今日の臨床サポート

大腸憩室症

著者: 新倉量太 東京大学医学部附属病院消化器内科

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正/監修レビュー済:2021/03/24
患者向け説明資料

概要・推奨   

  1. 大腸憩室炎の診断、治療方針の決定には腹部造影CT検査を行うことが勧められる(推奨度1)。
  1. 大腸憩室出血は下部消化管出血の主要な原因疾患の1つであり、特に無痛性の新鮮血便の患者には、本疾患の鑑別を念頭におくことが勧められる(推奨度1)。
  1. 大腸憩室炎の抗菌薬治療は、重症度に応じた薬剤の選択が勧められる(推奨度2)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
新倉量太 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 多施設ランダム化比較試験の結果に基づき、緊急下部内視鏡検査について改定を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 大腸憩室症は、大腸内視鏡検査を受けた40~60歳の日本人の18%、60歳以上の79%に大腸憩室を認めるcommon diseasesである[1] 。通常無症状(asymptomatic diverticulosis)だが、大腸憩室症の5%が大腸憩室炎や大腸憩室出血を起こす(symptomatic diverticulosis)[2]
  1. 大腸憩室炎は、憩室内の細菌感染や虚血性変化により、限局性の疼痛で発症する。保存的加療で軽快することが多いが、ときに膿瘍形成や腹膜炎、腸管穿孔により外科手術を要することがある。
  1. 大腸憩室出血は、憩室内の露出血管の破綻により、無痛性の突然の鮮血便を発症し、大量出血によりショック状態となり輸血や止血処置が必要になることがある。
問診・診察のポイント  
  1. 大腸憩室炎の腹痛は大腸憩室とその近傍の腹膜の炎症に由来する体性痛が主であることから局在性がはっきりし持続性である。大腸憩室炎の鑑別診断として虫垂炎、クローン病、骨盤腹膜炎、子宮外妊娠、卵管炎、進行大腸癌、感染性腸炎が挙げられる。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Naoyoshi Nagata, Ryota Niikura, Tomonori Aoki, Takuro Shimbo, Toshiyuki Itoh, Yoshimasa Goda, Ryuichiro Suda, Hideaki Yano, Junichi Akiyama, Mikio Yanase, Masashi Mizokami, Naomi Uemura
雑誌名: Int J Colorectal Dis. 2014 Mar;29(3):379-85. doi: 10.1007/s00384-013-1808-4. Epub 2013 Dec 7.
Abstract/Text PURPOSES: Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years.
METHODS: Twenty-eight thousand one hundred ninety-two patients who underwent colonoscopy at an emergency hospital were reviewed from an electronic endoscopy database. Diverticula were classified as right-sided, left-sided, and bilateral types, and time trends in the proportion in diverticulosis, type, and diverticular bleeding were determined. Associations of age (≤39, 40-59, and ≥60 years), sex, and year increase with disease and odds ratios were estimated using logistic regression.
RESULTS: Diverticulosis was identified in 6,150 patients (20.3 %; mean age, 67.6 years) and was predominantly right-sided (48.0 %). Diverticular bleeding was found in 427 (1.5 %; mean age, 69.7 years) and was predominantly bilateral (47.0 %). Proportion of colonic diverticulosis increased significantly (P < 0.01 for trend) from 66.0 % (1,424/2,157) in 2003 to 70.1 % (2,914/4,159) in 2011 and was associated (P < 0.01) with an increased number of patients aged ≥60 years. Proportion of diverticular bleeding increased significantly (P < 0.01 for trend) from 1.02 % (22/2,157) in 2003 to 1.67 % (69/4,159) in 2011 and was associated (P = 0.04) with an increased number of patients aged 40-59 years. Diverticulosis, right and bilateral type, and diverticular bleeding were independently associated with the 9-year trend after adjustment by age and sex.
CONCLUSIONS: Colonic diverticulosis and diverticular bleeding are prevalent and increasing in Japan. Given the significant association of age with this trend, both diseases can be expected to increase for decades to come.

PMID 24317937  Int J Colorectal Dis. 2014 Mar;29(3):379-85. doi: 10.10・・・
著者: H H McGuire
雑誌名: Ann Surg. 1994 Nov;220(5):653-6.
Abstract/Text OBJECTIVE: The study was undertaken to correct or reaffirm current recommendations based on old observations of doubtful validity because of their lack of routine colonoscopy, scintigraphy, or angiography.
METHOD: Patterns of bleeding were derived from transfusion records of 78 patients admitted 106 times for lower gastrointestinal bleeding with no detectable cause other than colon diverticula.
RESULT: Bleeding stopped spontaneously in 82 of 108 episodes and in 66 of 67 patients requiring less than four units of transfusion on any day. When four or more units were required in a day, 25 of 42 patients required emergency surgery. When a bleeding site was identified and removed, only 1 of 25 patients bled again from another diverticulum. After discharge without surgery, 28 of 73 began to bled again. After "blind" colectomy and ileoproctostomy, four of seven patients developed leaks or abscesses, and two died.
CONCLUSIONS: Bleeding stopped spontaneously in 75% of episodes and in 99% of patients requiring less than four units of transfusion per day. Bleeding continued in 25% of episodes and in most patients who required four or more units per day. Bleeding sites of those patients who continued to bleed were shown by scintigraphy or angiography. When a bleeding diverticulum is removed, rebleeding is rare. "Blind" resection is unsafe.

PMID 7979613  Ann Surg. 1994 Nov;220(5):653-6.
著者: Kamyar Shahedi, Garth Fuller, Roger Bolus, Erica Cohen, Michelle Vu, Rena Shah, Nikhil Agarwal, Marc Kaneshiro, Mary Atia, Victoria Sheen, Nicole Kurzbard, Martijn G H van Oijen, Linnette Yen, Paul Hodgkins, M Haim Erder, Brennan Spiegel
雑誌名: Clin Gastroenterol Hepatol. 2013 Dec;11(12):1609-13. doi: 10.1016/j.cgh.2013.06.020. Epub 2013 Jul 12.
Abstract/Text BACKGROUND & AIMS: Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10% to 25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis discovered incidentally on colonoscopy.
METHODS: We performed a retrospective study using administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, collecting data on patients who underwent colonoscopies from January 1996 through January 2011. We identified patients diagnosed with diverticulosis, determined incidence rates per 1000 patient-years, and analyzed a subgroup of patients with rigorously defined events confirmed by imaging or surgery. We used a Cox proportional hazards model to identify factors associated with the development of diverticulitis.
RESULTS: We identified 2222 patients with baseline diverticulosis. Over an 11-year follow-up period, 95 patients developed diverticulitis (4.3%; 6 per 1000 patient-years); of these, 23 met the rigorous definition of diverticulitis (1%; 1.5 per 1000 patient-years). The median time-to-event was 7.1 years. Each additional decade of age at time of diagnosis reduced the risk for diverticulitis by 24% (hazard ratio, 0.76; 95% confidence interval, 0.6-0.9).
CONCLUSIONS: Based on a study of the Veterans Affairs Greater Los Angeles Healthcare System, only about 4% of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. We also found that younger patients have a higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 23856358  Clin Gastroenterol Hepatol. 2013 Dec;11(12):1609-13. do・・・
著者: W Kempf, D V Kazakov, I E Belousova, C Mitteldorf, K Kerl
雑誌名: J Eur Acad Dermatol Venereol. 2015 Sep;29(9):1696-709. doi: 10.1111/jdv.13044. Epub 2015 Feb 25.
Abstract/Text Primary cutaneous lymphomas (CL) in children is rare. Only a few studies focused specifically on paediatric CL and therefore little is known whether primary CL in children are similar to or different from their adult counterparts with respect to the clinicopathological presentation, behaviour and prognosis. An extensive literature search using PubMed/MEDLINE from January 1995 through July 2014 was undertaken for articles reporting cases of paediatric CL. In addition, we identified 31 children with CL in our institutions. Mycosis fungoides and lymphomatoid papulosis are the two most prevalent lymphoma forms in children. A few entities of cutaneous lymphomas such as cutaneous diffuse large B-cell lymphoma leg type, and Sézary syndrome have not been reported so far in children. Other lymphoma entities such as hydroa vacciniforme-like lymphoma are mostly seen in certain geographic areas (Asia, Central and South America). In the paediatric population, low-malignant indolent forms such as primary cutaneous marginal zone lymphoma and primary cutaneous follicle centre lymphoma are very rare, whereas the more aggressive forms of B-cell lymphomas, precursor lymphoblastic lymphomas, and blastic plasmacytoid dendritic cell neoplasm are the most common forms in children, mostly involving the skin secondarily. Most paediatric lymphomas have similar clinicopathological features and course as their adults counterparts, particularly in the group of cutaneous T-cell lymphomas. The spectrum of cutaneous B-cell lymphomas in children significantly differs from the one in adults. Diagnostic work-up and treatment of paediatric patients with lymphomas are best achieved in close collaboration with paediatric haematopathologists and oncologists.

© 2015 European Academy of Dermatology and Venereology.
PMID 25715748  J Eur Acad Dermatol Venereol. 2015 Sep;29(9):1696-709. ・・・
著者: K C Cho, H T Morehouse, D D Alterman, B A Thornhill
雑誌名: Radiology. 1990 Jul;176(1):111-5. doi: 10.1148/radiology.176.1.2191360.
Abstract/Text The diagnostic value of computed tomography (CT) and barium enema (BE) studies was evaluated prospectively in hospitalized patients with the presumptive diagnosis of acute sigmoid diverticulitis based on the presence of left-lower-quadrant pain and tenderness, fever, and leukocytosis. Of 56 patients, 11 had sigmoid diverticulitis confirmed at surgery and 16 by clinical response to medical therapy. CT, performed in all diverticulitis patients, had positive results in 93% (25 of 27). These compared favorably with BE study results, of which 80% (20 of 25) were positive. Neither examination had false-positive results. In the 29 patients who did not have diverticulitis, an alternative diagnosis was made by means of CT in 20, but in only three by means of BE studies. Many of the extracolonic abnormalities recognized at CT were clinically unexpected and necessitated emergency surgery. The excellent sensitivity and specificity of CT coupled with its versatility in the detection of extracolonic disease give it an advantage over contrast enema studies for diagnosis of sigmoid diverticulitis. CT should be the initial study in acutely ill patients, especially when the clinical features are atypical for sigmoid diverticulitis.

PMID 2191360  Radiology. 1990 Jul;176(1):111-5. doi: 10.1148/radiolog・・・
著者: L B Ferzoco, V Raptopoulos, W Silen
雑誌名: N Engl J Med. 1998 May 21;338(21):1521-6. doi: 10.1056/NEJM199805213382107.
Abstract/Text
PMID 9593792  N Engl J Med. 1998 May 21;338(21):1521-6. doi: 10.1056/・・・
著者: Anil M Bahadursingh, Kathy S Virgo, Donald L Kaminski, Walter E Longo
雑誌名: Am J Surg. 2003 Dec;186(6):696-701.
Abstract/Text BACKGROUND: Diverticular disease is a common entity. The presentation, investigations performed, and management are variable. Our objectives were to assess the presentation, extent of disease, and treatment of a cohort of patients with colonic diverticulitis.
METHODS: All patients with a diagnosis of diverticulitis over a 9-year period were reviewed. Patients were assessed as to age, sex, presenting symptoms, diagnostic studies, extent of disease, treatment, and outcome.
RESULTS: Over a 9-year period (1992 to 2001), 192 patients were admitted with a diagnosis of colonic diverticulitis. The mean age was 61 years (range 28 to 90); 113 of 192 (59%) were female. The mean duration of symptoms prior to presentation was 14 days (range 1 to 270 days). One hundred eighteen of 192 (61%) had a previous documented attack of diverticulitis. Of the investigations performed 128 of 192 (66.7%) had a computed tomography (CT) scan of the abdomen and pelvis, 37 of 192 (20%) underwent a contrast enema, 61 of 192 (32%) underwent colonoscopy and 2 of 192 (1%) underwent a small bowel series. The abnormal findings on the CT scan were as follows: diverticular abscess (16%), diverticulitis (37%), diverticulosis without inflammation (15%), free air (10%) and fistula (1%). The locations of the diverticular abscesses were: pelvic (36%), pericolic sigmoid (36%), and "other," which included interloop (28%). Preoperative abscess drainage occurred in 10 of 192 (5%), which were either percutaneous, 6 of 192 (3%), or transrectal, 4 of 192 (2%). Nine of 192 (6%) presented with a fistula, colovesical fistulae (3%), colocutaneous (1%), enterocolic (1%), or colovaginal (1%). Overall, 73 of 192 (38%) underwent surgery. All patients undergoing surgery had a resection of their colon. The operative findings were localized abscess in 16 of 73 (22%), purulent/feculent peritonitis in 12 of 73 (17%), and phlegmon in 10 of 73 (14%). Sixty-seven of 73 (92%) had a primary resection with anastomosis; 38 of 67 (56%) had a protecting stoma. Five of 73 (7%) patients were found to have an unsuspected carcinoma. Overall, 29 of 192 (15%) developed a complication related to diverticulitis. Morbidity was 15.1%, of which 34% was infection related. Four of 192 patients (2%) died.
CONCLUSIONS: In our experience, most patients presented with abdominal pain predominantly in the left lower quadrant. The symptoms were present on average of 14 days, most were female (59%), and most patients had a previous attack of diverticulitis. The commonest investigation performed was a CT scan (66.7%); however, other investigations were performed, for example, barium enemas. The practice of resection and primary anastomosis for acute diverticulitis has an acceptable morbidity and mortality. For high-risk anastomoses, a covering loop ileostomy and not a Hartmann's procedure is preferred. Surgery remains safe for the majority of patients and is associated with resolution of symptoms. We believe that because of the high number of patients in our series who had a previous attack of diverticulitis, therapy should be focused on preventing recurrent and virulent attacks by earlier operative intervention.

PMID 14672782  Am J Surg. 2003 Dec;186(6):696-701.
著者: Patrick Ambrosetti, Roland Chautems, Claudio Soravia, Nyali Peiris-Waser, François Terrier
雑誌名: Dis Colon Rectum. 2005 Apr;48(4):787-91. doi: 10.1007/s10350-004-0853-z.
Abstract/Text PURPOSE: The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon.
METHODS: Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months.
RESULTS: of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09).
CONCLUSIONS: Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

PMID 15747071  Dis Colon Rectum. 2005 Apr;48(4):787-91. doi: 10.1007/s・・・
著者: D M Nagorney, M A Adson, J H Pemberton
雑誌名: Dis Colon Rectum. 1985 Feb;28(2):71-5.
Abstract/Text Sigmoid diverticulitis with perforation and generalized peritonitis is a grave complication of diverticular disease. To compare accurately the results of two operative approaches--proximal colostomy with drainage and proximal colostomy with resection or exteriorization--the authors assessed the clinical and pathologic features of 121 consecutive patients with perforating sigmoid diverticulitis. There were no differences between treatment groups in age, sex, mean duration of symptoms, clinical presentation, number of coexistent diseases, type of peritonitis or chronic corticosteroid use. Overall mortality for emergency operation was 12 percent. Mortality was significantly greater (P less than 0.05) among the 31 patients treated by colostomy and drainage (26 percent) than among the 90 patients treated by colostomy and resection or exteriorization (7 percent). Seven of the nine patients who died from persistent sepsis had undergone colostomy and drainage. Four clinical factors were found to be predictive of mortality (P less than 0.05): persistent postoperative sepsis, fecal peritonitis, preoperative hypotension, and prolonged duration of symptoms. These factors identified a subgroup of patients who, because of an increased risk of death, would be likely to benefit from the more complete eradication of the septic focus that is achieved by colostomy and resection.

PMID 3971809  Dis Colon Rectum. 1985 Feb;28(2):71-5.
著者: S Kriwanek, C Armbruster, P Beckerhinn, K Dittrich
雑誌名: Int J Colorectal Dis. 1994 Aug;9(3):158-62.
Abstract/Text Colonic perforation is an abdominal emergency with high morbidity and mortality. This retrospective study was performed to evaluate the prognostic relevance of several factors and to characterize patients at high risk. One hundred and twelve patients (61 women, 51 men) were treated for colonic perforation from 1979 to 1992. Diverticulitis [65 patients (58%)] and carcinoma [24 patients (21%)] were the commonest pathology. In 62 cases (55%) perforation was found to be covered; 50 (45%) times it was free. 34 (30%) patients had diffuse peritonitis. Resection with primary anastomosis was performed 43 times (7 times with a protective colostomy). Resection without restoration of the intestinal continuity was carried out 53 times (including 49 Hartmann operations). Suture with drainage was performed 16 times mainly after iatrogenic perforation (8 times with a colostomy). The overall mortality was 19.6% (22 patients). The prognostic importance of various factors was investigated by univariate analysis (Wilcoxon and Chi-square test) and stepwise logistic regression including sex, age, underlying disease, localization and type of perforation, degree of peritonitis, pre- or postoperative organ failure, surgical procedure, reoperation, sepsis and the Mannheimer Peritonitis Index (MPI) score. Age over 65 years (relative risk 4.6, P = 0.0089), organ failure (relative risk 40, P = 0.001) and MPI (relative risk for an increase of 10 points 2.72, P = 0.001) proved to be the only risk factors of significance. The patient's course is determined by the septic state, while the underlying pathology and degree of peritonitis did not significantly influence survival.

PMID 7814991  Int J Colorectal Dis. 1994 Aug;9(3):158-62.
著者: Leon Salem, David R Flum
雑誌名: Dis Colon Rectum. 2004 Nov;47(11):1953-64.
Abstract/Text PURPOSE: This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis.
METHODS: This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity.
RESULTS: Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent.
CONCLUSIONS: Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.

PMID 15622591  Dis Colon Rectum. 2004 Nov;47(11):1953-64.
著者: Vasilis A Constantinides, Paris P Tekkis, Thanos Athanasiou, Omer Aziz, Sanjay Purkayastha, Feza H Remzi, Victor W Fazio, Nail Aydin, Ara Darzi, Asha Senapati
雑誌名: Dis Colon Rectum. 2006 Jul;49(7):966-81. doi: 10.1007/s10350-006-0547-9.
Abstract/Text PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis.
METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed.
RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome.
CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

PMID 16752192  Dis Colon Rectum. 2006 Jul;49(7):966-81. doi: 10.1007/s・・・
著者: Jason F Hall, Patricia L Roberts, Rocco Ricciardi, Thomas Read, Christopher Scheirey, Christoph Wald, Peter W Marcello, David J Schoetz
雑誌名: Dis Colon Rectum. 2011 Mar;54(3):283-8. doi: 10.1007/DCR.0b013e3182028576.
Abstract/Text PURPOSE: The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively.
METHODS: We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008. Patients were identified with International Classification of Diseases, 9th Revision/Current Procedural Terminology codes. Patients were excluded if they had subsequent colectomy based on the first attack (n = 81), or if the attack they had between 2002 and 2008 was not their first attack (n = 201). We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists. These radiologists reviewed the available published literature for CT imaging characteristics thought to predict diverticulitis severity. CT variables (n = 20) were determined by prospective reevaluation of scans by blinded study radiologists. Clinical variables (n = 43) were coded based on a retrospective chart review. Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards modeling. Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm.
RESULTS: The study population included 672 patients; mean age, 61 ± 15 years; mean follow-up, 42.8 ± 24 months. The index presentation of diverticulitis was most commonly located in the sigmoid colon (72%), followed by descending colon (33%), right colon (5%), and transverse colon (3%). Overall recurrence at 5 years was 36% by (95% CI 31.4%-40.6%) Kaplan-Meier estimate. Complicated recurrence (fistula, abscess, free perforation) occurred in 3.9% (95% CI 2.2%-5.6%) of patients at 5 years by Kaplan-Meier estimate. Family history of diverticulitis (HR 2.2, 95% CI 1.4-3.2), length of involved colon >5 cm (HR 1.7, 95% CI 1.3-2.3), and retroperitoneal abscess (HR 4.5, 95% CI 1.1-18.4) were associated with diverticulitis recurrence. Right colon disease (HR 0.27, 95% CI 0.09-0.86) was associated with freedom from recurrence.
CONCLUSION: Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon. Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease. Patients who present with right-sided diverticulitis are at low risk for recurrent disease. These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.

PMID 21304297  Dis Colon Rectum. 2011 Mar;54(3):283-8. doi: 10.1007/DC・・・
著者: G A Binda, A Arezzo, A Serventi, L Bonelli, Italian Study Group on Complicated Diverticulosis (GISDIC), M Facchini, M Prandi, P S Carraro, M C Reitano, G Clerico, L Garibotto, R Aloesio, A Sganzaroli, M Zanoni, G Zanandrea, F Pellegrini, S Mancini, A Amato, P Barisone, C Bottini, D F Altomare, G Milito
雑誌名: Br J Surg. 2012 Feb;99(2):276-85. doi: 10.1002/bjs.7723. Epub 2011 Nov 21.
Abstract/Text BACKGROUND: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD.
METHODS: The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up.
RESULTS: Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment.
CONCLUSION: Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 22105809  Br J Surg. 2012 Feb;99(2):276-85. doi: 10.1002/bjs.7723・・・
著者: Jyrki T Mäkelä, Heikki O Kiviniemi, Seppo T Laitinen
雑誌名: Dig Surg. 2010 Aug;27(3):190-6. doi: 10.1159/000236903. Epub 2010 Jun 22.
Abstract/Text BACKGROUND: This study was designed to evaluate the natural history of patients admitted for acute diverticulitis.
METHODS: Nine hundred and seventy-seven patients admitted to Oulu University Hospital for acute symptoms of diverticular disease during the 20-year period from 1986 to 2005 were identified using a database.
RESULTS: Six hundred and ninety-five patients were admitted for uncomplicated diverticulitis and 282 for complicated diverticulitis. The patients admitted for uncomplicated diverticulitis were younger than the others and 66% of them were admitted only once. The number of admissions preceding perforation was higher in the 1980s, and the number of admissions was unrelated to the degree of perforation or the outcome of the patients. The annual prevalence of sigmoid diverticular perforation increased from 2.6/100,000 in 1986 to 4.2/100,000 in 2005. Seventy (10%) of the 695 patients admitted for the first time for acute diverticulitis underwent urgent surgery during the same admission and 66 (9%) had elective surgery during a later admission. Overall hospital mortality was 2.3%, being 1% among those admitted for acute diverticulitis and 5.5% among those admitted for diverticular perforation. Two hundred and thirty-four (42%) of the 555 nonoperated patients with acute diverticulitis developed a recurrent episode of diverticulitis. The course of recurrent disease was similar to the primary episode.
CONCLUSION: Two or more preceding admissions for acute diverticulitis do not warrant sigmoid resection after diverticulitis. Young patients do not have a greater risk of complicated diverticulitis than older ones.

PMID 20571265  Dig Surg. 2010 Aug;27(3):190-6. doi: 10.1159/000236903.・・・
著者: W H Schwesinger, C P Page, H V Gaskill, R M Steward, S Chopra, W E Strodel, K R Sirinek
雑誌名: Arch Surg. 2000 May;135(5):558-62; discussion 562-3.
Abstract/Text HYPOTHESIS: A selective surgical approach using either a 1- or a 2-stage resection is relatively safe and effective in the management of acute complicated colonic diverticulosis.
DESIGN: A consecutive cohort study.
SETTING: A university hospital.
PATIENTS: Eighty-nine consecutive patients who underwent emergency operations for diverticular disease between July 1, 1984, and June 30, 1999. There were 53 male and 36 female patients (mean age, 47 years). The ethnic background was predominantly Mexican American (58 patients [65.2%]).
INTERVENTIONS: Resections of the affected colon (n = 83) plus construction of a Hartmann pouch or mucous fistula (n = 72) or primary anastomosis (n = 11).
MAIN OUTCOME MEASURES: Morbidity, mortality, and length of hospital stay.
RESULTS: Sixty-eight operations were performed for perforation at an annual rate that has increased greater than 75% in the past 15 years. Another 14 patients underwent operations for obstruction, and 7 underwent operations to control unremitting hemorrhage. Surgical therapy included resection of the affected segment of the bowel in 83 (93%) of the 89 patients, and a Hartmann pouch or mucous fistula was added in 72 (81%). A primary anastomosis was performed in 4 (80%) of 5 right-sided lesions but in only 7 (8%) of 84 left-sided lesions. Morbidity occurred in 38 (43%) of the 89 patients, and the mortality was 4%, with 4 deaths occurring secondary to sepsis in high-risk patients with perforations (n = 3) or obstructions (n = 1). The average length of hospital stay was 19.7 days (range, 5-80 days).
CONCLUSIONS: Emergency operations for diverticular disease are uncommon but may be associated with substantial morbidity and occasional mortality. Complicated diverticulosis may present at a relatively young age, and perforated forms appear to be increasing rapidly in prevalence. Most diverticular lesions can be satisfactorily managed using a selective approach based on resection with either a primary anastomosis or a temporary colostomy.

PMID 10807280  Arch Surg. 2000 May;135(5):558-62; discussion 562-3.
著者: Danny O Jacobs
雑誌名: N Engl J Med. 2007 Nov 15;357(20):2057-66. doi: 10.1056/NEJMcp073228.
Abstract/Text
PMID 18003962  N Engl J Med. 2007 Nov 15;357(20):2057-66. doi: 10.1056・・・
著者: S Schechter, J Mulvey, T E Eisenstat
雑誌名: Dis Colon Rectum. 1999 Apr;42(4):470-5; discussion 475-6.
Abstract/Text PURPOSE: A survey was conducted to document current medical treatment of patients with uncomplicated acute diverticulitis.
METHODS: A survey was mailed to 667 fellows of The American Society of Colon and Rectal Surgeons certified by the American Board of Colon and Rectal Surgery. Queries were based on a clinical scenario of a patient with uncomplicated diverticulitis.
RESULTS: Three hundred seventy-three surveys (56 percent) were returned completed. The majority (66 percent) chose an abdominal computed tomographic scan as the initial diagnostic test. One-half used a single intravenous antibiotic with second-generation cephalosporins (27 percent) and ampicillin/sulbactam (16 percent) being the most common. Oral antibiotics given at discharge were ciprofloxacin (18 percent), amoxicillin/clavulanate (14 percent), metronidazole (7 percent), and doxycycline (6 percent). Combinations chosen were ciprofloxacin/metronidazole (28 percent) and metronidazole/trimethoprim sulfamethoxazole (6 percent), whereas 21 percent chose a variety of other antibiotics. The majority (74 percent) prescribed oral antibiotics for 7 to 10 days. Dietary recommendations at discharge were low residue (68 percent), regular (21 percent), and high residue (10 percent). Half of those surveyed believed avoidance of seeds and nuts were of no value. Follow-up examinations chosen included sigmoidoscopy and barium enema (29 percent), colonoscopy (25 percent), sigmoidoscopy (17 percent), barium enema (13 percent), and other (16 percent). Sixty-five percent of colon and rectal surgeons claim to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis.
CONCLUSION: Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies. The survey results are compared with the conclusions reached in The American Society of Colon and Rectal Surgeons practice parameters. Documentation of practice pattern variation may serve as an educational tool for physicians to improve their quality and cost of medical care. Consideration should be given to better publicize already existing American Society of Colon and Rectal Surgeons practice parameters for this common entity.

PMID 10215046  Dis Colon Rectum. 1999 Apr;42(4):470-5; discussion 475-・・・
著者: Holly Salzman, Dustin Lillie
雑誌名: Am Fam Physician. 2005 Oct 1;72(7):1229-34.
Abstract/Text Diverticular disease refers to symptomatic and asymptomatic disease with an underlying pathology of colonic diverticula. Predisposing factors for the formation of diverticula include a low-fiber diet and physical inactivity. Approximately 85 percent of patients with diverticula are believed to remain asymptomatic. Symptomatic disease without inflammation is a diagnosis of exclusion requiring colonoscopy because imaging studies cannot discern the significance of diverticula. Fiber supplementation may prevent progression to symptomatic disease or improve symptoms in patients without inflammation. Computed tomography is recommended for diagnosis when inflammation is present. Antibiotic therapy aimed at anaerobes and gram-negative rods is first-line treatment for diverticulitis. Whether treatment is administered on an inpatient or outpatient basis is determined by the clinical status of the patient and his or her ability to tolerate oral intake. Surgical consultation is indicated for disease that does not respond to medical management or for repeated attacks that may be less likely to respond to medical therapy and have a higher mortality rate. Prompt surgical consultation also should be obtained when there is evidence of abscess formation, fistula formation, obstruction, or free perforation.

PMID 16225025  Am Fam Physician. 2005 Oct 1;72(7):1229-34.
著者: A Chabok, L Påhlman, F Hjern, S Haapaniemi, K Smedh, AVOD Study Group
雑誌名: Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688. Epub 2012 Jan 30.
Abstract/Text BACKGROUND: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.
METHODS: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.
RESULTS: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881).
CONCLUSION: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 22290281  Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688.・・・
著者: K C Lau, K Spilsbury, Y Farooque, S B Kariyawasam, R G Owen, M H Wallace, G B Makin
雑誌名: Dis Colon Rectum. 2011 Oct;54(10):1265-70. doi: 10.1097/DCR.0b013e31822899a2.
Abstract/Text BACKGROUND: It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy.
PURPOSE: This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure.
DESIGN: This is a study of a retrospective cohort.
SETTINGS AND PATIENTS: From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable.
MAIN OUTCOME MEASURES: The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture.
RESULTS: Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps >1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis.
LIMITATIONS: This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study.
CONCLUSIONS: We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

PMID 21904141  Dis Colon Rectum. 2011 Oct;54(10):1265-70. doi: 10.1097・・・
著者: K Krobot, D Yin, Q Zhang, S Sen, A Altendorf-Hofmann, J Scheele, W Sendt
雑誌名: Eur J Clin Microbiol Infect Dis. 2004 Sep;23(9):682-7. doi: 10.1007/s10096-004-1199-0. Epub 2004 Aug 21.
Abstract/Text To assess the significance of initial empiric parenteral antibiotic therapy in patients requiring surgery for community-acquired secondary peritonitis, 425 patients hospitalized between January 1999 and September 2001 in 20 clinics across Germany were followed for a total of 6,521 patient days. Perforated appendix (38%), colon (27%), or gastroduodenum (22%) were the most common sites of infection. Escherichia coli was the most common pathogen. A total of 54 (13%) patients received inappropriate initial parenteral therapy not covering all bacteria isolated, or not covering both aerobes and anaerobes in the absence of culture results. Clinical success, predefined as the infection resolving with initial or step-down therapy after primary surgery, was achieved in 322 patients (75.7%; 95% confidence interval (CI), 70.6-81.2). Patients were more likely to have clinical success if initial antibiotic therapy was appropriate (78.6%; 95% CI, 73.6-83.9) rather than inappropriate (53.4%; 95% CI, 41.1-69.3). Patients having clinical success were estimated to stay 13.9 days in hospital (95% CI, 13.1-14.7), while those who had clinical failure stayed 19.8 days (95% CI, 17.3-22.3). In conclusion, appropriateness of initial parenteral antibiotic therapy was a predictor of clinical success, which in turn was associated with length of stay.

Copyright 2004 Springer-Verlag
PMID 15322931  Eur J Clin Microbiol Infect Dis. 2004 Sep;23(9):682-7. ・・・
著者: Lisa L Strate, Ian M Gralnek
雑誌名: Am J Gastroenterol. 2016 Apr;111(4):459-74. doi: 10.1038/ajg.2016.41. Epub 2016 Mar 1.
Abstract/Text This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

PMID 26925883  Am J Gastroenterol. 2016 Apr;111(4):459-74. doi: 10.103・・・
著者: Loren Laine, Abbid Shah
雑誌名: Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642. doi: 10.1038/ajg.2010.277. Epub 2010 Jul 20.
Abstract/Text OBJECTIVES: We sought to determine, in patients with serious hematochezia, the proportion who have an upper gastrointestinal (GI) source and whether urgent colonoscopy improves outcomes as compared with elective colonoscopy in those without an upper source.
METHODS: Patients with hematochezia were eligible if they also had heart rate >100, systolic blood pressure <100, orthostatic change in heart rate or blood pressure >20, hemoglobin drop ≥ 1.5 g/dl, or blood transfusion. Patients had upper endoscopy within 6 h. Those without an upper source were randomized to urgent (≤ 12 h) or elective (36-60 h after presentation) colonoscopy. The primary end point was further bleeding. Patients were followed for the duration of hospitalization.
RESULTS: Eighty-five eligible patients had urgent upper endoscopy; 13 (15%) had an upper source. The remaining 72 were randomized to urgent (N=36) or elective (N=36) colonoscopy. Further bleeding occurred in 8 (22%) vs. 5 (14%) of the urgent vs. elective groups (difference=8%, 95% confidence interval (CI)=-9 to 26%). Units of blood (1.5 vs. 0.7), hospital days (5.2 vs. 4.8), subsequent diagnostic or therapeutic interventions for bleeding (36% vs. 33%), and hospital charges ($27,590 vs. $26,633) also were not lower in the urgent group. A major limitation is that the study was terminated before reaching the prespecified sample size.
CONCLUSIONS: Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious lower GI bleeding showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

PMID 20648004  Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642・・・
著者: F Douglas Srygley, Charles J Gerardo, Tony Tran, Deborah A Fisher
雑誌名: JAMA. 2012 Mar 14;307(10):1072-9. doi: 10.1001/jama.2012.253.
Abstract/Text CONTEXT: Emergency physicians must determine both the location and the severity of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic approaches.
OBJECTIVES: To identify the historical features, symptoms, signs, bedside maneuvers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to have severe bleeding that necessitates an urgent intervention.
DATA SOURCES: A structured search of MEDLINE (1966-September 2011) and reference lists from retrieved articles, review articles, and physical examination textbooks.
STUDY SELECTION: High-quality studies were included of adult patients who were either admitted with GIB or evaluated in emergency departments with bedside evaluations and/or routine laboratory tests, and studies that did not include endoscopic findings in prediction models. The initial search yielded 2628 citations, of which 8 were retained that tested methods of identifying a UGIB and 18 that identified methods of determining the severity of UGIB.
DATA EXTRACTION: One author abstracted the data (prevalence, sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality, with confirmation by another author. Data were combined using random effects measures.
DATA SYNTHESIS: The majority of patients (N = 1776) had an acute UGIB (prevalence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitrogen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Conversely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38) decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the likelihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (summary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires urgent intervention.
CONCLUSIONS: Melena, nasogastric lavage with blood or coffee grounds, or serum urea nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which does not require nasogastric lavage, is very efficient for identifying patients who do not require urgent intervention.

PMID 22416103  JAMA. 2012 Mar 14;307(10):1072-9. doi: 10.1001/jama.201・・・
著者: D M Jensen, G A Machicado, R Jutabha, T O Kovacs
雑誌名: N Engl J Med. 2000 Jan 13;342(2):78-82. doi: 10.1056/NEJM200001133420202.
Abstract/Text BACKGROUND: Although endoscopy is often used to diagnose and treat acute upper gastrointestinal bleeding, its role in the management of diverticulosis and lower gastrointestinal bleeding is uncertain.
METHODS: We studied the role of urgent colonoscopy in the diagnosis and treatment of 121 patients with severe hematochezia and diverticulosis. All patients were hospitalized, received blood transfusions as needed, and received a purge to rid the colon of clots, stool, and blood. Colonoscopy was performed within 6 to 12 hours after hospitalization or the diagnosis of hematochezia. Among the first 73 patients, those with continued diverticular bleeding underwent hemicolectomy. For the subsequent 48 patients, those requiring treatment received therapy, such as epinephrine injections or bipolar coagulation, through the colonoscope.
RESULTS: Of the first 73 patients, 17 (23 percent) had definite signs of diverticular hemorrhage (active bleeding in 6, nonbleeding visible vessels in 4, and adherent clots in 7). Nine of the 17 had additional bleeding after colonoscopy, and 6 of these required hemicolectomy. Of the subsequent 48 patients, 10 (21 percent) had definite signs of diverticular hemorrhage (active bleeding in 5, nonbleeding visible vessels in 2, and adherent clots in 3). An additional 14 patients in this group (29 percent) were presumed to have diverticular bleeding because although they had no stigmata of diverticular hemorrhage, no other source of bleeding was identified. The other 24 patients (50 percent) had other identified sources of bleeding. All 10 patients with definite diverticular hemorrhage were treated endoscopically; none had recurrent bleeding or required surgery.
CONCLUSIONS: Among patients with severe hematochezia and diverticulosis, at least one fifth have definite diverticular hemorrhage. Colonoscopic treatment of such patients with epinephrine injections, bipolar coagulation, or both may prevent recurrent bleeding and decrease the need for surgery.

PMID 10631275  N Engl J Med. 2000 Jan 13;342(2):78-82. doi: 10.1056/NE・・・
著者: T L Angtuaco, S K Reddy, S Drapkin, L E Harrell, C W Howden
雑誌名: Am J Gastroenterol. 2001 Jun;96(6):1782-5. doi: 10.1111/j.1572-0241.2001.03871.x.
Abstract/Text OBJECTIVE: Urgent colonoscopy is often recommended to evaluate acute rectal bleeding. However, it may not identify a source because of blood in the lumen or inadequate preparation. Our aim was to determine the utility of urgent colonoscopy as the initial test for acute rectal bleeding.
METHODS: This was a retrospective chart review of all patients discharged in 1997 and 1998 with an International Classification of Diseases, 9th Revision, code for hematochezia or rectal bleeding.
RESULTS: We identified 514 charts but excluded 424 because of inaccurate coding. In the 90 with confirmed acute rectal bleeding, colonoscopy was the initial test in 39; age, sex, and race distributions were similar to those who did not have colonoscopy. A definite source of bleeding was seen at colonoscopy in only three patients, a probable source in 26, and no source in 10. Therapeutic intervention in four patients with a definite or probable source was successful in three. The commonest reasons for not performing urgent colonoscopy were bleeding from presumed hemorrhoids or bleeding that was clinically insignificant. Spontaneous resolution of bleeding and length of hospital stay were not affected by urgent colonoscopy. Five patients had surgery for unrelated reasons. In-hospital mortality was 2% and was unrelated to bleeding.
CONCLUSION: Urgent colonoscopy as the initial investigation in acute lower GI tract bleeding probably does not alter the outcome in most cases. Identification of a definite bleeding source leading to successful therapeutic intervention is rare. Spontaneous resolution is frequent, length of hospital stay is similar, and clinical outcome is excellent regardless of whether or not urgent colonoscopy is performed.

PMID 11419829  Am J Gastroenterol. 2001 Jun;96(6):1782-5. doi: 10.1111・・・
著者: Bryan T Green, Don C Rockey, G Portwood, Paul R Tarnasky, Steve Guarisco, Malcolm S Branch, Joseph Leung, Paul Jowell
雑誌名: Am J Gastroenterol. 2005 Nov;100(11):2395-402. doi: 10.1111/j.1572-0241.2005.00306.x.
Abstract/Text OBJECTIVES: We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care.
METHODS: Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy.
RESULTS: A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1-6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups-including: mortality 2%versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22%versus 30%, surgery 14%versus 12%, or late rebleeding 16%versus 14% (mean follow-up of 62 and 58 months).
CONCLUSION: Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.

PMID 16279891  Am J Gastroenterol. 2005 Nov;100(11):2395-402. doi: 10.・・・
著者: R S Bloomfeld, D C Rockey, M A Shetzline
雑誌名: Am J Gastroenterol. 2001 Aug;96(8):2367-72. doi: 10.1111/j.1572-0241.2001.04048.x.
Abstract/Text OBJECTIVE: Diverticular hemorrhage is a common cause of lower GI bleeding and can be diagnosed acutely during colonoscopy. However, whether early diagnosis leads to effective intervention remains controversial. The aim of this study was to evaluate whether urgent colonoscopic therapy is effective as acute and long term treatment for diverticular bleeding with stigmata of hemorrhage.
METHODS: We reviewed the medical records of all patients who underwent endoscopic therapy for diverticular bleeding from January, 1994 to June, 2000 at Duke University Medical Center. Patients or their families were contacted to obtain complete follow-up including data on subsequent bleeding.
RESULTS: We identified 13 patients who underwent colonoscopic hemostatic management for the treatment of acute diverticular bleeding. Therapy consisted of epinephrine injection and/or multipolar electrocoagulation. Five patients (38%) experienced early rebleeding, within 30 days of the index bleed, four of whom required surgery, and three patients (23%) had late rebleeding. There were no complications of endoscopic therapy.
CONCLUSIONS: Endoscopic therapy can provide early hemostasis in some cases of acute diverticular hemorrhage. However, its value in preventing subsequent diverticular bleeding is unclear.

PMID 11513176  Am J Gastroenterol. 2001 Aug;96(8):2367-72. doi: 10.111・・・
著者: Stephen I Zink, Stephen K Ohki, Barry Stein, Domenic A Zambuto, Ronald J Rosenberg, Jenny J Choi, Daniel S Tubbs
雑誌名: AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2214/AJR.07.3642.
Abstract/Text OBJECTIVE: The purpose of our study was to compare contrast-enhanced MDCT and (99m)Tc-labeled RBC scanning for the evaluation of active lower gastrointestinal bleeding.
SUBJECTS AND METHODS: Over 17 months, 55 patients (32 men, 23 women; age range, 21-92 years) were evaluated prospectively with contrast-enhanced MDCT using 100 mL of iopromide 300 mg I/mL. Technetium-99m-labeled RBC scans were obtained on 41 of 55 patients and select patients underwent angiography for attempted embolization. Each imaging technique was reviewed in a blinded fashion for sensitivity for detection of active bleeding as well as the active lower gastrointestinal bleeding location.
RESULTS: Findings were positive on both examinations in eight patients and negative on both examinations in 20 patients. Findings were positive on contrast-enhanced MDCT and negative on (99m)Tc-labeled RBC in two patients; findings were negative on contrast-enhanced MDCT and positive on (99m)Tc-labeled RBC in 11 patients. Statistics showed significant disagreement, with simple agreement = 68.3%, kappa = 0.341, and p = 0.014. Sixteen of 60 (26.7%) contrast-enhanced MDCT scans were positive prospectively, with all accurately localizing the site of bleeding and identification of the underlying lesion in eight of 16 (50%). Nineteen of 41 (46.3%) (99m)Tc-labeled RBC scans were positive. Eighteen of 41 matched patients went on to angiography. In four of these 18 (22.2%) patients, the site of bleeding was confirmed by angiography, but in 14 of 18 (77.8%), the findings were negative.
CONCLUSION: Contrast-enhanced MDCT and (99m)Tc-labeled RBC scanning show significant disagreement for evaluation of active lower gastrointestinal bleeding. Contrast-enhanced MDCT appears effective for detection and localization in cases of active lower gastrointestinal bleeding in which hemorrhage is active at the time of CT.

PMID 18806152  AJR Am J Roentgenol. 2008 Oct;191(4):1107-14. doi: 10.2・・・
著者: T Jaeckle, G Stuber, M H K Hoffmann, M Jeltsch, B L Schmitz, A J Aschoff
雑誌名: Eur Radiol. 2008 Jul;18(7):1406-13. doi: 10.1007/s00330-008-0907-z. Epub 2008 Mar 20.
Abstract/Text The purpose of this study was to evaluate the accuracy of multi-detector row helical CT (MDCT) for detection and localization of acute upper and lower gastrointestinal (GI) hemorrhage or intraperitoneal bleeding. Thirty-six consecutive patients with clinical signs of acute bleeding underwent biphasic (16- or 40-channel) MDCT. MDCT findings were correlated with endoscopy, angiography or surgery. Among the 36 patients evaluated, 26 were examined for GI bleeding and 10 for intraperitoneal hemorrhage. Confirmed sites of GI bleeding were the stomach (n = 5), duodenum (n = 5), small bowel (n = 6), large bowel (n = 8) and rectum (n = 2). The correct site of bleeding was identifiable on MDCT in 24/26 patients with GI bleeding. In 20 of these 24 patients, active CM extravasation was apparent during the exam. Among the ten patients with intraperitoneal hemorrhage, MDCT correctly identified the bleeding source in nine patients. Our findings suggest that fast and accurate localization of acute gastrointestinal and intraperitoneal bleeding is achievable on MDCT.

PMID 18351347  Eur Radiol. 2008 Jul;18(7):1406-13. doi: 10.1007/s00330・・・
著者: Woong Yoon, Yong Yeon Jeong, Sang Soo Shin, Hyo Soon Lim, Sang Gook Song, Nam Gyu Jang, Jae Kyu Kim, Heoung Keun Kang
雑誌名: Radiology. 2006 Apr;239(1):160-7. doi: 10.1148/radiol.2383050175. Epub 2006 Feb 16.
Abstract/Text PURPOSE: To prospectively evaluate accuracy of arterial phase multi-detector row helical computed tomography (CT) for detection and localization of acute massive gastrointestinal (GI) bleeding, with angiography as reference standard.
MATERIALS AND METHODS: Institutional review board approved this study; written informed consent was obtained from each patient or patient's family after procedures, including radiation dose, were explained. Twenty-six consecutive patients (17 men, nine women; age range, 18-89 years) had acute massive GI bleeding (defined as requirement of transfusion of at least 4 units of blood during 24 hours in the hospital or as hypotension with systolic blood pressure <90 mm Hg) and underwent arterial phase multi-detector row CT before angiography. Scans were obtained during arterial phase to identify extravasation of contrast material with attenuation greater than 90 HU within bowel lumen; this finding was considered diagnostic for active GI bleeding. Presence of contrast medium extravasation in each anatomic location was recorded. Sensitivity, specificity, positive and negative predictive values, and accuracy of multi-detector row CT for detection of acute GI bleeding were assessed. Accuracy for localization of acute GI bleeding was assessed by comparing locations of active bleeding at both multi-detector row CT and angiography in each patient who had active bleeding.
RESULTS: Arterial phase multi-detector row CT depicted extravasation of contrast material in 21 of 26 patients. Overall location-based sensitivity, specificity, accuracy, and positive and negative predictive values of multi-detector row CT for detection of GI bleeding were 90.9% (20 of 22), 99% (107 of 108), 97.6% (127 of 130), 95% (20 of 21), and 98% (107 of 109), respectively. Overall patient-based accuracy of multi-detector row CT for detection of acute GI bleeding was 88.5% (23 of 26). The location of contrast material extravasation on multi-detector row CT scans corresponded exactly to that of active bleeding on angiograms in all patients with contrast medium extravasation at both multi-detector row CT and angiography.
CONCLUSION: Arterial phase multi-detector row CT is accurate for detection and localization of bleeding sites in patients with acute massive GI bleeding.

(c) RSNA, 2006.
PMID 16484350  Radiology. 2006 Apr;239(1):160-7. doi: 10.1148/radiol.2・・・
著者: A Alavi, E J Ring
雑誌名: AJR Am J Roentgenol. 1981 Oct;137(4):741-8. doi: 10.2214/ajr.137.4.741.
Abstract/Text Preliminary experience with technetium-99m sulfur colloid scintigraphy in 43 patients with lower gastrointestinal bleeding is described. Within minutes of the intravenous introduction of the radiopharmaceutical, a fraction of the injected activity extravasates at the bleeding site and is eliminated from the circulation. Because of rapid clearance of the radiopharmaceutical from the vascular pool by the reticuloendothelial system, a contrast develops between the site of bleeding and surrounding background. Based on animal experiments, bleeding rates as low as 0.05-0.1 ml/min can be detected with this technique. The sensitivity of this technique in the detection of the site of hemorrhage is significantly higher than arteriography or other techniques that use radioactive blood pool indicators. In this study all patients underwent both scintigraphy and arteriography within several hours. In 20 patients with negative scintigrams, arteriography showed no evidence of bleeding. In the other 23 patients with scintigraphic evidence of hemorrhage, arteriograms were positive for bleeding only in 10. In 19 of the 23 patients, a cause for bleeding was eventually established by other means. This technique appears to offer a simple, practical, and reliable approach to the evaluation of patients with lower gastrointestinal bleeding.

PMID 6974970  AJR Am J Roentgenol. 1981 Oct;137(4):741-8. doi: 10.221・・・
著者: Ralf Czymek, Alexander Kempf, Uwe Johannes Roblick, Franz Georg Bader, Jens Habermann, Peter Kujath, Hans-Peter Bruch, Frank Fischer
雑誌名: J Gastrointest Surg. 2008 Dec;12(12):2212-20. doi: 10.1007/s11605-008-0597-5. Epub 2008 Jul 18.
Abstract/Text BACKGROUND AND PURPOSE: To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years.
METHODS: Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases.
RESULTS: Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%.
CONCLUSIONS: Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.

PMID 18636299  J Gastrointest Surg. 2008 Dec;12(12):2212-20. doi: 10.1・・・
著者: Tanja Brunnler, Frank Klebl, Sascha Mundorff, Christoph Eilles, Michael Reng, Hans von Korn, Jurgen Scholmerich, Julia Langgartner, Stefan Grune
雑誌名: World J Gastroenterol. 2008 Aug 28;14(32):5015-9.
Abstract/Text AIM: To determine the role of scintigraphy in patients with gastrointestinal (GI) bleeding of unknown localisation.
METHODS: We performed retrospective analyses on 92 patients receiving scintigraphies from 1993 to 2000 in the University of Regensburg hospital, which were done for localisation of GI bleeding as a diagnostic step after an unsuccessful endoscopy. In addition to the scintigraphies, further diagnostic steps such as endoscopy, angiography or operations were performed. In some of the scintigraphies with negative results, a provocation test for bleeding with heparinisation was carried out.
RESULTS: 73% of all scintigraphies showed a positive result. In 4.5% of the positive results, the source was located in the stomach, in 37% the source was the small bowel, in 25% the source was the right colon, in 4.5% the source was the left colon, and in 20% no clear localisation was possible. Only 4% of all scintigraphies were false positive. A reliable positive scintigraphy was independent of the age of the examined patient. A provocation test for bleeding with heparin resulted in an additional 46% of positive scintigraphies with a reliable localisation in primary negative scintigraphies.
CONCLUSION: Our results show that scintigraphy and scintigraphy with heparin provocation tests are reliable procedures. They enable a reliable localisation in about half of the obscure GI-bleeding cases. Scintigraphy is superior to angiography in locating a bleeding. It is shown that even in the age of video capsule endoscopy and double-balloon enteroscopy, scintigraphy provides a reliable and directed localization of GI bleeding and offers carefully targeted guidance for other procedures.

PMID 18763283  World J Gastroenterol. 2008 Aug 28;14(32):5015-9.
著者: Naoyoshi Nagata, Ryota Niikura, Toshiyuki Sakurai, Takuro Shimbo, Tomonori Aoki, Shiori Moriyasu, Katsunori Sekine, Hidetaka Okubo, Koh Imbe, Kazuhiro Watanabe, Chizu Yokoi, Mikio Yanase, Junichi Akiyama, Naomi Uemura
雑誌名: Clin Gastroenterol Hepatol. 2016 Apr;14(4):558-64. doi: 10.1016/j.cgh.2015.10.011. Epub 2015 Oct 19.
Abstract/Text BACKGROUND & AIMS: We investigated the safety and effectiveness of early colonoscopy (performed within 24 hours of hospital admission) for acute lower gastrointestinal bleeding (LGIB) vs elective colonoscopy (performed 24 hours after admission).
METHODS: We conducted a retrospective study by using a database of endoscopies performed at the National Center for Global Health and Medicine in Tokyo, Japan from January 2009 through December 2014. We analyzed data from 538 patients emergently hospitalized for acute LGIB. We used propensity score matching to adjust for differences between patients who underwent early colonoscopy vs elective colonoscopy. Outcomes included rates of adverse events during bowel preparation and colonoscopy procedures, stigmata of recent hemorrhage, endoscopic therapy, blood transfusion requirement, 30-day rebleeding and mortality, and length of hospital stay.
RESULTS: We selected 163 pairs of patients for analysis on the basis of propensity matching. We observed no significant differences between the early and elective colonoscopy groups in bowel preparation-related rates of adverse events (1.8% vs 1.2%, P = .652), colonoscopy-related rates of adverse events (none in either group), blood transfusion requirement (27.6% vs 27.6%, P = 1.000), or mortality (1.2% vs 0, P = .156). The early colonoscopy group had higher rates than the elective group for stigmata of recent hemorrhage (26.4% vs 9.2%, P < .001) and endoscopic therapy (25.8% vs 8.6%, P < .001), including clipping (17.8% vs 4.9%, P < .001), band ligation (6.1% vs 1.8%, P = .048), and rebleeding (13.5% vs 7.4%, P = .070). Patients in the early colonoscopy group stayed in the hospital for a shorter mean time (10 days) than patients in the elective colonoscopy group (13 days) (P < .001).
CONCLUSIONS: Early colonoscopy for patients with acute LGIB is safe, allows for endoscopic therapy because it identifies the bleeding source, and reduces hospital stay. However, compared with elective colonoscopy, early colonoscopy does not reduce mortality and may increase the risk for rebleeding.

Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 26492844  Clin Gastroenterol Hepatol. 2016 Apr;14(4):558-64. doi:・・・
著者: Ryota Niikura, Naoyoshi Nagata, Atsuo Yamada, Tetsuro Honda, Kenkei Hasatani, Naoki Ishii, Yasutoshi Shiratori, Hisashi Doyama, Tsutomu Nishida, Tetsuya Sumiyoshi, Tomoki Fujita, Shu Kiyotoki, Tomoyuki Yada, Katsumi Yamamoto, Tomohiro Shinozaki, Munenori Takata, Tatsuya Mikami, Katsuhiro Mabe, Kazuo Hara, Mitsuhiro Fujishiro, Kazuhiko Koike
雑誌名: Gastroenterology. 2020 Jan;158(1):168-175.e6. doi: 10.1053/j.gastro.2019.09.010. Epub 2019 Sep 26.
Abstract/Text BACKGROUND & AIMS: We performed a large, multicenter, randomized controlled trial to determine the efficacy and safety of early colonoscopy on outcomes of patients with acute lower gastrointestinal bleeding (ALGIB).
METHODS: We performed an open-label study at 15 hospitals in Japan of 170 patients with ALGIB randomly assigned (1:1) to groups that underwent early colonoscopy (within 24 hours of initial visit to the hospital) or elective colonoscopy (24-96 hours after hospital admission). The primary outcome was identification of stigmata of recent hemorrhage (SRH). Secondary outcomes were rebleeding within 30 days, endoscopic treatment success, need for transfusion, length of stay, thrombotic events within 30 days, death within 30 days, and adverse events.
RESULTS: SRH were identified in 17 of 79 patients (21.5%) in the early colonoscopy group vs 17 of 80 patients (21.3%) in the elective colonoscopy group (difference, 0.3; 95% confidence interval, -12.5 to 13.0; P = .967). Rebleeding within 30 days of hospital admission occurred in 15.3% of patients in the early colonoscopy group and 6.7% of patients in the elective colonoscopy group (difference, 8.6; 95% confidence interval, -1.4 to 18.7); there were no significant differences between groups in successful endoscopic treatment rate, transfusion rate, length of stay, thrombotic events, or death within 30 days. The adverse event of hemorrhagic shock occurred during bowel preparation in no patient in the early group vs 2 patients (2.5%) in the elective colonoscopy group.
CONCLUSIONS: In a randomized controlled study, we found that colonoscopy within 24 hours after hospital admission did not increase SRH or reduce rebleeding compared with colonoscopy at 24-96 hours in patients with ALGIB. ClinicalTrials.gov, Numbers: UMIN000021129 and NCT03098173.

Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 31563627  Gastroenterology. 2020 Jan;158(1):168-175.e6. doi: 10.1・・・
著者: P Roberts, M Abel, L Rosen, W Cirocco, J Fleshman, E Leff, D Levien, T Pritchard, S Wexner, T Hicks
雑誌名: Dis Colon Rectum. 1995 Feb;38(2):125-32.
Abstract/Text It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

PMID 7851165  Dis Colon Rectum. 1995 Feb;38(2):125-32.
著者: G F Longstreth
雑誌名: Am J Gastroenterol. 1997 Mar;92(3):419-24.
Abstract/Text OBJECTIVES: Population-based data on the epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage (ALGIH) are lacking. This survey of the incidence, etiology, therapy, and long-term outcome of patients with ALGIH was conducted in a defined population.
METHODS: In a large health maintenance organization, discharge data and colonoscopy records were used to identify adults hospitalized with ALGIH from 1990 to 1993. Data were collected by record review and telephone calls.
RESULTS: Two hundred nineteen patients had 235 hospitalizations, yielding an estimated annual incidence rate of 20.5 patients/100,000 (24.2 in males versus 17.2 in females, p < .001). The rate increased > 200-fold from the third to the ninth decades of life. Diagnoses were: colonic diverticulosis, 91 (41.6%); colorectal malignancy, 20 (9.1%); ischemic colitis, 19 (8.7%); miscellaneous, 63 (28.8%); and unknown, 26 (11.9%). Eight (3.6%) patients died in the hospital (5 of 206 (2.4%) with hemorrhage before admission versus 3 of 13 (23.1%) with hemorrhage after admission, p < .001). Follow-up of 210 of 211 (99.5%) survivors was 34.0 +/- 1.1 months. In the 83 diverticulosis patients without definitive therapy, the hemorrhage recurrence rate (Kaplan-Meier method) was 9% at 1 year, 10% at 2 years, 19% at 3 years, and 25% at 4 years. In the 89 diverticulosis patients who survived hospitalization, all-cause mortality rates (none from hemorrhage) were 11% at 1 year, 15% at 2 years, 18% at 3 years, and 20% at 4 years.
CONCLUSIONS: Hospitalization with ALGIH is related to age and male gender. After hemorrhage from colonic diverticulosis, the leading cause, rates of ALGIH recurrence and unrelated death are similar during the next 4 years.

PMID 9068461  Am J Gastroenterol. 1997 Mar;92(3):419-24.
著者: Kathryn Oakland, Vipul Jairath, Raman Uberoi, Richard Guy, Lakshmana Ayaru, Neil Mortensen, Mike F Murphy, Gary S Collins
雑誌名: Lancet Gastroenterol Hepatol. 2017 Sep;2(9):635-643. doi: 10.1016/S2468-1253(17)30150-4. Epub 2017 Jun 23.
Abstract/Text BACKGROUND: Acute lower gastrointestinal bleeding is a common reason for emergency hospital admission, and identification of patients at low risk of harm, who are therefore suitable for outpatient investigation, is a clinical and research priority. We aimed to develop and externally validate a simple risk score to identify patients with lower gastrointestinal bleeding who could safely avoid hospital admission.
METHODS: We undertook model development with data from the National Comparative Audit of Lower Gastrointestinal Bleeding from 143 hospitals in the UK in 2015. Multivariable logistic regression modelling was used to identify predictors of safe discharge, defined as the absence of rebleeding, blood transfusion, therapeutic intervention, 28 day readmission, or death. The model was converted into a simplified risk scoring system and was externally validated in 288 patients admitted with lower gastrointestinal bleeding (184 safely discharged) from two UK hospitals (Charing Cross Hospital, London, and Hammersmith Hospital, London) that had not contributed data to the development cohort. We calculated C statistics for the new model and did a comparative assessment with six previously developed risk scores.
FINDINGS: Of 2336 prospectively identified admissions in the development cohort, 1599 (68%) were safely discharged. Age, sex, previous admission for lower gastrointestinal bleeding, rectal examination findings, heart rate, systolic blood pressure, and haemoglobin concentration strongly discriminated safe discharge in the development cohort (C statistic 0·84, 95% CI 0·82-0·86) and in the validation cohort (0·79, 0·73-0·84). Calibration plots showed the new risk score to have good calibration in the validation cohort. The score was better than the Rockall, Blatchford, Strate, BLEED, AIMS65, and NOBLADS scores in predicting safe discharge. A score of 8 or less predicts a 95% probability of safe discharge.
INTERPRETATION: We developed and validated a novel clinical prediction model with good discriminative performance to identify patients with lower gastrointestinal bleeding who are suitable for safe outpatient management, which has important economic and resource implications.
FUNDING: Bowel Disease Research Foundation and National Health Service Blood and Transplant.

Copyright © 2017 Elsevier Ltd. All rights reserved.
PMID 28651935  Lancet Gastroenterol Hepatol. 2017 Sep;2(9):635-643. do・・・
著者: Tomonori Aoki, Naoyoshi Nagata, Takuro Shimbo, Ryota Niikura, Toshiyuki Sakurai, Shiori Moriyasu, Hidetaka Okubo, Katsunori Sekine, Kazuhiro Watanabe, Chizu Yokoi, Mikio Yanase, Junichi Akiyama, Masashi Mizokami, Naomi Uemura
雑誌名: Clin Gastroenterol Hepatol. 2016 Nov;14(11):1562-1570.e2. doi: 10.1016/j.cgh.2016.05.042. Epub 2016 Jun 14.
Abstract/Text BACKGROUND & AIMS: We aimed to develop and validate a risk scoring system to determine the risk of severe lower gastrointestinal bleeding (LGIB) and predict patient outcomes.
METHODS: We first performed a retrospective analysis of data from 439 patients emergently hospitalized for acute LGIB at the National Center for Global Health and Medicine in Japan, from January 2009 through December 2013. We used data on comorbidities, medication, presenting symptoms, and vital signs, and laboratory test results to develop a scoring system for severe LGIB (defined as continuous and/or recurrent bleeding). We validated the risk score in a prospective study of 161 patients with acute LGIB admitted to the same center from April 2014 through April 2015. We assessed the system's accuracy in predicting patient outcome using area under the receiver operating characteristics curve (AUC) analysis. All patients underwent colonoscopy.
RESULTS: In the first study, 29% of the patients developed severe LGIB. We devised a risk scoring system based on nonsteroidal anti-inflammatory drugs use, no diarrhea, no abdominal tenderness, blood pressure of 100 mm Hg or lower, antiplatelet drugs use, albumin level less than 3.0 g/dL, disease scores of 2 or higher, and syncope (NOBLADS), which all were independent correlates of severe LGIB. Severe LGIB developed in 75.7% of patients with scores of 5 or higher compared with 2% of patients without any of the factors correlated with severe LGIB (P < .001). The NOBLADS score determined the severity of LGIB with an AUC value of 0.77. In the validation (second) study, severe LGIB developed in 35% of patients; the NOBLADS score predicted the severity of LGIB with an AUC value of 0.76. Higher NOBLADS scores were associated with a requirement for blood transfusion, longer hospital stay, and intervention (P < .05 for trend).
CONCLUSIONS: We developed and validated a scoring system for risk of severe LGIB based on 8 factors (NOBLADS score). The system also determined the risk for blood transfusion, longer hospital stay, and intervention. It might be used in decision making regarding intervention and management.

Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 27311620  Clin Gastroenterol Hepatol. 2016 Nov;14(11):1562-1570.e・・・
著者: Naoyoshi Nagata, Ryota Niikura, Tomonori Aoki, Takuro Shimbo, Katsunori Sekine, Hidetaka Okubo, Kazuhiro Watanabe, Toshiyuki Sakurai, Chizu Yokoi, Junichi Akiyama, Mikio Yanase, Masashi Mizokami, Naomi Uemura
雑誌名: World J Gastroenterol. 2015 Jan 28;21(4):1292-8. doi: 10.3748/wjg.v21.i4.1292.
Abstract/Text AIM: To determine the effect of discontinuing non-steroidal antiinflammatory drugs (NSAIDs) on recurrence in long-term follow-up patients with colonic diverticular bleeding (CDB).
METHODS: A cohort of 132 patients hospitalized for CDB examined by colonoscopy was prospectively enrolled. Comorbidities, lifestyle, and medications (NSAIDs, low-dose aspirin, antiplatelet agents, anticoagulants, acetaminophen, and corticosteroids) were assessed. After discharge, patients were requested to visit the hospital on scheduled days during the follow-up period. The Kaplan-Meier method was used to estimate recurrence.
RESULTS: Median follow-up was 15 mo. The probability of recurrence at 1, 6, 12, and 24 mo was 3.1%, 19%, 27%, and 38%, respectively. Of the 41 NSAID users on admission, 26 (63%) discontinued NSAID use at discharge. Many of the patients who could discontinue NSAIDs were intermittent users, and could be switched to alternative therapies, such as acetaminophen or an antiinflammatory analgesic plaster. The probability of recurrence at 12 mo was 9.4% in discontinuing NSAID users compared with 77% in continuing users (P<0.01, log-rank test). The hazard ratio for recurrence in the discontinuing NSAIDs users was 0.06 after adjusting for age>70 years, right-sided diverticula, history of hypertension, and hemodialysis. No patients developed cerebrocardiovascular events during follow-up.
CONCLUSION: There is a substantial recurrence rate after discharge among patients hospitalized for diverticular bleeding. Discontinuation of NSAIDs is an effective preventive measure against recurrence. This study provides new information on risk reduction strategies for diverticular bleeding.

PMID 25632204  World J Gastroenterol. 2015 Jan 28;21(4):1292-8. doi: 1・・・
著者: Daniel M Witt, Thomas Delate, David A Garcia, Nathan P Clark, Elaine M Hylek, Walter Ageno, Francesco Dentali, Mark A Crowther
雑誌名: Arch Intern Med. 2012 Oct 22;172(19):1484-91. doi: 10.1001/archinternmed.2012.4261.
Abstract/Text BACKGROUND: Patients who not only survive a warfarin-associated gastrointestinal tract bleeding (GIB) event but also have an ongoing risk for thromboembolism present 2 clinical dilemmas: whether and when to resume anticoagulation. The objective of this study was to determine the incidence of thrombosis, recurrent GIB, and death, as well as the time to resumption of anticoagulant therapy, during the 90 days following a GIB event.
METHODS: In this retrospective, cohort study using administrative and clinical databases, patients experiencing GIB during warfarin therapy were categorized according to whether they resumed warfarin therapy after GIB and followed up for 90 days. Variables describing the management and severity of the index GIB were also collected. Kaplan-Meier curves were constructed to estimate the survival function of thrombosis, recurrent GIB, and death between the "resumed warfarin therapy" and "did not resume warfarin therapy" groups, with Cox proportional hazards modeling to adjust for potentially confounding factors.
RESULTS: There were 442 patients with warfarin-associated index GIB included in the analyses. Following the index GIB, 260 patients (58.8%) resumed warfarin therapy. Warfarin therapy resumption after the index GIB was associated with a lower adjusted risk for thrombosis (hazard ratio [HR], 0.05; 95% CI, 0.01-0.58) and death (HR, 0.31; 95% CI, 0.15-0.62), without significantly increasing the risk for recurrent GIB (HR, 1.32; 95% CI, 0.50-3.57).
CONCLUSIONS: The decision to not resume warfarin therapy in the 90 days following a GIB event is associated with increased risk for thrombosis and death. For many patients who have experienced warfarin-associated GIB, the benefits of resuming anticoagulant therapy will outweigh the risks.

PMID 22987143  Arch Intern Med. 2012 Oct 22;172(19):1484-91. doi: 10.1・・・
著者: R Niikura, N Nagata, A Yamada, J Akiyama, T Shimbo, N Uemura
雑誌名: Colorectal Dis. 2012 Mar;14(3):302-5. doi: 10.1111/j.1463-1318.2011.02611.x.
Abstract/Text AIM: Colonic diverticular bleeding often recurs, but the risk factors remain unclear. Our aim was to identify risk factors for recurrence in patients with diverticular bleeding.
METHOD: Seventy-two hospitalized patients who were diagnosed with diverticular bleeding between 2004 and 2008 were analyzed. Rebleeding was considered as the main outcome measure, with the duration until recurrence identified from medical records. Potential risk factors for rebleeding, such as underlying pathologies, medication and smoking and drinking habits, were investigated from the medical records on initial admission.
RESULTS: Of the 72 patients, 19 had a diverticular disease on the right, 16 on the left side and 37 on both sides of the colon. Recurrence was identified in 27 (38%) patients at a median interval of 1535 days. The cumulative incidence of rebleeding at 6, 12 and 24 months was 15%, 20% and 33%. Multivariate analysis revealed nonsteroid anti-inflammatory drugs (NSAIDs) (hazard ratio (HR), 2.57; 95% confidence interval (CI), 0.89-7.46; P=0.08), antiplatelet drugs (HR, 2.39; 95% CI, 1.01-5.67; P=0.05) and hypertension (HR, 4.16; 95% CI, 1.22-14.2; P=0.02) to be risk factors for rebleeding.
CONCLUSION: Patients with colonic diverticular bleeding show high recurrence rates within a short period. Risk factors for recurrence have been identified as the use of NSAIDs or antiplatelet drugs and hypertension.

© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.
PMID 21692963  Colorectal Dis. 2012 Mar;14(3):302-5. doi: 10.1111/j.14・・・
著者: Tomoko Okamoto, Hirotsugu Watabe, Atsuo Yamada, Yoshihiro Hirata, Haruhiko Yoshida, Kazuhiko Koike
雑誌名: Int J Colorectal Dis. 2012 Sep;27(9):1161-6. doi: 10.1007/s00384-012-1491-x. Epub 2012 May 15.
Abstract/Text PURPOSE: We previously reported that hypertension is related to colonic diverticular bleeding, suggesting the involvement of arteriosclerosis. The recurrence of diverticular bleeding has been little investigated. We aimed to elucidate additional risk factors for diverticular bleeding and also to investigate the incidence rates and risk factors for re-bleeding.
METHODS: Between January 2006 and September 2010, 62 patients with diverticular bleeding were admitted to our hospital. We then selected 124 control subjects with non-bleeding diverticula from the colonoscopy database of our department. Additionally, a retrospective cohort study was conducted using these case patients to estimate the re-bleeding rate after initial diverticular bleeding and the risk factors for re-bleeding. Odds ratios for diverticular bleeding were calculated by multivariate logistic regression in a case-control study. Cumulative re-bleeding rates since initial bleeding and hazard ratios of risk factors were estimated by Kaplan-Meier method and Cox proportional hazard model.
RESULTS: Sixty-two patients presented 99 bleeding episodes including the initial ones. Diabetes mellitus (OR 2.5, 95 % CI 1.2-5.2, P = 0.03), cardio- or cerebrovascular diseases (OR 4.2, 95 % CI 1.7-11.3, P = 0.003), and NSAID use (OR 3.7, 95 % CI 1.3-11.6, P = 0.02) were shown to be independent risk factors. The cumulative re-bleeding rates were 21 %, 34 %, and 40 % at 1, 2, and 3 years, respectively, in which NSAID use (HR 6.3, 95 % CI 1.7-20.7, P = 0.007) was a risk factor for re-bleeding.
CONCLUSIONS: Diabetes mellitus and vascular diseases were risk factors for diverticular bleeding, suggesting systemic metabolic disorders and arteriosclerosis might play an important role.

PMID 22584295  Int J Colorectal Dis. 2012 Sep;27(9):1161-6. doi: 10.10・・・
著者: Yoshimasa Tanaka, Yasuaki Motomura, Kazuya Akahoshi, Risa Iwao, Keishi Komori, Naotaka Nakama, Takashi Osoegawa, Soichi Itaba, Masaru Kubokawa, Terumasa Hisano, Eikichi Ihara, Kazuhiko Nakamura, Ryoichi Takayanagi
雑誌名: Gut Liver. 2012 Jul;6(3):334-8. doi: 10.5009/gnl.2012.6.3.334. Epub 2012 Jul 12.
Abstract/Text BACKGROUND/AIMS: Colonic diverticular bleeding can stop spontaneously or be stopped by endoscopic hemostasis. We analyzed the clinical and colonoscopic features of patients with colonic diverticular bleeding to establish the predictive factors for rebleeding.
METHODS: A total of 111 patients (median age, 72 years) with colonic diverticular bleeding in Aso Iizuka Hospital between April 2007 and July 2010 were enrolled. Age, sex, body mass index (BMI), comorbidity, medication, location of bleeding, colonoscopic findings and hemostatic methods were analyzed retrospectively from the hospital records.
RESULTS: The most common sites of bleeding were the ascending (39.6%) and sigmoid (29.7%) colon. Overt rebleeding occurred in 30 patients (27.0%). Spontaneous hemostasis was seen in 81 patients (73.0%), and endoscopic hemostatic treatment was performed in 30 patients. The BMI in the patients with colonic diverticular rebleeding was significantly higher than in patients without rebleeding. Colonoscopic findings of actively bleeding or nonbleeding visible vessels in the responsible diverticula were more frequent in the group with rebleeding.
CONCLUSIONS: A higher BMI and colonoscopic findings of actively bleeding or nonbleeding visible vessels can be used as predictive factors for colonic diverticular rebleeding. Patients with such findings should be carefully followed up after hemostasis of the initial colonic diverticular bleeding.

PMID 22844561  Gut Liver. 2012 Jul;6(3):334-8. doi: 10.5009/gnl.2012.6・・・
著者: R G Wilson, A N Smith, I M Macintyre
雑誌名: Br J Surg. 1990 Oct;77(10):1103-4.
Abstract/Text Previous retrospective studies have suggested an association between consumption of non-steroidal anti-inflammatory drugs (NSAIDs) and the complications of diverticular disease. Ninety-two patients were entered into a prospective study of the complications of diverticular disease over a 3 year period; 31 were taking NSAIDs, compared with only four age- and sex-matched controls from a representative general practice (P less than 0.001). A second control group comprised 306 patients with cancer of the colon in whom NSAID consumption was again significantly lower than in patients with diverticular disease (22 of 306 versus 31 of 92, P less than 0.001). Of the 31 patients taking NSAIDs, 19 presented with a perforation or peritonitis. By contrast, only eight of the 61 patients not taking NSAIDs had such complications (P less than 0.001). Eleven patients presented with bleeding of whom five were taking NSAIDs and six were not. Patients admitted with complications of diverticular disease have a high incidence of NSAID intake, and it appears that NSAID consumption is associated with a more severe form of the disease.

PMID 2121310  Br J Surg. 1990 Oct;77(10):1103-4.
著者: K Campbell, R J Steele
雑誌名: Br J Surg. 1991 Feb;78(2):190-1.
Abstract/Text Fifty patients with severe complications of diverticular disease were compared with two groups of 50 controls, matched for age and sex. The first control group (A) was randomly selected from all emergency hospital admissions, and the second group (B) from patients with uncomplicated diverticular disease. Of the 50 study patients, 24 (48 per cent) were taking non-steroidal anti-inflammatory drugs (NSAIDs) at the time of admission compared with nine (18 per cent) of control group A and ten (20 per cent) of control group B. Both of these differences were statistically significant, indicating a strong association between the ingestion of NSAIDs and the development of severe complications of diverticular disease.

PMID 2015469  Br J Surg. 1991 Feb;78(2):190-1.
著者: P G Foutch
雑誌名: Am J Gastroenterol. 1995 Oct;90(10):1779-84.
Abstract/Text OBJECTIVE: This retrospective study was performed to determine if certain endoscopic features of a bleeding diverticulum predict outcome for patients and to assess the role of nonsteroidal anti-inflammatory drugs (NSAID) as a risk factor for hemorrhage.
METHODS: Over a 28-month period, colonoscopy was performed on 13 patients (mean, age 74 yr) in whom a specific diverticulum was unequivocally identified as a cause for bleeding. Endoscopic features of the affected diverticulum were recorded and correlated with outcome for patients. Drug histories were reviewed to document use of NSAID before bleeding.
RESULTS: Three patients had a visible vessel located inside a diverticulum, and one subject had an adherent clot with active bleeding. These colonoscopic findings were classified as stigmata of significant hemorrhage (SSH). In the remaining nine patients the diverticula were ulcerated. This endoscopic finding was classified as stigmata of insignificant hemorrhage (SIH). Compared with patients with SIH, individuals with SSH experienced a greater number of bleeding episodes (3.5 vs 1.3, p = 0.006), had a lower initial hemoglobin concentration (8.2 vs 12.5 gm%, p = 0.009), and required more transfusions (3.3 vs 0, p = 0.04) and invasive treatments (75% with SSH were managed by endoscopy or surgery vs 0% for those with SIH, p = 0.01). Ninety-two percent of the patients were taking NSAID (100% with SSH and 89% with SIH). Seventy-five percent of subjects with SSH compared with 0% of patients with SIH had a combined exposure to NSAID and ASA (p = 0.01).
CONCLUSIONS: Presence of a visible vessel or an adherent clot with active bleeding is a reliable marker for significant hemorrhage. Ulcerated diverticula are the cause of trivial bleeding, and presence of this endoscopic finding accurately predicts a benign clinical course. NSAID may be an important risk factor for diverticular bleeding. It is possible that combined exposure to NSAID and ASA results in more severe bleeding compared with use of NSAID alone.

PMID 7572894  Am J Gastroenterol. 1995 Oct;90(10):1779-84.
著者: Lisa L Strate, Yan L Liu, Edward S Huang, Edward L Giovannucci, Andrew T Chan
雑誌名: Gastroenterology. 2011 May;140(5):1427-33. doi: 10.1053/j.gastro.2011.02.004. Epub 2011 Feb 12.
Abstract/Text BACKGROUND & AIMS: Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been implicated in diverticular complications. We examined the influence of aspirin and NSAID use on risk of diverticulitis and diverticular bleeding in a large prospective cohort.
METHODS: We studied 47,210 US men in the Health Professionals Follow-up Study cohort who were 40-75 years old at baseline in 1986. We assessed use of aspirin, nonaspirin NSAIDs, and other risk factors biennially. We identified men with diverticulitis or diverticular bleeding based on responses to biennial and supplementary questionnaires.
RESULTS: We documented 939 cases of diverticulitis and 256 cases of diverticular bleeding during a 22-year period of follow-up evaluation. After adjustment for risk factors, men who used aspirin regularly (≥2 times/wk) had a multivariable hazard ratio (HR) of 1.25 (95% confidence interval [CI], 1.05-1.47) for diverticulitis and a HR of 1.70 (95% CI, 1.21-2.39) for diverticular bleeding, compared with nonusers of aspirin and NSAIDs. Use of aspirin at intermediate doses (2-5.9 standard, 325-mg tablets/wk) and frequency (4-6 days/wk) were associated with the highest risk of bleeding (multivariable HR, 2.32; 95% CI, 1.34-4.02, and multivariable HR, 3.13; 95% CI, 1.82-5.38, respectively). Regular users of nonaspirin NSAIDs also had an increased risk of diverticulitis (multivariable HR, 1.72; 95% CI, 1.40-2.11) and diverticular bleeding (multivariable HR, 1.74; 95% CI, 1.15-2.64), compared with men who denied use of these medications.
CONCLUSIONS: Regular use of aspirin or NSAIDs is associated with an increased risk of diverticulitis and diverticular bleeding. Patients at risk of diverticular complications should carefully consider the potential risks and benefits of using these medications.

Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 21320500  Gastroenterology. 2011 May;140(5):1427-33. doi: 10.1053・・・
著者: W H Aldoori, E L Giovannucci, E B Rimm, A L Wing, W C Willett
雑誌名: Arch Fam Med. 1998 May-Jun;7(3):255-60.
Abstract/Text OBJECTIVE: To examine prospectively the relationship between self-reported regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen and the risk of symptomatic diverticular disease.
DESIGN: Prospective cohort study using a mailed baseline questionnaire in 1986, and follow-up every 2 years through 1992.
SETTING: Male health professionals residing in 50 US states.
PATIENTS: A total of 35 615 male health professionals (dentists, optometrists, veterinarians, physicians, pharmacists, osteopathic physicians, podiatrists) 40 to 75 years of age at baseline and free of diagnosed diverticular disease, colon or rectal polyp, ulcerative colitis, and cancer prior to 1988.
MAIN OUTCOME MEASURES: Follow-up questionnaires in 1988, 1990, and 1992 about use of NSAIDs, acetaminophen, and other variables including the diagnosis of symptomatic diverticular disease.
RESULTS: During 4 years of follow-up, we documented 310 newly diagnosed cases of symptomatic diverticular disease. After adjustment for age, physical activity, and energy-adjusted dietary fiber and total fat intake, regular and consistent use of NSAIDs and acetaminophen was positively associated with the overall risk of symptomatic diverticular disease (for users vs nonusers, relative risk [RR] for NSAIDs = 2.24, 95% confidence interval [CI], 1.28-3.91; RR for acetaminophen = 1.81, 95% CI, 0.79-4.11). Most of this positive association was attributable to cases associated with bleeding, particularly for acetaminophen (for users vs nonusers, RR for NSAIDs = 4.64, 95% CI, 0.99-21.74; RR for acetaminophen = 13.63, 95% CI, 3.53-52.60).
CONCLUSIONS: These results suggest that regular and consistent use of NSAIDs in general and acetaminophen is associated with symptoms of severe diverticular disease, particularly bleeding. Further research is needed to investigate the potentially deleterious effect of NSAIDs and other medications on the lower gastrointestinal tract.

PMID 9596460  Arch Fam Med. 1998 May-Jun;7(3):255-60.
著者: Antje Jansen, Sabine Harenberg, Uwe Grenda, Christoph Elsing
雑誌名: World J Gastroenterol. 2009 Jan 28;15(4):457-61. doi: 10.3748/wjg.15.457.
Abstract/Text AIM: To evaluate the risk factors-other than nonsteroidal anti-inflammatory drugs-for colonic diverticular bleeding in a westernized population.
METHODS: One hundred and forty patients, treated for symptomatic diverticular disease in a community based hospital, were included. Thirty (21%) had signs of diverticular bleeding. Age, gender, and the results of colonoscopy were collected and compared to a group of patients with nonbleeding symptomatic diverticulosis. Records were reviewed for comorbidities, such as obesity, alcohol consumption, smoking habits and metabolic diseases. Special emphasis was put on arterial hypertension, cardiovascular events, diabetes mellitus, hyperuricemia and hypercholesterinemia.
RESULTS: There was no difference between patients with diverticular hemorrhage and those with nonbleeding symptomatic diverticulosis regarding gender ratio (male/female 9/21 vs 47/63) and diverticular localisation. Bleeding patients differed in respect to age (73.4+/-9.9 vs 67. 8+/-13.0, P<0.013). Significant differences were found between both groups regarding the presence of hyperuricemia and use of steroids and nonsteroidal anti-inflammatory drugs. Patients with three concomitant metabolic diseases were also identified as being at risk of bleeding. A forward stepwise logistic regression analysis revealed steroids, hyperuricemia and the use of calcium-channel blockers as independent risk factors of bleeding.
CONCLUSION: Beside nonsteroidal anti-inflammatory steroid drug use, antihypertensive medication and concomitant arteriosclerotic diseases are risk factors for colonic diverticular hemorrhage. Our results support the hypothesis of an altered arteriosclerotic vessel as the source of bleeding.

PMID 19152450  World J Gastroenterol. 2009 Jan 28;15(4):457-61. doi: 1・・・
著者: Ryota Niikura, Naoyoshi Nagata, Junichi Akiyama, Takuro Shimbo, Naomi Uemura
雑誌名: Int J Colorectal Dis. 2012 Sep;27(9):1137-43. doi: 10.1007/s00384-012-1422-x. Epub 2012 Feb 22.
Abstract/Text PURPOSE: Colonic diverticular bleeding is a major cause of lower gastrointestinal bleeding. However, a limited number of studies have been reported on the risk factors for diverticular bleeding. Our aim was to identify risk factors for diverticular bleeding.
METHODS: Our study design is a case (diverticular bleeding)-control (diverticulosis) study. We prospectively collected information of habits, comorbidities, history of medications and symptoms by a questionnaire, and diagnosed diverticular bleeding and diverticulosis by colonoscopy. Logistic regression models were used to estimate odds ratio (OR) and 95% confidence interval (CI).
RESULTS: A total of 254 patients (diverticular bleeding, 45; diverculosis, 209) were selected for analysis. Cluster (≥10 diverticula) type (OR, 4.0; 95% CI, 1.8-8.9), hypertension (OR, 2.2; 95% CI, 1.0-4.6), ischemic heart disease (OR, 2.4; 95% CI, 1.1-5.4), and chronic renal failure (OR, 6.4; 95% CI, 1.3-32) were independent risk factors for diverticular bleeding.
CONCLUSIONS: Large number of diverticula, hypertension, and concomitant arteriosclerotic diseases including ischemic heart disease and chronic renal failure are risk factors for diverticular bleeding. This study identifies new information on the risk factors for diverticular bleeding.

PMID 22354135  Int J Colorectal Dis. 2012 Sep;27(9):1137-43. doi: 10.1・・・
著者: Atsuo Yamada, Takafumi Sugimoto, Shintaro Kondo, Miki Ohta, Hirotsugu Watabe, Shin Maeda, Goichi Togo, Yutaka Yamaji, Keiji Ogura, Makoto Okamoto, Haruhiko Yoshida, Takao Kawabe, Tateo Kawase, Masao Omata
雑誌名: Dis Colon Rectum. 2008 Jan;51(1):116-20. doi: 10.1007/s10350-007-9137-8. Epub 2007 Dec 18.
Abstract/Text PURPOSE: Colonic diverticulosis, although usually asymptomatic, sometimes causes diverticular hemorrhage. Studies about risk factors, other than nonsteroidal anti-inflammatory drugs, for colonic diverticular hemorrhage are limited. We conducted the present study to elucidate their significance as a risk factor.
METHODS: Colonic diverticulosis was found in 1,753 patients and diverticular hemorrhage in 44 patients among 9,499 total colonoscopy examinees at the authors' institutions between September 1995 and December 2005. After reviewing their clinical features, we chose two controls for each case with diverticular hemorrhage matched for age, gender, and the location of diverticulosis. We evaluated the effects of comorbidities (hypertension, hyperlipidemia, diabetes mellitus, cerebrovascular disease, ischemic heart disease), habits (alcohol, smoking), and medications, including nonsteroidal anti-inflammatory drugs, by using conditional logistic regression analysis.
RESULTS: There were no significant differences between patients with diverticular hemorrhage and those with nonbleeding diverticulosis regarding age (67 +/- 13 vs. 64 +/- 11 years) or gender ratio (male/female ratio: 36/8 vs. 1,237/472). As for location, the proportion of bilateral diverticulosis was larger among patients with hemorrhage (43 vs. 22 percent). In the case-control study, nonsteroidal anti-inflammatory drugs (odds ratio, 15.6; 95 percent confidence interval, 1.1-214; P = 0.04), hypertension (odds ratio, 6.6; 95 percent confidence interval, 2.1-20.5; P = 0.0011), and aspirin and/or other anticoagulant (odds ratio, 3; 95 percent confidence interval, 1.04-8.6; P = 0.042) were shown to be significant risk factors by multivariate analysis.
CONCLUSIONS: Hypertension, nonsteroidal anti-inflammatory drugs, and anticoagulants, including aspirin, are independent risk factors for colonic diverticular hemorrhage.

PMID 18085336  Dis Colon Rectum. 2008 Jan;51(1):116-20. doi: 10.1007/s・・・
著者: Omar Kherad, Sophie Restellini, Myriam Martel, Michael Sey, Michael F Murphy, Kathryn Oakland, Alan Barkun, Vipul Jairath
雑誌名: Aliment Pharmacol Ther. 2019 Apr;49(7):919-925. doi: 10.1111/apt.15158. Epub 2019 Feb 25.
Abstract/Text BACKGROUND: Restrictive red blood cell (RBC) transfusion reduces mortality and rebleeding after upper gastrointestinal bleeding (UGIB). However, there is no evidence to guide transfusion strategies in lower gastrointestinal bleeding (LGIB).
AIM: To assess the association between RBC transfusion strategies and outcomes in patients with LGIB METHODS: This was a post hoc analysis of the UK National Comparative Audit of LGIB and the Use of Blood. The relationships between liberal RBC transfusion and clinical outcomes of rebleeding, mortality and a composite outcome for safe discharge were examined. Transfusion strategy was dichotomised and defined as "liberal" when transfusion was administered for haemoglobin (Hb) ≥80 g/L (or ≥90 g/L in patients with acute coronary syndrome) or major haemorrhage, and "restrictive" otherwise. Multivariable logistic regression models were used to assess the independent association between liberal RBC transfusion and outcomes.
RESULTS: Of 2528 consecutive patients enrolled from 143 hospitals in the original study, 666 (26.3%) received RBC transfusion (mean age 73.3 ± 16 years, 49% female, initial mean haemoglobin 90 ± 24 g/L, 2.3% had haemodynamic instability). The rebleeding rate in transfused patients was 42.3%. After adjusting for potential confounders, there was no difference between liberal and restrictive RBC transfusion strategies for the odds of rebleeding (OR 0.89, 95% CI 0.6-1.22), in-hospital mortality (OR 0.54, 95% CI 0.3-1.1) or of achieving the composite outcome (OR 0.72, 95% CI 0.5-1.1).
CONCLUSION: Although these results could be due to residual confounding, they provide an important foundation for the design of randomised trials to evaluate transfusion strategies for LGIB.

© 2019 John Wiley & Sons Ltd.
PMID 30805962  Aliment Pharmacol Ther. 2019 Apr;49(7):919-925. doi: 10・・・
著者: Naoki Ishii, Takeshi Setoyama, Gautam A Deshpande, Fumio Omata, Michitaka Matsuda, Shoko Suzuki, Masayo Uemura, Yusuke Iizuka, Katsuyuki Fukuda, Koyu Suzuki, Yoshiyuki Fujita
雑誌名: Gastrointest Endosc. 2012 Feb;75(2):382-7. doi: 10.1016/j.gie.2011.07.030. Epub 2011 Sep 23.
Abstract/Text 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.

Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
PMID 21944311  Gastrointest Endosc. 2012 Feb;75(2):382-7. doi: 10.1016・・・
著者: Tonya Kaltenbach, Rabindra Watson, Janak Shah, Shai Friedland, Tohru Sato, Amandeep Shergill, Kenneth McQuaid, Roy Soetikno
雑誌名: Clin Gastroenterol Hepatol. 2012 Feb;10(2):131-7. doi: 10.1016/j.cgh.2011.10.029. Epub 2011 Nov 2.
Abstract/Text BACKGROUND & AIMS: Diverticular bleeding is the most common cause of acute severe lower gastrointestinal bleeding (LGIB) in Western countries. Diagnostic and therapeutic approaches, including endoscopy, radiology, or surgery, have not been standardized. We investigated colonoscopy as a first-line modality to diagnose and manage patients with LGIB.
METHODS: We performed a retrospective study of data collected from 2 tertiary Veterans hospitals of 64 patients (61 men, 76 ± 11 years) with acute severe diverticular bleeding, based on colonoscopy examination. We assessed primary hemostasis using endoscopic clipping for diverticular bleeding and described the bleeding stigmata. We measured early (<30 days) and late rebleeding, blood transfusion requirements, hospital stay and complications.
RESULTS: Patients received 3.1 ± 3.0 and 0.9 ± 2.2 U of blood before and after colonoscopy, respectively. Twenty-four of the 64 patients (38%) had diverticular stigmata of recent hemorrhage; and 21 of these patients (88%) were treated successfully using endoscopic clips, without complication or early rebleeding. Hospital stays averaged 6.4 ± 5.6 days. Endoscopic clipping provided primary hemostasis in 9/12 patients (75%) with active diverticular bleeding. During 35 ± 18 months of follow-up, late recurrent diverticular bleeding occurred in 22% of the patients (14/64) after a mean time period of 22 months; 5 of the patients (21%) with stigmata of recent hemorrhage who received clip treatment had rebleeding at 43 months. Rebleeding was self-limited in 8 patients (57%), was clipped in 4 (29%), or was embolized in 2 (14%).
CONCLUSIONS: Colonoscopy can be a safe first-line diagnostic and therapeutic approach for patients with severe LGIB. Endoscopic clipping provides hemostasis of active diverticular bleeding. Recurrent bleeding occurs in about 21% of patients who were treated with clips, at approximately 4 years; most bleeding is self-limited or can be retreated by endoscopic clipping.

Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 22056302  Clin Gastroenterol Hepatol. 2012 Feb;10(2):131-7. doi: ・・・
著者: Naoyoshi Nagata, Naoki Ishii, Mitsuru Kaise, Takuro Shimbo, Toshiyuki Sakurai, Junichi Akiyama, Naomi Uemura
雑誌名: Gastrointest Endosc. 2018 Nov;88(5):841-853.e4. doi: 10.1016/j.gie.2018.07.018. Epub 2018 Jul 20.
Abstract/Text BACKGROUND AND AIMS: Very few prospective studies with over 100 samples have evaluated the long-term outcomes of endoscopic therapy for colonic diverticular bleeding (CDB). This study sought to elucidate the recurrent bleeding risk of endoscopic band ligation versus clipping for definitive CDB based on stigmata of recent hemorrhage (SRH).
METHODS: Patients emergently hospitalized for acute lower GI bleeding and examined by high-resolution colonoscopy were enrolled. Better visualization of SRH from a diverticulum was obtained using a water-jet device. Endoscopic band ligation or clipping was performed as first-line treatment, and patients were prospectively followed after discharge.
RESULTS: No statistical difference was found between the ligation (n = 61) and clipping (n = 47) groups in baseline characteristics or follow-up period. The probability of 1-year recurrent bleeding was 11.5% in the ligation group versus 37.0% in the clipping group (P = .018). No patients required surgery or experienced perforation. One patient in the ligation group experienced diverticulitis the next day. In patients with recurrent bleeding within 7 days, the recurrent bleeding site was the same diverticulum, and ulceration was found in the ligation group on repeat colonoscopy. In patients with recurrent bleeding after 2 months, repeat colonoscopy identified that the recurrent bleeding site was different, and scar formation was seen in the ligation group. The left side of the colon was an independent predictor for recurrent bleeding in the ligation group but not in the clipping group.
CONCLUSIONS: Band ligation for definitive CDB has better outcomes than clipping during long-term follow-up after endoscopic therapy, probably because of complete elimination of the diverticulum. CDB can recur at the same diverticulum in the short term but at a different diverticulum in the long term.

Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
PMID 30036505  Gastrointest Endosc. 2018 Nov;88(5):841-853.e4. doi: 10・・・
著者: Jun-ichi Iwamoto, Yuji Mizokami, Koichi Shimokobe, Takeshi Matsuoka, Yasushi Matsuzaki
雑誌名: World J Gastroenterol. 2008 Nov 7;14(41):6413-7.
Abstract/Text The prevalence of diverticular diseases of the colon, including severe and persistent bleeding in Eastern countries, has increased in the last decades. The bleeding from colonic diverticula is the most common cause of acute lower gastrointestinal bleeding. Herein, we report four cases of severe and persistent bleeding of colonic diverticular disease that could be treated with a high concentration barium enema. These four cases showed a similar pattern of bleeding whose source could not be identified. Colonoscopy revealed fresh blood in the entire colon and many diverticula were noted throughout the colon. No active bleeding source was identified, but large adherent clots in some diverticula were noted. After endoscopic and angiographic therapies failed, therapeutic barium enema stopped the severe bleeding. These patients remained free of re-bleeding in the follow-up period (range 17-35 mo) after the therapy. We report the four case series of therapeutic barium enema and reviewed the literature pertinent to this procedure.

PMID 19009662  World J Gastroenterol. 2008 Nov 7;14(41):6413-7.
著者: Nobuyuki Matsuhashi, Masaaki Akahane, Atsushi Nakajima
雑誌名: AJR Am J Roentgenol. 2003 Feb;180(2):490-2. doi: 10.2214/ajr.180.2.1800490.
Abstract/Text
PMID 12540457  AJR Am J Roentgenol. 2003 Feb;180(2):490-2. doi: 10.221・・・
著者: S M Cohn, B A Moller, P M Zieg, K A Milner, P B Angood
雑誌名: Arch Surg. 1998 Jan;133(1):50-5.
Abstract/Text OBJECTIVE: To evaluate the benefits and risks of selective angiography for the evaluation of acute lower gastrointestinal (GI) bleeding to identify the site of bleeding and theoretically limit the extent of colonic resection.
DESIGN: Retrospective chart review.
SETTING: Tertiary care hospital.
PATIENTS: Sixty-five patients undergoing 75 selective angiograms for evaluation of acute lower GI bleeding. Mean age was 71 years (range, 27-93 years), and 37 (57%) were women.
MAIN OUTCOME MEASURES: Demographic data were collected that included any associated medical problems, potential factors contributing to an increased risk for bleeding, and the diagnostic methods used in evaluating the source of lower GI bleeding. The details of angiography procedures were recorded with special attention to the impact of the procedure on clinical management and any associated complications.
RESULTS: Twenty-three patients (35%) had positive angiography findings, and 14 of them (61%) required operations. Forty-two patients (65%) had negative angiography findings, and 8 of them (19%) required operations. Surgery for the 22 patients included hemicolectomy in 11 patients, subtotal colectomy in 10 patients, and small-bowel tumor resection in 1 patient. In 9 patients, a hemicolectomy was performed on the basis of angiography findings. Three patients (2 with negative angiography findings) experienced rebleeding after a hemicolectomy and required a subsequent subtotal colectomy. Overall, only 8 (12%) of the 65 patients underwent a segmental colon resection that was based on angiography findings and did not bleed after their operation. Complications from angiography occurred in 7 patients (11%).
CONCLUSION: Selective angiography appears to add little clinically useful information in patients with acute lower GI bleeding and carries a relatively high complication risk.

PMID 9438759  Arch Surg. 1998 Jan;133(1):50-5.
著者: Lisa L Strate, Christopher R Naumann
雑誌名: Clin Gastroenterol Hepatol. 2010 Apr;8(4):333-43; quiz e44. doi: 10.1016/j.cgh.2009.12.017. Epub 2009 Dec 29.
Abstract/Text There are multiple strategies for evaluating and treating lower intestinal bleeding (LIB). Colonoscopy has become the preferred initial test for most patients with LIB because of its diagnostic and therapeutic capabilities and its safety. However, few studies have directly compared colonoscopy with other techniques and there are controversies regarding the optimal timing of colonoscopy, the importance of colon preparation, the prevalence of stigmata of hemorrhage, and the efficacy of endoscopic hemostasis. Angiography, radionuclide scintigraphy, and multidetector computed tomography scanning are complementary modalities, but the requirement of active bleeding at the time of the examination limits their routine use. In addition, angiography can result in serious complications. This review summarizes the available evidence regarding colonoscopy and radiographic studies in the management of acute LIB.

Copyright 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 20036757  Clin Gastroenterol Hepatol. 2010 Apr;8(4):333-43; quiz ・・・
著者: V Setya, J A Singer, S L Minken
雑誌名: Am Surg. 1992 May;58(5):295-9.
Abstract/Text A 7-year experience involving 12 cases of massive, unrelenting lower gastrointestinal hemorrhage is presented. In these patients, the bleeding could not be localized by multiple diagnostic modalities and was managed by blind subtotal colectomy. While the procedure was efficacious in arresting bleeding in all cases, a resultant mortality of four cases (33%) ensued. Morbidity among the survivors was significant. Only three patients (25%) survived without complications, which enabled an early discharge from the hospital. Diverticulosis was the most common cause (83%) of uncontrollable and preoperatively undiagnosed bleeding in this group of patients. These 12 cases of blind subtotal colectomy for massive lower gastrointestinal bleeding represent one of the larger series in the literature. These data are consistent with more recent reports that indicate that subtotal colectomy for lower gastrointestinal bleeding is an effective but a formidable procedure. This is contrary to the earlier published results.

PMID 1622010  Am Surg. 1992 May;58(5):295-9.
著者: Ryota Niikura, Naoyoshi Nagata, Hisashi Doyama, Ryosuke Ota, Naoki Ishii, Katsuhiro Mabe, Tsutomu Nishida, Takuto Hikichi, Kazuki Sumiyama, Jun Nishikawa, Toshio Uraoka, Shu Kiyotoki, Mitsuhiro Fujishiro, Kazuhiko Koike
雑誌名: World J Gastrointest Endosc. 2016 Dec 16;8(20):785-794. doi: 10.4253/wjge.v8.i20.785.
Abstract/Text AIM: To clarify the current state of practice for colonic diverticular bleeding (CDB) in Japan.
METHODS: We conducted multicenter questionnaire surveys of the practice for CDB including clinical settings (8 questions), diagnoses (8 questions), treatments (7 questions), and outcomes (4 questions) in 37 hospitals across Japan. The answers were compared between hospitals with high and low number of inpatient beds to investigate which factor influenced the answers.
RESULTS: Endoscopists at all 37 hospitals answered the questions, and the mean number of endoscopists at these hospitals was 12.7. Of all the hospitals, computed tomography was performed before colonoscopy in 67% of the hospitals. The rate of bowel preparation was 46.0%. Early colonoscopy was performed within 24 h in 43.2% of the hospitals. Of the hospitals, 83.8% performed clipping as first-line endoscopic therapy. More than half of the hospitals experienced less than 20% rebleeding events after endoscopic hemostasis. No significant difference was observed in the annual number of patients hospitalized for CDB between high- (≥ 700 beds) and low-volume hospitals. More emergency visits (P = 0.012) and endoscopists (P = 0.015), and less frequent participation of nursing staff in early colonoscopy (P = 0.045) were observed in the high-volume hospitals.
CONCLUSION: Some practices unique to Japan were found, such as performing computed tomography before colonoscopy, no bowel preparation, and clipping as first-line therapy. Although, the number of staff differed, the practices for CDB were common irrespective of hospital size.

PMID 28042393  World J Gastrointest Endosc. 2016 Dec 16;8(20):785-794.・・・
著者: Amit Khanna, Steven J Ognibene, Leonidas G Koniaris
雑誌名: J Gastrointest Surg. 2005 Mar;9(3):343-52. doi: 10.1016/j.gassur.2004.09.039.
Abstract/Text The study goal was to determine which etiologies of lower gastrointestinal bleeding (LGIB) may best be treated with superselective embolization. A meta-analysis was undertaken of 25 identified publications reporting the use of embolization and an unpublished series of 12 consecutive patients with LGIB from the authors' institution. Six published series and the authors' series met selection criteria for further analysis. Multiple regression analysis demonstrated no significant difference in pooled outcomes when varying the included study, age, or embolization method on the outcome of rebleeding. The pooled odds ratio for arteriovenous dysplastic lesions and other diseases was 3.53 compared with rebleeding after localization and embolization for diverticular disease (95% confidence interval odds ratio, 1.33, 9.41; P < 0.01). Embolization for diverticular bleeding was successful in 85% of patients. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in greater than 40% of patients and over a more protracted period. Embolization for LGIB is most effective for the treatment of diverticular bleeding. Caution should be used when applying embolization therapy for nondiverticular causes due to the considerably higher associated failure rate. An inpatient observation period of 2 days is suggested following embolization for diverticular bleeding.

PMID 15749594  J Gastrointest Surg. 2005 Mar;9(3):343-52. doi: 10.1016・・・

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