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• W2239191159 abstract "Diverticular bleeding is the most common source of acute lower GI bleeding, accounting for approximately 200,000 hospitalizations each year.1Strate L.L. Naumann C.R. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding.Clin Gastroenterol Hepatol. 2010; 8: 333-343Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Although the precise etiopathogenesis is unknown, histologic examination of bleeding sites reveals asymmetric thickening of small nutrient arteries with rupture into the colon lumen. Little is known about the natural history of diverticular bleeding stigmata, and the endoscopic management of diverticular hemorrhage has not been standardized. By contrast, stigmata of recent hemorrhage (SRH) are of clear prognostic significance in peptic ulcer disease (PUD), and endoscopic treatment of major stigmata is known to improve outcomes, including rebleeding. Our understanding of the natural history of diverticular stigmata is largely based on a historical case-control study by Jensen and colleagues of 17 patients with definitive diverticular bleeding managed medically and 10 patients with diverticular SRH treated endoscopically.2Jensen D.M. Machicado G.A. Jutabha R. et al.Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.N Engl J Med. 2000; 342: 78-82Crossref PubMed Scopus (529) Google Scholar The rebleeding rate was 53% in patients treated medically versus 0% in patients treated endoscopically, and rebleeding varied according to the specific stigmata: 67% in patients with actively bleeding lesions, 50% in those with nonbleeding visible vessels (NBVV), and 43% in those with adherent clots. In this issue of Gastrointestinal Endoscopy, Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar build on their previous work to describe the 30-day rebleeding and intervention rates in 45 patients with definitive diverticular hemorrhage who did not receive endoscopic treatment. Two separate prospective cohorts of patients with severe hematochezia found to be from a diverticular source at the time of urgent colonoscopy were included: 28 patients recruited from 2001 to 2013, and the 17 previously described patients recruited from 1986 to 1998.2Jensen D.M. Machicado G.A. Jutabha R. et al.Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.N Engl J Med. 2000; 342: 78-82Crossref PubMed Scopus (529) Google Scholar The definitions of major and minor SRH were based on those commonly used in PUD (Forrest classification) and previously adapted for use in diverticular disease. The combined rebleeding rates according to SRH were 84% (16/19) for actively bleeding lesions, 60% (3/5) for NBVV, and 43% (6/14) for adherent clots (remaining after targeted jet irrigation). Similarly, the proportion of patients undergoing angiography or surgery to control bleeding was high in patients with SRH (60% for active bleeding, 40% for NBVV, and 29% for adherent clot). By contrast, none of the 7 patients with no or minor stigmata (flat spot or nonadherent clot) experienced rebleeding. In a second aim, the authors examine the use of through-the-scope Doppler ultrasound probe (DEP) monitoring as an adjunct to the endoscopic management of diverticular hemorrhage in a cohort of 46 patients recruited from 2009 to 2014. Twenty-four of these patients had definitive diverticular hemorrhage at the time of urgent colonoscopy, of whom 92% had superficial arterial flow detected by DEP (80% with adherent clot, 93% with NBVV, and 100% with active bleeding). Colonoscopic hemostasis was performed, and the adequacy was confirmed by DEP, after which no patient experienced rebleeding. The remaining 22 patients had presumptive diverticular hemorrhage with vessels without SRH visualized within diverticula. None of these patients had blood flow detected by DEP. We know very little about the natural history of SRH in the colon, in part because the stigmata are difficult to identify, and the aggregate number of cases at individual centers tends to be small. The systematic and meticulous efforts at the CURE Digestive Research Center over the past 3 decades have led to a significant advancement in our understanding of the prognostic significance of diverticular SRH. These data indicate that major SRH predict a high risk of rebleeding without treatment, and there appears to be a stepwise increase in risk of rebleeding from adherent clot to NBVV to active bleeding similar to that seen in PUD. Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar conclude that the risk associated with active bleeding is higher in diverticular bleeding than in PUD. However, the estimates of risk, particularly for NBVV, are imprecise, given the small number of patients with these lesions (eg, 5 patients with NBVV). In addition, the risk estimates in this study may be high because inclusion in the natural history cohort versus the treatment cohort was nonrandom. Some patients with severe bleeding were followed up for natural history and not treated endoscopically because their bleeding was too severe to treat. Last, the stigmata were identified and classified by a highly experienced team under optimal circumstances (urgent colonoscopy with excellent colon preparation). In other settings, it has proved more difficult to identify diverticular SRH, and interobserver variability in classifying SRH is likely to be high, as has been shown in PUD.4Lau J.Y. Sung J.J. Chan A.C. et al.Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts.Gastrointest Endosc. 1997; 46: 33-36Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar In the literature, diverticular SRH are detected in 6% to 26% of patients with lower GI bleeding who undergo urgent colonoscopy.1Strate L.L. Naumann C.R. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding.Clin Gastroenterol Hepatol. 2010; 8: 333-343Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Stigmata of recent hemorrhage are identified infrequently when colonoscopy is delayed beyond 24 hours from presentation.5Green B.T. Rockey D.C. Portwood G. et al.Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial.Am J Gastroenterol. 2005; 100: 2395-2402Crossref PubMed Scopus (256) Google Scholar, 6Laine L. Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding.Am J Gastroenterol. 2010; 105 (quiz 2642): 2636-2641Crossref PubMed Scopus (148) Google Scholar On the other end of the spectrum, Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar noted no rebleeding in patients with no or minor stigmata (flat spots). This is likely a reflection of very experienced eyes and extremely meticulous colonoscopy. Therefore, the rebleeding rate in patients with presumed diverticular bleeding (no SRH on colonoscopy and no other potential bleeding source) is likely to be higher in practice because of missed or misclassified SRH. Presumably, all patients with diverticular bleeding have SRH at some point, but in most cases these lesions resolve spontaneously before colonoscopy. This is demonstrated by the low likelihood of detecting SRH during delayed colonoscopy.5Green B.T. Rockey D.C. Portwood G. et al.Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial.Am J Gastroenterol. 2005; 100: 2395-2402Crossref PubMed Scopus (256) Google Scholar, 6Laine L. Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding.Am J Gastroenterol. 2010; 105 (quiz 2642): 2636-2641Crossref PubMed Scopus (148) Google Scholar In this study, the time to colonoscopy was not reported separately for patients with and without stigmata, but all patients underwent urgent colonoscopy, which suggests that any delay was not substantial. Ideally, clinical predication tools based on findings on presentation would be used to risk stratify patients with lower GI bleeding according to the likelihood of major SRH, so that urgent colonoscopy could be reserved for those at highest risk. In the study by Jensen et al,3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar univariate analysis found that patients with major SRH on colonoscopy were more likely to be male, use nonsteroidal antiinflammatory drugs, have lower hematocrits on presentation, and receive blood transfusions than were patients with minor or no SRH. Several prediction rules have been developed for patients with lower GI bleeding,7Strate L.L. Orav E.J. Syngal S. Early predictors of severity in acute lower intestinal tract bleeding.Arch Intern Med. 2003; 163: 838-843Crossref PubMed Scopus (167) Google Scholar, 8Velayos F.S. Williamson A. Sousa K.H. et al.Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study.Clin Gastroenterol Hepatol. 2004; 2: 485-490Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 9Das A. Ben-Menachem T. Cooper G.S. et al.Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model.Lancet. 2003; 362: 1261-1266Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar but further validation is needed, particularly with respect to the presence of major SRH and need for endoscopic treatment. The DEP findings in the study by Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar validate the prognostic significance of SRH in diverticular bleeding, and they provide a possible means to improve endoscopic hemostasis. The correlation between diverticular SRH and detection of Doppler flow parallel the DEP findings in PUD.10Wong R.C.K. Nonvariceal upper gastrointestinal hemorrhage: probing beneath the surface.Gastroenterology. 2009; 137 (1902): 1897Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Although the use of DEP monitoring is not expanded on in this report, the authors indicate that its use enabled targeted and complete hemostasis. Indeed, no patient experienced rebleeding after endoscopic therapy in the DEP cohort. However, no comparison was made to patients treated endoscopically without DEP guidance. An earlier study by the Jensen group2Jensen D.M. Machicado G.A. Jutabha R. et al.Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.N Engl J Med. 2000; 342: 78-82Crossref PubMed Scopus (529) Google Scholar of endoscopic treatment of diverticular stigmata in 10 patients without the use of DEP also reported excellent results (no rebleeding), which suggests that in experienced hands DEP may not be necessary. By contrast, rebleeding after endoscopic hemostasis of diverticular SRH is reported to be as high as 38% in the literature. In a systematic review of 137 cases, early rebleeding occurred in 8%.1Strate L.L. Naumann C.R. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding.Clin Gastroenterol Hepatol. 2010; 8: 333-343Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar In addition, although 2 randomized trials of urgent versus delayed or elective colonoscopy have shown that earlier examinations are more likely to identify SRH in the colon, major clinical outcomes including rebleeding were not improved. These disappointing results likely reflect in part that colon SRH are difficult to treat effectively. Endoscopists are generally less familiar with the identification, classification, and treatment of diverticular SRH in comparison with PUD, and they are more likely to be concerned about potential treatment-related adverse events, particularly with thermal modalities. Therefore, DEP monitoring could be a promising adjunct to the endoscopic treatment of diverticular SRH, and head-to-head comparisons of DEP-guided versus unguided treatment are needed. The DEP technology consists of a flexible, linear probe that is passed through the accessory channel of either a diagnostic or a therapeutic endoscope.10Wong R.C.K. Nonvariceal upper gastrointestinal hemorrhage: probing beneath the surface.Gastroenterology. 2009; 137 (1902): 1897Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The probe tip is placed directly on the lesion of interest, and the angle and signal depth are varied in an effort to detect flow (no flow will be detected if the probe is at a 90° angle to the vessel). In this manner, the location, source (venous vs arterial), and depth of the bleeding lesion can be discerned. Few details are given in the study by Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar regarding the approach to DEP interrogation of diverticular SRH, aside from the fact that vessel depth tended to be shallow (<4 mm). Based on the illustration of the vascular anatomy of a diverticular SRH (Fig. 3 in the article by Jensen et al3Jensen D.M. Ohning G.V. Kovacs T.O.G. et al.Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis.Gastrointest Endosc. 2016; 83: 416-423Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar), the culprit vessel appears to course across the entire base of the diverticulum. Presumably, this technology could be adapted in clinical practice, although it may be difficult to interrogate some diverticula because of factors such as small openings and sigmoid location. In addition, SRH need to be identified visually before DEP, and, as noted above, this has generally been more difficult in practice than in the hands of experienced groups. In conclusion, the diligent efforts of Jensen and colleagues to understand the natural history of SRH in diverticular bleeding have revealed that major SRH in the colon portend a high risk of rebleeding and need for intervention. Doppler US probe–guided endoscopic treatment may decrease these risks by enabling more targeted and durable hemostasis. Unfortunately, achieving similar results in everyday practice will undoubtedly prove difficult. Additional comparative studies are needed to define the optimal endoscopic treatment approach for diverticular SRH, including studies of DEP-guided versus unguided hemostasis. In the meantime, endoscopists should seek to find and treat diverticular SRH in patients with signs of severe bleeding. All authors disclosed no financial relationships relevant to this publication. Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasisGastrointestinal EndoscopyVol. 83Issue 2PreviewFew prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. Full-Text PDF" @default.
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