Abstract
Introduction: Contrast-enhanced computed tomography (CE-CT) has been gaining attention as an initial investigation in the management of colonic diverticular bleeding (CDB), yet the role of CE-CT other than its diagnostic yield has not been adequately clarified. We aimed to determine whether the use of urgent CE-CT improves identification of stigmata of recent hemorrhage (SRH) in subsequently performed early colonoscopy (≤24 h of arrival) or other clinical outcomes of CDB. Methods: We conducted a randomized, open-label, controlled trial at 23 institutions in Japan. Outpatients with suspected CDB were randomly assigned to undergo either urgent CE-CT followed by early colonoscopy (urgent-CE-CT + early-colonoscopy group) or early colonoscopy alone (early-colonoscopy group). The primary outcome was SRH identification. Secondary outcomes included successful endoscopic hemostasis, early (<30 days) and late (<1 year) rebleeding, length of hospital stay, and transfusion requirements. Results: In total, 240 patients, mostly in a hemodynamically stable condition, were randomized. A contrast extravasation on CE-CT was observed in 20 of 115 patients (17.4%) in the urgent-CE-CT + early-colonoscopy group. SRH was identified in 23 of 115 patients (20.0%) in the urgent-CE-CT + early-colonoscopy group and 21 of 118 patients (17.8%) in the early-colonoscopy group (difference, 2.2; 95% confidence interval [CI], −7.9 to 12.3; p = 0.739). Successful endoscopic hemostasis was achieved in 21 patients in each group (18.3% and 17.8%, respectively) (difference, 0.5; 95% CI, −9.4 to 10.4; p = 1.000). There were also no significant differences between groups in early and late rebleeding, length of hospital stay, and transfusion requirements. Conclusion: The use of urgent CE-CT before early colonoscopy did not improve SRH identification or other clinical outcomes in patients with suspected CDB in a hemodynamically stable condition. The routine use of urgent CE-CT as an initial investigation is not recommended in this population, also considering the low rate of extravasation-positive cases (UMIN registry number, UMIN000026865).
References
1.
Gralnek
IM
, Neeman
Z
, Strate
LL
. Acute lower gastrointestinal bleeding
. N Engl J Med
. 2017
;376
(11
):1054
–63
. 2.
Oakland
K
, Guy
R
, Uberoi
R
, Hogg
R
, Mortensen
N
, Murphy
MF
, et al. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit
. Gut
. 2018
;67
(4
):654
–62
. 3.
Vajravelu
RK
, Mamtani
R
, Scott
FI
, Waxman
A
, Lewis
JD
. Incidence, risk factors, and clinical effects of recurrent diverticular hemorrhage: a large cohort study
. Gastroenterology
. 2018
;155
(5
):1416
–27
. 4.
Aytac
E
, Stocchi
L
, Gorgun
E
, Ozuner
G
. Risk of recurrence and long-term outcomes after colonic diverticular bleeding
. Int J Colorectal Dis
. 2014
;29
(3
):373
–8
. 5.
Kaise
M
, Nagata
N
, Ishii
N
, Omori
J
, Goto
O
, Iwakiri
K
. Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding
. Dig Endosc
. 2020
;32
:240
–50
. 6.
Gobinet-Suguro
M
, Nagata
N
, Kobayashi
K
, Yamauchi
A
, Yamada
A
, Omori
J
, et al. Treatment strategies for reducing early and late recurrence of colonic diverticular bleeding based on stigmata of recent hemorrhage: a large multicenter study
. Gastrointest Endosc
. 2022
;95
(6
):1210
–22.e12
. 7.
Hayasaka
J
, Kikuchi
D
, Odagiri
H
, Nomura
K
, Ochiai
Y
, Okamura
T
, et al. Effectiveness of clipping for definitive colonic diverticular bleeding in preventing early recurrent bleeding
. Intern Med
. 2022
;61
(4
):451
–60
. 8.
Jensen
DM
, Machicado
GA
, Jutabha
R
, Kovacs
TO
. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage
. N Engl J Med
. 2000
;342
(2
):78
–82
. 9.
Kaltenbach
T
, Watson
R
, Shah
J
, Friedland
S
, Sato
T
, Shergill
A
, et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding
. Clin Gastroenterol Hepatol
. 2012
;10
(2
):131
–7
. 10.
Jensen
DM
. Diagnosis and treatment of definitive diverticular hemorrhage (DDH)
. Am J Gastroenterol
. 2018
;113
(11
):1570
–3
. 11.
Wada
M
, Kato
M
, Hirai
Y
, Kubosawa
Y
, Sunata
Y
, Abe
K
, et al. Initial management of colonic diverticular bleeding: observational study
. Digestion
. 2018
;98
(1
):41
–7
. 12.
Ichiba
T
, Hara
M
, Miyahara
K
, Urashima
M
, Shintani
A
, Naitou
H
, et al. Impact of computed tomography evaluation before colonoscopy for the management of colonic diverticular hemorrhage
. J Clin Gastroenterol
. 2019
;53
(2
):e75
–83
. 13.
Oakland
K
, Isherwood
J
, Lahiff
C
, Goldsmith
P
, Desborough
M
, Colman
KS
, et al. Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review
. Endosc Int Open
. 2017
;5
(10
):E959
–73
. 14.
Niikura
R
, Nagata
N
, Doyama
H
, Ota
R
, Ishii
N
, Mabe
K
, et al. Current state of practice for colonic diverticular bleeding in 37 hospitals in Japan: a multicenter questionnaire study
. World J Gastrointest Endosc
. 2016
;8
(20
):785
–94
. 15.
Clerc
D
, Grass
F
, Schafer
M
, Denys
A
, Demartines
N
, Hübner
M
. Lower gastrointestinal bleeding-computed tomographic angiography, colonoscopy or both
. World J Emerg Surg
. 2017
;12
:1
. 16.
Jacovides
CL
, Nadolski
G
, Allen
SR
, Martin
ND
, Holena
DN
, Reilly
PM
, et al. Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization
. JAMA Surg
. 2015
;150
(7
):650
–6
. 17.
Takada
H
, Kadokura
M
, Yasumura
T
, Yoda
H
, Okuwaki
T
, Imagawa
N
, et al. Extravasation and fluid collection on computed tomography imaging in patients with colonic diverticular bleeding
. PLoS One
. 2020
;15
(4
):e0229884
. 18.
Sugiyama
T
, Hirata
Y
, Kojima
Y
, Kanno
T
, Kimura
M
, Okuda
Y
, et al. Efficacy of contrast-enhanced computed tomography for the treatment strategy of colonic diverticular bleeding
. Intern Med
. 2015
;54
(23
):2961
–7
. 19.
Nakatsu
S
, Yasuda
H
, Maehata
T
, Nomoto
M
, Ohinata
N
, Hosoya
K
, et al. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding
. Intern Med
. 2015
;54
(6
):553
–8
. 20.
Ochi
M
, Kamoshida
T
, Hamano
Y
, Ohkawara
A
, Ohkawara
H
, Kakinoki
N
, et al. Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding
. World J Clin Cases
. 2021
;9
(11
):2446
–57
. 21.
Umezawa
S
, Nagata
N
, Arimoto
J
, Uchiyama
S
, Higurashi
T
, Nakano
K
, et al. Contrast-enhanced CT for colonic diverticular bleeding before colonoscopy: a prospective multicenter study
. Radiology
. 2018
;288
(3
):755
–61
. 22.
Nagata
N
, Niikura
R
, Aoki
T
, Moriyasu
S
, Sakurai
T
, Shimbo
T
, et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy
. J Gastroenterol
. 2015
;50
(12
):1162
–72
. 23.
Kominami
Y
, Ohe
H
, Kobayashi
S
, Uchida
D
, Numata
N
, Matsushita
H
, et al. Dynamic computed tomography is useful for the diagnosis and colonoscopic treatment of colonic diverticular bleeding
. Nihon Shokakibyo Gakkai Zasshi
. 2011
;108
(2
):223
–30
.24.
Guglielmo
FF
, Wells
ML
, Bruining
DH
, Strate
LL
, Huete
Á
, Gupta
A
, et al. Gastrointestinal bleeding at CT angiography and CT enterography: imaging atlas and glossary of terms
. Radiographics
. 2021
;41
(6
):1632
–56
. 25.
Sengupta
N
, Kastenberg
DM
, Bruining
DH
, Latorre
M
, Leighton
JA
, Brook
OR
, et al. The role of imaging for GI bleeding: ACG and SAR consensus recommendations
. Radiology
. 2024
;310
(3
):e232298
. 26.
Jensen
DM
, Jensen
ME
, Kovacs
TOG
, Ghassemi
KA
, Ohning
GV
, Kaneshiro
M
, et al. Sa1705 flat spots are unrecognized as stigmata for diagnoses of definitive diverticular hemorrhage in the colon
. Gastrointest Endosc
. 2017
;85
(5
):AB247
. 27.
Obana
T
, Fujita
N
, Sugita
R
, Hirasawa
D
, Sugawara
T
, Harada
Y
, et al. Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding
. Dig Dis Sci
. 2013
;58
(7
):1985
–90
. 28.
Nagata
N
, Ishii
N
, Manabe
N
, Tomizawa
K
, Urita
Y
, Funabiki
T
, et al. Guidelines for colonic diverticular bleeding and colonic diverticulitis: Japan Gastroenterological Association
. Digestion
. 2019
;99
(Suppl 1
):1
–26
. 29.
Triantafyllou
K
, Gkolfakis
P
, Gralnek
IM
, Oakland
K
, Manes
G
, Radaelli
F
, et al. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline
. Endoscopy
. 2021
;53
(8
):850
–68
. 30.
Oakland
K
, Chadwick
G
, East
JE
, Guy
R
, Humphries
A
, Jairath
V
, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology
. Gut
. 2019
;68
(5
):776
–89
. 31.
Sengupta
N
, Feuerstein
JD
, Jairath
V
, Shergill
AK
, Strate
LL
, Wong
RJ
, et al. Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline
. Am J Gastroenterol
. 2023
;118
(2
):208
–31
. 32.
Green
BT
, Rockey
DC
, Portwood
G
, Tarnasky
PR
, Guarisco
S
, Branch
MS
, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial
. Am J Gastroenterol
. 2005
;100
(11
):2395
–402
. 33.
Laine
L
, Shah
A
. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding
. Am J Gastroenterol
. 2010
;105
(12
):2636
–42
. 34.
van Rongen
I
, Thomassen
BJW
, Perk
LE
. Early versus standard colonoscopy: a randomized controlled trial in patients with acute lower gastrointestinal bleeding: results of the bleed study
. J Clin Gastroenterol
. 2019
;53
(8
):591
–8
. 35.
Niikura
R
, Nagata
N
, Yamada
A
, Honda
T
, Hasatani
K
, Ishii
N
, et al. Efficacy and safety of early vs elective colonoscopy for acute lower gastrointestinal bleeding
. Gastroenterology
. 2020
;158
(1
):168
–75.e6
. 36.
Tsay
C
, Shung
D
, Stemmer Frumento
K
, Laine
L
. Early colonoscopy does not improve outcomes of patients with lower gastrointestinal bleeding: systematic review of randomized trials
. Clin Gastroenterol Hepatol
. 2020
;18
(8
):1696
–703.e2
. 37.
Anvari
S
, Lee
Y
, Yu
J
, Doumouras
AG
, Khan
KJ
, Hong
D
. Urgent versus standard colonoscopy for management of acute lower gastrointestinal bleeding: a systematic review and meta-analysis of randomized controlled trials
. J Clin Gastroenterol
. 2020
;54
(6
):493
–502
. 38.
Nagata
N
, Niikura
R
, Ishii
N
, Kaise
M
, Omata
F
, Tominaga
N
, et al. Cumulative evidence for reducing recurrence of colonic diverticular bleeding using endoscopic clipping versus band ligation: systematic review and meta-analysis
. J Gastroenterol Hepatol
. 2021
;36
(7
):1738
–43
. 39.
Nagata
N
, Kobayashi
K
, Yamauchi
A
, Yamada
A
, Omori
J
, Ikeya
T
, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study
. Am J Gastroenterol
. 2021
;116
(11
):2222
–34
. 40.
Lau
JY
, Sung
JJ
, Chan
AC
, Lai
GW
, Lau
JT
, Ng
EK
, et al. Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts
. Gastrointest Endosc
. 1997
;46
(1
):33
–6
. 41.
Laine
L
, Freeman
M
, Cohen
H
. Lack of uniformity in evaluation of endoscopic prognostic features of bleeding ulcers
. Gastrointest Endosc
. 1994
;40
(4
):411
–7
. 42.
Jensen
DM
, Ohning
GV
, Kovacs
TO
, Ghassemi
KA
, Jutabha
R
, Dulai
GS
, et al. Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding
. Gastrointest Endosc
. 2016
;83
(1
):129
–36
. 43.
Jensen
DM
. The importance of arterial blood flow detection for risk stratification and eradication to achieve definitive hemostasis of severe non-variceal UGI hemorrhage
. J Clin Med
. 2023
;12
(20
):6473
. © 2024 S. Karger AG, Basel
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
2024
You do not currently have access to this content.
