Effectiveness of risk scoring systems in predicting endoscopic treatment in colonic diverticular bleeding

Abstract

Background and Aims:The identification of stigmata of recent hemorrhage (SRH) in colonic diverticular bleeding (CDB) enables an endoscopic treatment and can improve the clinical outcome. However, SRH identification rate remains low. This study aims to investigate whether NOBLADS and Strate scoring systems are useful for predicting SRH identification rate of CDB pre-procedurally via colonoscopy. Methods: In this single-center retrospective observational study, 302 patients who experienced their first episode of CDB from April 2008 to March 2018 were included. Patients were classified into SRH-positive and SRH-negative groups. The primary outcome was SRH identification rate. The secondary outcomes were active bleeding in SRH and early rebleeding rates. The usefulness of the NOBLADS and Strate scores as predicted values of SRH identification was evaluated using the area under the receiver operating characteristic curve. Results: There were 126 and 176 patients in the SRH-positive and SRH-negative groups, respectively. The area under the receiver operating characteristic curve for SRH identification using the NOBLADS score was 0.74 (95% confidence interval, 0.69-0.80) and that using the Strate score was 0.74 (95% confidence interval, 0.68-0.79). Active bleeding and early rebleeding rates increased according to each score. By setting the cut-off of the NOBLADS score to four points, treatment was possible in 70.2% (66/94) patients. Addition of extravasation at computed tomography to a NOBLADS score of ≧ 4 points allowed treatment of all patients (24/24). Conclusions: Severity scoring in acute lower gastrointestinal bleeding was effective for predicting SRH identification in CDB. We suggest that combination of these scorings and CT findings could offer a new therapeutic strategy.

Utility of the Gel Immersion Method for Treating Massive Colonic Diverticular Bleeding

“…Although the number of patients was limited, and the study was retrospective and was performed at a single center without a control group, we showed that OS-1 Jelly injection is a useful technique for difficult situations. Oguri et al reported the relatively equal distribution of SRH as follows: AB, 34.9%; NBVV, 32.5%; and AC, 32.5%; this meant that 65% of stigmata were NBVV and AC [ 12 ]. Thus, improvement of NBVV and AC detection rate should be considered as the key for CDB management.…”

“…Oguri et al reported the relatively equal distribution of SRH as follows: AB, 34.9%; NBVV, 32.5%; and AC, 32.5%; this meant that 65% of stigmata were NBVV and AC. 12 Thus, improvement of NBVV and AC detection rate should be considered as the key for CDB management. By applying the gel immersion method, we considered that the detection of SRH would improve and the rate of re-bleeding and readmission would decrease.…”

“…[8][9][10] In Japan, 68%-76% of confirmed diverticular bleeding cases were right-sided. 11,12 In approximately 75% of patients, CDB stops spontaneously; while bleeding persists in the remaining 25%. 13,14 However, the identification rates of the stigmata of recent hemorrhage (SRH) defined as active bleeding (AB), non-bleeding visible vessels (NBVVs), and adherent clot (AC), 15 remain relatively low, 16 and this is mainly due to two reasons.…”

“…Right-sided diverticular bleeding is more common in Asia, and it often causes massive bleeding with a potential risk of re-bleeding and complications [ 8 - 10 ]. In Japan, 68%–76% of confirmed diverticular bleeding cases were right-sided [ 11 , 12 ]. In approximately 75% of patients, CDB stops spontaneously; while bleeding persists in the remaining 25% [ 13 , 14 ].…”

“…Detecting small NBVV and AC hidden under accumulated blood clots is very challenging [ 17 ]. The SRH identification rates were reported to be 17%–42% [ 11 , 12 ], and re-bleeding frequently occurred in approximately 50% of untreated SRH patients [ 18 ]. Surgical intervention may be needed for patients with uncontrollable bleeding [ 19 , 20 ].…”