroenterology, Hiratsuka City Hospital, Hiratsuka, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan,Corresponding author Atsushi Nakajima 3-9 Fukuura, Kanazawa-kuYokohama 236-0004Japan+81-45-784-3546
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Dirweesh A, Amodu A, Khan M, Zijoo R, Ambreen B, Ibrahim M, Ijaz M, Nawwar A, Genena K, Tahir M, Kumar N, Debari VA, Wallach S. Symptomatic Diverticular Disease in Patients With Severely Reduced Kidney Function: Higher Rates of Complications and Transfusion Requirement. Gastroenterology Res 2017; 10:15-20. [PMID: 28270872 PMCID: PMC5330688 DOI: 10.14740/gr784w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 12/31/2022] Open
Abstract
Background The prevalence of diverticulosis is increasing with 5-10% of patients developing diverticulitis and 5-15% developing symptomatic bleeding. Diverticulitis can result in abscess, perforation, fistula, or obstruction. Bleeding has combined morbidity and mortality rates of 10-20%. The purpose of this study was to compare diverticulitis-related complications and transfusion requirements for diverticular bleeding in patients with normal to moderately reduced kidney function (glomerular filtration rate (GFR) ≥ 30 mL/min/1.73 m2) and patients with severe renal impairment (GFR < 30 mL/min/1.73 m2), and identify factors associated with these outcomes. Methods We retrospectively reviewed records of all patients with diverticulitis and diverticular bleeding treated at our hospital from January 1, 2011 to July 31, 2016. Patients were evaluated for baseline characteristics, GFR, baseline hemoglobin, medications, comorbidities, length of stay (LOS), presence of perforations or abscesses and the need for transfusion. Results Of the 291 patients included, males were 167 (58%). Perforations and abscesses complicating diverticulitis developed in 31/136 (23%) of patients with GFR ≥ 30 mL/min/1.73 m2, and in 13/26 (50%) of patients with GFR < 30 mL/min/1.73 m2 (odds ratio (OR): 3.4; 95% confidence interval (CI): 1.423 - 8.06; P = 0.0073). Mean LOS (days) was 6.3 ± 4 in the GFR ≥ 30 mL/min/1.73 m2 group and 8.5 ± 4.4 in GFR < 30 mL/min/1.73 m2 group (P = 0.0001). Blood transfusion for diverticular bleeding occurred in 11/78 (14%) of patients with GFR ≥ 30 mL/min/1.73 m2 and in 22/51 (43%) of patients with GFR < 30 mL/min/1.73 m2 (OR: 4.6; 95% CI: 1.99 - 10.76; P = 0.0004). Among patients who needed transfusion, mean LOS was 8.5 ± 2.5 in GFR ≥ 30 mL/min/1.73 m2 group and 9 ± 5 in those with GFR < 30 mL/min/1.73 m2 (P = 0.04). There were no differences in age, gender or race between the study groups. Conclusion There was a significant increase in complicated diverticulitis cases, transfusion requirements for diverticular bleeding and LOS in patients with severely reduced kidney function compared to patients with normal-moderately reduced renal function.
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Affiliation(s)
- Ahmed Dirweesh
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Afolarin Amodu
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Muhammad Khan
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Ritika Zijoo
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Bushra Ambreen
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Mohammad Ibrahim
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Muhammad Ijaz
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Abdelhameed Nawwar
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Kareem Genena
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Muhammad Tahir
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Naresh Kumar
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Vincent A Debari
- Department of Internal Medicine, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
| | - Sara Wallach
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
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Uno Y, van Velkinburgh JC. Logical hypothesis: Low FODMAP diet to prevent diverticulitis. World J Gastrointest Pharmacol Ther 2016; 7:503-512. [PMID: 27867683 PMCID: PMC5095569 DOI: 10.4292/wjgpt.v7.i4.503] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
Despite little evidence for the therapeutic benefits of a high-fiber diet for diverticulitis, it is commonly recommended as part of the clinical management. The ongoing uncertainty of the cause(s) of diverticulitis confounds attempts to determine the validity of this therapy. However, the features of a high-fiber diet represent a logical contradiction for colon diverticulitis. Considering that Bernoulli’s principle, by which enlarged diameter of the lumen leads to increased pressure and decreased fluid velocity, might contribute to development of the diverticulum. Thus, theoretically, prevention of high pressure in the colon would be important and adoption of a low FODMAP diet (consisting of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help prevent recurrence of diverticulitis.
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Yamashina T, Takeuchi Y, Uedo N, Hamada K, Aoi K, Yamasaki Y, Matsuura N, Kanesaka T, Akasaka T, Yamamoto S, Hanaoka N, Higashino K, Ishihara R, Iishi H. Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm. J Gastroenterol Hepatol 2016. [PMID: 26202127 DOI: 10.1111/jgh.13052] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is a promising treatment for large gastrointestinal superficial neoplasms, although it is technically difficult, and perforation and delayed bleeding are well-known adverse events. However, there have been no large studies about electrocoagulation syndrome after colorectal ESD. The aim of this study was to evaluate the incidence and clinical significant risk factors of post-ESD coagulation syndrome (PECS). METHODS This was a retrospective cohort study conducted in a referral cancer center. A total of 336 patients with colorectal neoplasms (143 adenomas or serrated lesions and 193 carcinomas) underwent ESD from January 2011 to June 2013. Incidence, outcome, and factors associated with occurrence of PECS were investigated. RESULTS Occurred in 32 patients (9.5%). The median time until PECS was 15.5 h, and the median period of PECS was 32.5 h. Fever (≥37.6 °C) after ESD was found in 41% of the PECS group and 9% of the non-PECS group (P < 0.001). All PECS cases were managed conservatively. On multivariate analysis, female patients (odds ratio [OR] = 3.2, P = 0.002), lesion location at ascending colon and cecum (OR = 3.5, P = 0.001), and resected specimen ≥40 mm (OR = 2.1, P = 0.05) were independent risk factors for PECS. CONCLUSIONS Occurred in 32 patients (9.5%) with colorectal ESD; however, all cases had a good outcome with conservative management. Female sex, tumor location at the ascending colon and cecum, and resected specimen ≥40 mm were independently significant risk factors for PECS.
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Affiliation(s)
- Takeshi Yamashina
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.,Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Kenta Hamada
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Kenji Aoi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Yasushi Yamasaki
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Tomofumi Akasaka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Noboru Hanaoka
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hiroyasu Iishi
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Aicart-Ramos M, Mesonero F, Parejo S, Peñas B. Enfermedad diverticular del colon. MEDICINE - PROGRAMA DE FORMACIÓN MÉDICA CONTINUADA ACREDITADO 2016; 12:285-296. [DOI: 10.1016/j.med.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Abstract
Lower gastrointestinal bleeding (LGIB) is a frequent reason for hospitalization especially in the elderly. Patients with LGIB are frequently admitted to the intensive care unit and may require transfusion of packed red blood cells and other blood products especially in the setting of coagulopathy. Colonoscopy is often performed to localize the source of bleeding and to provide therapeutic measures. LGIB may present as an acute life-threatening event or as a chronic insidious condition manifesting as iron deficiency anemia and positivity for fecal occult blood. This article discusses the presentation, diagnosis, and management of LGIB with a focus on conditions that present with acute blood loss.
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Affiliation(s)
- Emad Qayed
- Grady Memorial Hospital, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, USA
| | - Gaurav Dagar
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53188, USA
| | - Rahul S Nanchal
- Critical Care Fellowship Program, Medical Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Nakano K, Ishii N, Ikeya T, Ego M, Shimamura Y, Takagi K, Nakamura K, Fukuda K, Fujita Y. Comparison of long-term outcomes between endoscopic band ligation and endoscopic clipping for colonic diverticular hemorrhage. Endosc Int Open 2015; 3:E529-33. [PMID: 26528513 PMCID: PMC4612232 DOI: 10.1055/s-0034-1392510] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Long-term outcomes of endoscopic band ligation (EBL) for colonic diverticular hemorrhage have not been reported to date. The aim of this study was to determine the long-term outcomes of EBL and to retrospectively compare them with those of endoscopic clipping (EC) in the treatment of colonic diverticular hemorrhage. PATIENTS AND METHODS The study included patients with colonic diverticular hemorrhage who were treated with EBL or EC from January 2004 to November 2014 and followed up more than 1 year (61 patients in the EBL group and 39 patients in the EC group). Time-to-event analysis of rebleeding was performed with the Kaplan-Meier method. A follow-up colonoscopy was performed to confirm the disappearance of the banded diverticula in the EBL group. RESULTS Rebleeding occurred in 21 patients in the EBL group and in 26 patients in the EC group. The cumulative incidence of rebleeding at 1, 12, 24, and 36 months after first treatments was 14 %, 23 %, 26 %, and 41 % in the EBL group and 38 %, 49 %, 59 %, and 68 % in the EC group, respectively. Time-to-event analysis revealed statistically significant data (Log-rank test, P = 0.0036). Scar formation with fold convergence at the previously banded site was observed in 11 of 24 patients who underwent follow-up colonoscopy (46 %). However, late rebleeding (rebleeding more than 30 days after EBL) occurred in five of these 11 cases. CONCLUSIONS EBL was superior to EC in the treatment of colonic diverticular hemorrhage. However, the risk of rebleeding was not avoided even after the diverticula had been resolved using EBL.
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Affiliation(s)
- Kaoru Nakano
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Naoki Ishii
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan,Corresponding author Naoki Ishii, MD Department of GastroenterologySt. Luke’s International Hospital9-1 Akashi-choChuo-kuTokyo, Japan 104-8560+81-3-3544-0649
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Mai Ego
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Koichi Takagi
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Kenji Nakamura
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
| | - Yoshiyuki Fujita
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
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Mehrzad R, Mishra S, Faller G, Memon B, Fiore J. Right-Sided Diverticulosis and Disparities from Left-Sided Diverticulosis in the Vietnamese Population Living in Boston, Mass., USA: A Retrospective Cohort Study. Med Princ Pract 2015; 24:355-61. [PMID: 25924839 PMCID: PMC5588236 DOI: 10.1159/000381548] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 03/10/2015] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To report the prevalence, clinical differences and complications of right-sided diverticulosis (RD) and to investigate the potential disparities from left-sided diverticulosis (LD) in the Vietnamese population. SUBJECTS AND METHODS A retrospective cohort study was conducted using medical records of Vietnamese-born patients from 2000 to 2013 in a community teaching hospital in Boston, Mass., USA. By simple randomization, a randomized control group of 299 Caucasian patients was also selected from the same time frame [167 males (M) and 132 females (F)]. Colonoscopy reports were reviewed for demographics (age and gender), indication and anatomical location of the colonic diverticulosis (CD), concomitant colonic findings, symptoms, and endoscopic complications. RESULTS A total of 207 patients were included in the Vietnamese cohort (mean age 61.6 ± 8.9 years). The mean age at first screening colonoscopy was 58.2 ± 7.2 years (114 F/92 M, 55.7/44.4%). Our study identified 104 (50.5%) patients with LD (57 M/47 F), 65 (31.1%) with RD (35 M/30 F) and 38 (18.4%) with both LD and RD (23 M/15 F); 133 (64%) were asymptomatic. A total of 21 (33%) patients with RD were symptomatic. The mean age of the control group was 61.6 ± 8.1 years. The average age at first screening colonoscopy was 52.8 ± 6.4 years. Of the 299 in the Caucasian group, 254 (84.9%) had LD (114 M/140 F), 9 (3.0%) had RD (2 M/7 F) and 36 (12%) had both LD and RD (16 M/20 F); 225 (75%) were asymptomatic and came in for screening colonoscopies. A total of 2 patients (22%) with RD were symptomatic. CONCLUSION RD was common in this Vietnamese population, and the prevalence was higher than in the Caucasian control group.
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Affiliation(s)
- Raman Mehrzad
- Department of Internal Medicine, Steward Carney Hospital, Boston, USA
- *Raman Mehrzad, MD, Steward Carney Hospital, 2100 Dorchester Ave., Boston, MA 02169 (USA), E-Mail
| | - Suprav Mishra
- Department of Internal Medicine, Steward Carney Hospital, Boston, USA
| | - Garrey Faller
- Department of Pathology, Steward Carney Hospital, Boston, USA
| | - Babar Memon
- Department of Internal Medicine, Steward Carney Hospital, Boston, USA
| | - Joseph Fiore
- Department of Medicine, Division of Gastroenterology, Steward Carney Hospital, Boston, Mass., USA
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Endoscopic management of diverticular bleeding. Gastroenterol Res Pract 2014; 2014:353508. [PMID: 25548554 PMCID: PMC4274660 DOI: 10.1155/2014/353508] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 11/23/2014] [Indexed: 02/07/2023] Open
Abstract
Diverticular hemorrhage is the most common reason for lower gastrointestinal bleeding (LGIB) with substantial cost of hospitalization and a median length of hospital stay of 3 days. Bleeding usually is self-limited in 70-80% of cases but early rebleeding is not an uncommon problem that can be reduced with proper endoscopic therapies. Colonoscopy is recommended as first-line diagnostic and therapeutic approach. In the vast majority of patients diverticular hemorrhage can be readily managed by interventional endotherapy including injection, heat cautery, clip placement, and ligation to achieve endoscopic hemostasis. This review will serve to highlight the various interventions available to endoscopists with specific emphasis on superior modalities in the endoscopic management of diverticular bleeding.
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Oh HK, Han EC, Ha HK, Choe EK, Moon SH, Ryoo SB, Jeong SY, Park KJ. Surgical management of colonic diverticular disease: Discrepancy between right- and left-sided diseases. World J Gastroenterol 2014; 20:10115-10120. [PMID: 25110438 PMCID: PMC4123340 DOI: 10.3748/wjg.v20.i29.10115] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 05/04/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of the surgical management of left-sided and right-sided diverticular disease.
METHODS: The medical records of 77 patients who were surgically treated for diverticular disease between 1999 and 2010 in a tertiary referral hospital were retrospectively reviewed. The study population was limited to cases wherein the surgical specimen was confirmed as diverticulosis by pathology. Right-sided diverticula were classified as those arising from the cecum, ascending colon, and transverse colon, and those from the descending colon, sigmoid colon, and rectum were classified as left-sided diverticulosis. To assess the changing trend of occurrence of diverticulosis, data were compared with two previous studies of 51 patients.
RESULTS: The proportion of left-sided disease cases was significantly increased compared to the results of our previous studies in 1994 and 2001, (27.5% vs 48.1%, P < 0.05). Moreover, no differences in gender, body mass index, multiplicity of the diverticula, fever, or leukocytosis were noted between patients with right-sided and left-sided disease. However, patients with right-sided disease were significantly younger (50.9 year vs 64.0 year, P < 0.01). Furthermore, left-sided disease was significantly associated with a higher incidence of complicated diverticulitis (89.2% vs 57.5%, P < 0.01), combined resection due to extensive inflammation (21.6% vs 5.0%, P < 0.05), operative complications (51.4% vs 27.5%, P < 0.05), and in-hospital mortality (10.8% vs 0%, P < 0.05), along with longer post-operative hospitalization duration (21.3 ± 10.2 d vs 10.6 ± 8.1 d, P < 0.05).
CONCLUSION: Compared with right-sided diverticular disease, the incidence of left-sided disease in Korea has increased since 2001 and is associated with worse surgical outcomes.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Colectomy/adverse effects
- Colectomy/mortality
- Colon/pathology
- Colon/surgery
- Diverticulitis, Colonic/diagnosis
- Diverticulitis, Colonic/mortality
- Diverticulitis, Colonic/surgery
- Diverticulosis, Colonic/diagnosis
- Diverticulosis, Colonic/mortality
- Diverticulosis, Colonic/surgery
- Diverticulum, Colon/diagnosis
- Diverticulum, Colon/mortality
- Diverticulum, Colon/surgery
- Female
- Hospital Mortality
- Humans
- Incidence
- Length of Stay
- Male
- Middle Aged
- Postoperative Complications/mortality
- Postoperative Complications/therapy
- Republic of Korea/epidemiology
- Retrospective Studies
- Risk Factors
- Tertiary Care Centers
- Time Factors
- Treatment Outcome
- Young Adult
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Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis. J Gastroenterol 2014; 49:992-1000. [PMID: 24221694 DOI: 10.1007/s00535-013-0905-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 10/20/2013] [Indexed: 02/07/2023]
Abstract
Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.
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Raphaeli T, Menon R. Current treatment of lower gastrointestinal hemorrhage. Clin Colon Rectal Surg 2013; 25:219-27. [PMID: 24294124 DOI: 10.1055/s-0032-1329393] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Massive lower gastrointestinal bleeding is a significant and expensive problem that requires methodical evaluation, management, and treatment. After initial resuscitation, care should be taken to localize the site of bleeding. Once localized, lesions can then be treated with endoscopic or angiographic interventions, reserving surgery for ongoing or recurrent bleeding.
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Affiliation(s)
- Tal Raphaeli
- Swedish Colon and Rectal Clinic, Seattle, Washington
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Abstract
BACKGROUND Little research has been performed on the impact of race/ethnicity and obesity on the course of diverticulitis. PURPOSE To determine whether patients of different racial/ethnic backgrounds and patients who are obese have disparate courses of disease with regard to complications, recurrence rates, and need for surgery. METHODS We conducted a retrospective review of the charts of 347 patients with confirmed diverticulitis in 2 university teaching hospitals at Bronx, NY. RESULTS African Americans were more likely [odds ratio (OR), 2.28, 95% confidence interval (CI), 1.04-5.00, P = 0.04] and Hispanics were less likely than other racial/ethnic groups (OR, 0.47; 95% CI, 0.22-0.97; P = 0.04) to require surgery for recurrent diverticulitis after at least 1 medically managed hospital admission for diverticulitis. Caucasians were less likely than other racial/ethnic groups to suffer a recurrence of diverticulitis (OR, 0.48; 95% CI, 0.27-0.86; P = 0.01). Obese patients [ body mass index (BMI) >30] were more likely than nonobese patients to experience a recurrent episode of diverticulitis (OR, 1.69; 95% CI, 1.08-2.64; P = 0.02). The odds of requiring surgery on the initial presentation of diverticulitis were not significantly different among the various races/ethnicities nor was the likelihood of surgery influenced by BMI. Complication rates did not differ significantly when patients were stratified by age, sex, race, BMI, or number of prior episodes of diverticulitis. CONCLUSIONS Surgery for diverticulitis after at least 1 medically managed hospital admission for diverticulitis is more frequently needed in African Americans and less frequently needed in Hispanics. Caucasians are less likely than other races/ethnicities to suffer a recurrence of diverticulitis. Finally, obesity is a risk factor for recurrent diverticulitis, but not for surgical therapy of diverticulitis.
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Ben Maamer A, Zaafouri H, Jaoua H, Haoues N, Noomene R, Bouhafa A, Oueslati A, Cherif A. Prise en charge des complications de la diverticulose colique de 1998 à 2010 à l’hôpital Habib Thameur de Tunis. JOURNAL AFRICAIN D'HÉPATO-GASTROENTÉROLOGIE 2012; 6:276-283. [DOI: 10.1007/s12157-012-0410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ishii N, Hirata N, Omata F, Itoh T, Uemura M, Matsuda M, Suzuki S, Iizuka Y, Fukuda K, Fujita Y. Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping. Gastrointest Endosc 2012; 76:1175-81. [PMID: 23021162 DOI: 10.1016/j.gie.2012.07.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 07/30/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Predictors of refractory colonic diverticular hemorrhage after endoscopic clipping (EC) remain unclear. OBJECTIVE To elucidate the predictors of uncontrolled bleeding after EC. DESIGN Retrospective study. SETTING Two tertiary referral centers. PATIENTS Eighty-nine patients with colonic diverticular hemorrhage who underwent EC as a first-line treatment were included. INTERVENTIONS If bleeding remained uncontrolled after 1 or 2 EC sessions, other interventions (transcatheter arterial embolization, endoscopic band ligation, or surgery) were performed. Patients were divided into EC-controlled and EC-uncontrolled groups; the characteristics of each group were compared. MAIN OUTCOME MEASUREMENTS Comorbidities, location of bleeding diverticula, and EC technique (direct vs indirect placement). RESULTS Initial treatment with EC was successful in 87 patients. Early rebleeding (primary failure) occurred in 30 of 87 patients (34%). Secondary failure occurred in 6 of 22 patients treated with reclipping (27%). Cumulatively, 78 patients were successfully managed with EC. Non-EC treatments were required in 11 patients. Location in the right side of the colon, particularly in the ascending colon, was significantly more common in the EC-uncontrolled group than in the EC-controlled group (P = .017 and P = .0029, respectively). Although the difference was not significant, bleeding was successfully managed in all 13 patients treated with direct placement. Bleeding remained uncontrolled after EC in 11 of 52 ascending cases (21%) treated with indirect placement. Diverticular hemorrhage in other locations was managed regardless of EC technique. LIMITATIONS Retrospective study. CONCLUSIONS Location in the ascending colon is a significant predictor of refractory colonic diverticular hemorrhage after EC. Indirect placement of hemoclips in ascending lesions is ineffective.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
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Ishii N, Setoyama T, Deshpande GA, Omata F, Matsuda M, Suzuki S, Uemura M, Iizuka Y, Fukuda K, Suzuki K, Fujita Y. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75:382-7. [PMID: 21944311 DOI: 10.1016/j.gie.2011.07.030] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/04/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of sample cases of colonic diverticular hemorrhage treated with endoscopic band ligation (EBL) has been small to date. OBJECTIVE To elucidate the safety and efficacy of EBL for colonic diverticular hemorrhage. DESIGN Retrospective study. SETTING General hospital. PATIENTS A total of 29 patients with 31 colonic diverticula with stigmata of recent hemorrhage (SRH). INTERVENTIONS Urgent colonoscopy was performed after bowel preparation. When diverticula with SRH were identified, marking with hemoclips was done near the diverticula. The endoscope was removed and reinserted after a band-ligator device was attached to the tip of endoscope. At first, EBL was attempted. In patients who could not be treated with EBL, epinephrine injection or endoscopic clipping was performed. MAIN OUTCOME MEASUREMENTS Procedure time, rate of hemostasis and rebleeding, complications. RESULTS The mean procedure time was 47 ± 19 minutes. EBL was successfully completed in 27 colonic diverticula (87%); except in 3 diverticula with a small orifice and large dome and 1 diverticula in which the orifice was too large. Early rebleeding after EBL occurred in 3 of 27 cases (11%). Although 2 cases of sigmoid rebleeding could be managed by repeat EBL or conservatively, right hemicolectomy was performed in 1 ascending diverticulum, in which the bleeding source was not identified on repeat colonoscopy. Scar formation at previously banded diverticula was identified in 7 of 11 patients who underwent follow-up colonoscopy. There were no complications after EBL in any of the patients. LIMITATIONS Retrospective study. CONCLUSIONS EBL is a safe and effective treatment for colonic diverticular hemorrhage, and colonic diverticula resolve after EBL.
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Affiliation(s)
- Naoki Ishii
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
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Pitchumoni CS, Pitchumoni CS, Pitchumoni CS. Diverticular Disease. GERIATRIC GASTROENTEROLOGY 2012:511-517. [DOI: 10.1007/978-1-4419-1623-5_53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Tan KK, Liu JZ, Shen SF, Sim R. Emergency surgery in colonic diverticulitis in an Asian population. Int J Colorectal Dis 2011; 26:1045-1050. [PMID: 21360277 DOI: 10.1007/s00384-011-1160-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Diverticulitis in Asians differs significantly from their Western counterparts in various aspects. This study was performed to highlight our institution's surgical experiences in patients with diverticulitis. The secondary aim was to compare the patients who underwent surgery for right- and left-sided diverticulitis. METHODS A retrospective review of all patients who underwent emergency surgery in patients with acute diverticulitis from July 2003 to April 2008 was performed. Right-sided pathology was regarded if it was located from the caecum till the transverse colon. Left-sided disease was regarded if it commenced from the splenic flexure. RESULTS The study group comprised of 104 patients, 68 (65.4%) of whom had right-sided diverticulitis. Caecum was the commonest site of disease, and the majority had only mild disease. In the 36 (34.6%) patients with left-sided diverticulitis, majority (63.8%) had an ASA score of three or four, with the sigmoid colon being the most common site of involvement. Most (91.7%) had worse peritoneal contamination with Hartmann's procedure being performed in 22 (61.1%) patients. Worse peri-operative outcome was also seen in this group. After multivariate analysis, the independent factors for right-sided disease were younger age, lower ASA score and no necessity for stoma. CONCLUSIONS In an Asian population, surgery in right-sided diverticulitis is more commonly performed and is associated with lower morbidity and mortality. Patients who underwent surgery for right-sided diverticulitis were younger, with lower ASA score and less likely to have stoma created.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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Setoyama T, Ishii N, Fujita Y. Enodoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25:3574-8. [PMID: 21638178 DOI: 10.1007/s00464-011-1760-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 04/30/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently, endoscopic band ligation (EBL) has been used to treat colonic diverticular hemorrhage, but the number of EBL cases treated to date has been limited. This study aimed to evaluate the clinical outcomes of EBL in the treatment of colonic diverticular hemorrhage compared with those of endoclips. METHODS At St. Luke's International Hospital in Tokyo, 66 patients were treated with EBL or endoclips from January 2004 to October 2010. Early rebleeding was defined as clinical evidence of recurrent bleeding within 30 days after initial treatment. Patients' demographics, rate of early rebleeding, and complications were retrospectively evaluated. RESULTS Of the 66 patients, 18 were treated with EBL. The initial success rate for hemostasis with EBL was 100% with no complications. Early rebleeding was observed in one patient (6%), for whom eversion of a bleeding diverticulum in the sigmoid colon could not be obtained and early loss of the O-band occurred. However, the patient could be retreated with EBL. On the other hand, complete eversion could be obtained for all 10 patients with right-sided diverticula, and no early rebleeding occurred. Endoclips were used to treat 48 patients. Although the initial success rate for hemostasis was 100% without any complications, the rate of early rebleeding was 33% (16 patients), which was significantly higher than the rate for the EBL-treated group (P = 0.018). CONCLUSIONS According to the findings, EBL should be considered safe, effective, and superior to endoclips for the treatment of colonic diverticular hemorrhage. The EBL procedure should be attempted as the initial therapy especially for the right-sided disease.
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Affiliation(s)
- Takeshi Setoyama
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan.
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Bianchi M, Festa V, Moretti A, Ciaco A, Mangone M, Tornatore V, Dezi A, Luchetti R, De Pascalis B, Papi C, Koch M. Meta-analysis: long-term therapy with rifaximin in the management of uncomplicated diverticular disease. Aliment Pharmacol Ther 2011; 33:902-10. [PMID: 21366632 DOI: 10.1111/j.1365-2036.2011.04606.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diverticular disease of the colon is a common gastrointestinal disease. Although most patients remain asymptomatic for their whole life, about 20-25% present symptoms related to 'diverticular disease'. Several randomised trials verified efficacy of a poorly absorbed antibiotic, such as rifaximin-α (rifaximin), in soothing symptoms and preventing diverticulitis. AIM To evaluate the long-term efficacy administration of rifaximin plus fibre supplementation vs. fibre supplementation alone, on symptoms and complications, in patient with symptomatic uncomplicated diverticular disease. METHODS Pertinent studies were selected from the Medline, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The outcomes were 1- year complete symptom relief, and 1- year complication incidence. The rate difference (RD, with 95% CI) and the Number Needed to Treat (NNT) were used as measure of the therapeutic effect on each outcome. RESULTS Four prospective randomised trials including 1660 patients were selected. The pooled RD for symptom relief was 29.0% (rifaximin vs. control; 95% CI 24.5-33.6%; P<0.0001; NNT=3). The pooled RD for complication rate was -1.7% in favour of rifaximin (95% CI -3.2 to -0.1%; P=0.03; NNT=59). When considering only acute diverticulitis, the pooled RD in the treatment group was -2% (95% CI -3.4 to -0.6%; P=0.0057; NNT=50). CONCLUSIONS In symptomatic uncomplicated diverticular disease, treatment with rifaximin plus fibre supplementation is effective in obtaining symptom relief and preventing complications at 1 year.
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Affiliation(s)
- M Bianchi
- Gastroenterology and Liver Unit, Azienda Ospedaliera San Filippo Neri, Rome, Italy
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Tan KK, Hong CC, Zhang J, Liu JZ, Sim R. Predictors of outcome following surgery in colonic perforation: an institution's experience over 6 years. J Gastrointest Surg 2011; 15:277-284. [PMID: 20824374 DOI: 10.1007/s11605-010-1330-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 08/11/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Colonic perforation is associated with abysmal outcome. The aims of our study were to review the surgical outcome of patients with perforated colon and to identify factors predicting peri-operative complications. METHODS A retrospective review of all patients who underwent surgery for colonic perforation from January 2003 to August 2008 was performed. Patients with iatrogenic or traumatic perforation were excluded. The severity of abdominal sepsis was graded using the Mannheim peritonitis index (MPI). RESULTS A total of 129 patients, with median age of 65 years (22-97 years), formed the study group. While 29.5% had severe peritoneal contamination, 56.6% had an American Society of Anesthesiologists (ASA) score ≥3. Sigmoid colon (47.3%) and caecum (24.8%) were the most common sites of perforation. Diverticulitis and malignancy were the diagnoses in 51.9% and 34.9%, respectively. Hartmann's procedure and right hemicolectomy were performed in 43.4% and 34.1% of the patients, respectively. Stoma was created in 59.7%. The in-hospital mortality rate in our series was 15.5%. After multivariate analysis, the independent variables associated with worse peri-operative complications were ASA score ≥3, MPI >26 and creation of stoma. Malignant perforation was associated with higher ASA score and lower haematocrit level compared to diverticular perforation. Stoma was created more frequently in patients with MPI >26 and left-sided perforation, and was associated with worse complications. CONCLUSIONS Surgery for colonic perforation is associated with high morbidity and mortality rates. Short-term outcome is determined by ASA score and severity of peritonitis. A lower haematocrit level must alert the possibility of malignancy.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
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Abstract
Radiological techniques are important in evaluating patients with gastrointestinal bleeding. Scintigraphic, computed tomographic angiographic, and enterographic techniques are sensitive tools in identifying the source of bleeding and may be useful in identifying patients likely to have a benign course and in selecting patients for therapeutic intervention. Angiography plays a key role in bleeding localization, and modern embolization techniques make this a viable therapeutic option. With the refining developments in body imaging and related reconstructive techniques, it is likely that radiological interventions will play an expanding and critical role in evaluating patients with gastrointestinal hemorrhage in the future.
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Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47:680-735. [PMID: 20684920 DOI: 10.1067/j.cpsurg.2010.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jason Hall
- Department of Colon and Rectal Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Abstract
Elective surgical resection in cases of diverticulitis should be offered to patients who have experienced two episodes. High-risk patients such as immunocompromised individuals or transplant patients may warrant resection after one episode. It is controversial whether young patients or patients with right-sided diverticulitis need to be treated differently. Chronic diverticulitis can be successfully treated surgically in selected cases. Adequate surgical resection margins should include the top of the true rectum and the proximal extent of thickened inflamed colon to minimize the risk of recurrence. Careful operative planning and the use of proximal diversion if unsuspected significant inflammatory changes are encountered will improve surgical outcomes.
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Affiliation(s)
- Brett T Gemlo
- Division of Colon and Rectal Surgery, University of Minnesota, St. Paul, MN 55102, USA.
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Tan KK, Nallathamby V, Wong D, Sim R. Can superselective embolization be definitive for colonic diverticular hemorrhage? An institution's experience over 9 years. J Gastrointest Surg 2010; 14:112-118. [PMID: 19841988 DOI: 10.1007/s11605-009-1069-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 10/06/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Superselective mesenteric embolization is effective in arresting colonic diverticular hemorrhage with minimal complications, but long-term results are lacking. We aimed to review the short- and long-term outcome of superselective embolization in arresting colonic diverticular hemorrhage in an Asian population. METHODS A retrospective review of all patients who underwent superselective embolization for bleeding colonic diverticula from December 2000 to March 2009 was performed. These cases were drawn from a database of embolization for active gastrointestinal hemorrhage. Short-term outcomes (< or =30 days from procedure) identified included rebleeding, ischemia, or any further intervention for any of these two complications. Readmission for rebleeding and/or definitive surgery after 30 days (long-term outcome) was also documented. RESULTS Twenty-three patients, median age 65 years (range 41-79 years), formed the study group. Nineteen (82.6%) patients had active hemorrhage from right colonic diverticula while four (17.4%) had left-sided diverticular bleeding. Technical success was achieved in all 23 (100%) patients. SHORT-TERM OUTCOME: Five (21.7%) patients rebled within the same admission, and all underwent surgery. One patient perished from ensuing anastomotic dehiscence and septic shock and accounted for the only mortality (4.3%) in our series. There was no patient with ischemic complications. Another two (8.7%) patients underwent elective surgical resection on the advice of their surgeons in the absence of rebleeding. LONG-TERM OUTCOME: The median follow-up was 40 months (5-99 months). Of the remaining 16 (69.6%) patients for whom the procedure was definitive initially, four (25.0%) rebled within 2 years from the primary procedure, and elective surgery was performed in one of them. Another had repeat embolization, while the other two were successfully managed conservatively. These three patients refused surgical intervention. One patient was lost to follow-up, and the remaining 11 patients had no further complications. CONCLUSION Superselective embolization for active colonic diverticular hemorrhage is safe and effective and should be considered as a first line treatment if possible and available. The procedure could act as a bridge to a subsequent more definitive elective surgery or be definitive as seen in over 50% of our patients over a period of 40 months.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
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Savides TJ, Jensen DM. Gastrointestinal Bleeding. SLEISENGER AND FORDTRAN'S GASTROINTESTINAL AND LIVER DISEASE 2010:285-322.e8. [DOI: 10.1016/b978-1-4160-6189-2.00019-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Ooi K, Wong SW. Management of symptomatic colonic diverticular disease. Med J Aust 2009; 190:37-40. [DOI: 10.5694/j.1326-5377.2009.tb02262.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 06/19/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Kevin Ooi
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Sydney, NSW
| | - Shing W Wong
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Sydney, NSW
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Tan KK, Wong D, Sim R. Superselective embolization for lower gastrointestinal hemorrhage: an institutional review over 7 years. World J Surg 2008; 32:2707-2715. [PMID: 18843444 DOI: 10.1007/s00268-008-9759-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Superselective embolization of visceral arterial branches has become integral in the management of acute lower gastrointestinal (GI) hemorrhage. The present study aimed to evaluate the success of superselective embolization as a primary therapeutic modality in the control of lower GI hemorrhage and to identify factors associated with rebleeding and surgical intervention after the procedure. METHODS We performed a retrospective review of all cases of superselective embolization for acute lower GI bleeding during a 7-year period (December 2000-October 2007) in a single 1,300-bed hospital in Singapore. Hemostasis was achieved with microcoils, polyvinyl alcohol particles, gelfoam, or by selective vasopressin infusion. Various clinical and hematologic factors were analyzed against rebleeding and surgical intervention after the procedure. RESULTS A total of 265 patients underwent mesenteric angiography for GI hemorrhage. Superselective embolization of visceral vessels for lower GI hemorrhage was performed in 32 patients (12%) whose median age was 66 years (range: 34-82 years). The group was of similar gender distribution, and the median follow-up was 8 months (range: 1-32 months). Location was the small bowel in 19% and the colon in 81%. The underlying etiologies included diverticular disease (59%), angiodysplasia (19%), ulcers (19%), and malignancy (3%). In 31 patients (97%) technical success was achieved, with immediate cessation of hemorrhage in every case. Clinical success was achieved in 20 patients (63%), all of whom were discharged well with no further intervention. Seven patients rebled, and 9 underwent surgery: 1 for incomplete hemostasis, 4 for rebleeding, 1 for infarcted bowel postembolization, and 3 on the basis of the surgeon's decision. There were 2 anastomotic leaks; 1 after surgery for postembolization ischemia and 1 after surgery for rebleeding. Overall mortality in this series was 9%. Rebleeding was more likely to occur if the site of bleeding was located in the small bowel compared to the colon (OR: 8.33, 95% CI 1.03-66.67). It was also more likely in patients with a hematocrit level CONCLUSIONS The use of superselective mesenteric embolization for the treatment of lower GI bleeding is highly successful and relatively safe-97% technical success and 3% postembolization ischemia in our series. In 63% of cases it is definitive without any further intervention. Postembolization ischemia and surgery may be associated with a higher risk of anastomotic leak. Greater vigilance must be adopted in treating patients who have active hemorrhage from the small bowel and in those with a hematocrit
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
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Abstract
Diverticulosis of the colon is a very common condition. Described as early as the 17th century, most of the information we now have is based on much of the work during the 20th century. Age, sex, race, and geography all play a specific role in the development of diverticula. It is the merging of these factors that changes the prevalence of diverticula and their manifestations. Symptomatic diverticula can lead to serious complications requiring both medical and surgical interventions to treat these complications when they occur. This review will focus on the history and epidemiology of diverticulosis in regard to age, sex, race, geography, and the epidemiology of complicated diverticular disease.
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Affiliation(s)
- Jerry Martel
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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