Nationwide large-scale data of acute lower gastrointestinal bleeding in Japan uncover detailed etiologies and relevant outcomes: CODE BLUE J-Study

Abstract

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.

Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study

“…We believe that this reduction in rebleeding during hospitalization following EBL led to the reduced need for IVR, which in turn probably led to the shorter LOS seen with EBL. Indeed, the association between rebleeding and IVR need was found to be significant in the entire CODE BLUE-J Study population [15,16]. In contrast, the number of cases needing surgery or resulting in thromboembolism or death was too small to reach statistical significance between the two treatments.…”

“…The dataset analyzed in this study is from the CODE BLUE-J Study (COlonic DivErticular Bleeding Leaders Update Evidence from multicenter Japanese Study), a retrospective multicenter cohort study that was conducted at 49 hospitals across Japan [15,16]. From among patients emergently hospitalized for acute hematochezia between January 2010 and December 2019, a total of 10,342 patients were enrolled [15,16]. The ethics committees and institutional review boards of all 49 participating hospitals approved conducting this study with the opt-out method (Supplementary Table 1).…”

“…A total of 72 items were collected for evaluation from the electronic medical records and endoscopic database [15,16]. Data on baseline characteristics included age, sex, presenting symptoms, vital signs, laboratory data, past history, comorbidities, medications, computed tomography (CT) and endoscopic findings, and endoscopic The outcome of most interest was the rate of early rebleeding.…”

Endoscopic direct clipping versus indirect clipping for colonic diverticular bleeding: A large multicenter cohort study

“…We assessed 42 items of clinical data, including baseline characteristics such as age, sex, vital signs on admission, lifestyle, presenting symptoms, laboratory data, comorbidities, and medication use within 30 days of admission, and reviewed in-hospital examination findings obtained from the electronic medical records and endoscopic databases, as previously reported. 17,18 Comorbidity was assessed using the modified Charlson Comorbidity Index (CCI), composed of the conventional CCI items 19 plus those for hypertension and hyperlipidemia. The CCI is an index for classifying prognostic comorbidity and has been extensively validated for gastrointestinal bleeding.…”

“…The strengths of this study include a large number of cases (n = 1041) and few missing values in data collection. 17,18 Moreover, we were able to collect detailed information on, for example, endoscopic findings (e.g., type and location of SRH) and extravasation on CT as well as long-term follow-up data, which have not been analyzed in previous studies.In conclusion, our large nationwide study highlights the use of direct clipping for CDB treatment whenever possible. Differences in bleeding pattern and colonic location can also be considered when deciding which clipping options to use.…”