INTRODUCTION: The bleeding source of hematochezia is unknown without performing colonoscopy. We sought to identify whether colonoscopy is a risk-stratifying tool to identify etiology and predict outcomes and whether presenting symptoms can differentiate the etiologies in patients with hematochezia. METHODS: This multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia. RESULTS: Patients were mostly elderly population, and 29.5% had hemodynamic instability. Computed tomography was performed in 69.1% and colonoscopy in 87.7%. Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding. Thirty-day rebleeding rates were significantly higher with diverticulosis and small bowel bleeding than with other etiologies. In-hospital mortality was significantly higher with angioectasia, malignancy, rectal ulcer, and upper gastrointestinal bleeding. Colonoscopic treatment rates were significantly higher with diverticulosis, radiation colitis, angioectasia, rectal ulcer, and postendoscopy bleeding. More interventional radiology procedures were needed for diverticulosis and small bowel bleeding. Etiologies with favorable outcomes and low procedure rates were ischemic colitis and infectious colitis. Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis. The same was true in cases of hematochezia with diarrhea, fever, and hemodynamic instability. DISCUSSION: This nationwide data set of acute hematochezia highlights the importance of colonoscopy in accurately detecting bleeding etiologies that stratify patients at high or low risk of adverse outcomes and those who will likely require more procedures. Predicting different bleeding etiologies based on initial presentation would be challenging.

BackgroundThe value of endoscopy for acute lower GI bleeding (ALGIB) remains unclear, given few large cohort studies. We aim to provide detailed clinical data for ALGIB management and to identify patients at risk for adverse outcomes based on endoscopic diagnosis.MethodsWe conducted a multicenter, retrospective cohort study, named CODE BLUE J-Study, in 49 hospitals throughout Japan and studied 10,342 cases admitted for outpatient-onset of acute hematochezia.ResultsCases were mostly elderly, with 29.5% hemodynamic instability and 60.1% comorbidity. 69.1% and 87.7 % of cases underwent CT and colonoscopy, respectively. Diagnostic yield of colonoscopy reached 94.9%, revealing 48 etiologies, most frequently diverticular bleeding. During hospitalization, the endoscopic therapy rate was 32.7%, mostly using clipping and band ligation. IVR and surgery were infrequently performed, for 2.1% and 1.4%. In-hospital rebleeding and death occurred in 15.2% and 0.9%. Diverticular bleeding cases had higher rates of hemodynamic instability, rebleeding, endoscopic therapy, IVR, and transfusion, but lower rates of death and surgery than other etiologies. Small bowel bleeding cases had significantly higher rates of surgery, IVR, and transfusion than other etiologies. Malignancy or upper GIB cases had significantly higher rates of thromboembolism and death than other etiologies. Etiologies that have favorable outcomes were ischemic colitis, infectious colitis, and post-endoscopy bleeding.ConclusionsLarge-scale data of patients with acute hematochezia revealed high proportions of colonoscopy and CT, resulting in high endoscopic therapy rates. We highlight the importance of colonoscopy in detecting accurate bleeding etiologies that stratify patients at high or low risk of adverse outcomes.

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Depression is implicated as a risk factor for the recurrence of inflammatory bowel disease (IBD). Near-infrared spectroscopy (NIRS) and brain-derived neurotrophic factor (BDNF) are useful tools for evaluation of brain activity and a depressive state, respectively. The aim of this study was to clarify the association between brain activity or depressive symptoms and IBD using NIRS and BDNF. This study included 36 ulcerative colitis (UC) patients, 32 Crohn’s disease (CD) patients, and 17 healthy controls (HC). Center for Epidemiologic Studies Depression Scale (CES-D) scores were determined, NIRS was performed, and serum BDNF levels were measured in all subjects. NIRS showed that the mean oxygenated hemoglobin concentration was significantly lower in the frontal lobe in the UC group than in the HC group (HC 167 ± 106 vs. UC 83.1 ± 85.3, p < 0.05). No significant difference was seen between the HC and CD groups. There were also no significant differences in CED-D scores and BDNF levels among the groups. Changes in the NIRS values of the UC group may indicate decreased brain activity and a fundamental difference between UC and CD, which are often lumped together as two types of IBD.

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Rationale: Intestinal Behçet disease (BD) with myelodysplastic syndrome (MDS) is a rare condition that is resistant to various immunosuppressive therapies. Several cases in which hematopoietic stem cell transplantation (HSCT) was effective for intestinal BD with MDS accompanying trisomy 8 have been reported. Patient concerns: We report an 18-year-old female with a 7-year history of BD. Colonoscopy demonstrated a huge ulcer in the cecum. Chromosomal examination revealed a karyotype of trisomy 8 in 87% of cells. Bone marrow examination revealed dysplastic cells in multilineages. Diagnoses: A diagnosis of intestinal BD associated with MDS accompanying trisomy 8 was made. Interventions: The patient underwent ileocecal resection due to microperforations of ileocecal ulcers; she then underwent allogeneic peripheral blood stem cell transplantation (PBSCT) with her mother as a donor. Outcomes: After the PBSCT, the patient's symptoms due to BD (fever, oral aphthae, abdominal pain, and genital ulcers) completely disappeared, with no severe adverse events. Lessons: The present case demonstrates that HSCT including PBSCT might be an effective new therapeutic option for refractory intestinal BD with MDS when immunosuppressive therapy has achieved insufficient efficacy.