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Tu1183 Incidence and Outcomes of Patients Presenting to the Emergency Department With Acute Lower Gastrointestinal Hemorrhage
of DD during a long-term follow-up. Patients and Methods: We reviewed 311 patients suffer from recent episode of AUD and undergoing to mesalazine treatment: 207 (group A, 105 males, median age 63 years, range 47-74 years) were treated with mesalazine 1.6 grams for 10 days each month, whilst 104 (group B, 55 males, median age 65 years, range 50-72 years) were treated with mesalazine 1.6 grams every day. Patients were followed-up every 6 months (median 7.5 months, range 5-13 months). Results: Patients were followed-up for a mean time of 3 years (range 12-72 months). Overall, occurrence of complication recurred more frequently in group A than in group B (p=0.030, log-rank test). Acute diverticulitis recurred in 17 (8.2%) patients in group A and in 3 (2.9%) in group B; diverticular bleeding occurred in 4 (1.9%) patients in group A and in 1 (0.96%) patient in group B; surgery was required in 3 (1.4%) patients in group A and in no (0%) patient in group B. Conclusions: This is the first study showing that long-term mesalazine treatment is significantly better that intermittent mesalazine treatment in preventing occurrence of DD complications after an attack of acute diverticulitis.
patients can be managed supportively, although access to interventional radiology and endoscopy is important.
The Risk of Colorectal Cancer Is Not Increased in Patients After an Attack of Diverticulitis Bjarki T. Alexandersson, Johann P. Hreinsson, Tryggvi Stefánsson, Einar Bjornsson Background: According to clinical guidelines a colonoscopy is recommended after an attack of diverticulitis in order to exclude colorectal cancer (CRC). This recommendation is based on studies performed more than 20 years ago when the diagnosis of diverticulitis was in most cases made clinically and not confirmed with an abdominal computerized tomography (CT). We aimed to investigate the findings of a subsequent colonoscopy after an attack of diverticulitis in order to determine the frequency of CRC in these patients. Methods: The study was retrospective and population based. The cohort consisted of all patients with the diagnosis of diverticulitis who underwent a subsequent colonoscopy 6-8 weeks after the attack during a six year period in a European teaching hospital catchment area (population: 238.000 inhabitants). The diagnosis of diverticulitis was based on clinical symptoms such as abdominal pain with tenderness, compatible with diverticulitis, verified with a CT of the abdomen showing diverticulosis as well as thickening of the colonic wall and/or inflammation in the surrounding fat tissue. Relevant clinical information was obtained from medical records. Results: A total of 212 patients underwent endoscopy after the episode of diverticulitis, 93 males and 119 females, median age 59 (IQR 50-67) years. A total of 197/212 (93.4%) were examined with a full colonoscopy whereas 14/212 (6.6%) underwent a flexible sigmoidoscopy. Among those who underwent a full colonoscopy 181/197 (92%) had a successful colonoscopy examination of the whole colon including the cecum. One patient (0.47%), who did not recover clinically and developed iron-deficiency anemia was found to have colorectal cancer whereas all other patients recovered clinically before the colonoscopy was performed. A total of 34/212 (16%) had colonic polyps. In 19/34 (56%) cases the histology demonstrated hyperplastic polyps and in 14/34 (41%) adenoma with mild dysplasia and one with normal histology. Only 1/34 (2.9%) of the colonic polyps were more than 1 cm in size. During the attack of diverticulitis the median hemoglobin value was 135 (IQR 125145), white cell count 11.7 (9.6-13.8) and CRP 73 (49-118). Conclusions: Among patients experiencing an attack of diverticulitis where the diagnosis was verified by a CT investigation the frequency of CRC was equal to what could be expected compared to the average risk in the population. In these patients a routine colonoscopy in the absence of other clinical signs of CRC seems hardly necessary, especially if the clinical course is uneventful and the patient recovers.
Tu1182 Gender Difference in Acute Colonic Diverticulitis: Large Retrospective Multicenter Study in Japan Eiji Yamada, Takuma Higurashi, Hidenori Ohkubo, Eiji Sakai, Hiroki Endo, Hirokazu Takahashi, Noriaki Manabe, Atsushi Nakajima, Ken Haruma Background and Aims: Diverticulosis of the colon has been increasing in Japan as well as in Western countries. About 10-25% of patients with diverticulosis will develop diverticular disease, such as diverticulitis. However, pathogenic mechanism and risk factor of diverticulitis is still unclear. In recent years, gender-specific medicine is now attracting attention. For diseases with gender differences, comparing the patient backgrounds by gender provide some information about risk factor of disease. However, gender difference in colonic diverticulitis has not been discussed in detail. Therefore, the aim of this multicenter retrospective study was to assess the gender difference in diverticulitis in Japanese general population and to clarify the factor which influences this difference. Methods: This study was conducted in 20 flagship hospital in Japan. Study subjects were consecutive Japanese 1,100 patients with acute colonic diverticulitis (mean age 51.8 years) who were diagnosed by ultrasonography or computed tomography between January 2006 and May 2011. Patients were divided into two groups based on gender and compared with respect to patient background. Results: Male-to-female ratio of diverticulitis was (1.43:1) in total and (1.73:1) in under age of 50. The strongest male-to-female ratio was (2.45:1) in 40s which was peak age of diverticulitis. Mean age of diverticulitis was significantly higher in female compared to male (50.6±15.7 vs. 53.1±17.9, P=0.0138). Multiple regression analysis showed smoking rate (OR, 2.73; 95% CI, 1.94-3.84), drinking rate (OR, 2.18; 95% CI, 1.59-2.97), obesity rate (OR, 2.09; 95% CI, 1.50-2.90), and low-dose aspirin users rate (OR, 3.03; 95% CI, 1.35-6.84) was significantly greater in male compared to female. Discussion/Conclusions: Diverticulitis was more common among male than female in Japan. In diverticulitis, there is the possibility that difference of drinking, obesity, low-dose aspirin use and smoking caused male patient predominance in Japan. In other words, these factors could be considered as a risk factor of diverticulitis. Interestingly, previous reports showed that male-to-female ratio of diverticulitis varies greatly by countries (0.64~1.3:1). Difference in lifestyle, study period and race could be considered as a reason. However, the precise reason is unclear. Therefore, it is necessary to conduct a similar study in each region. Then, it'll lead to a greater understanding about risk factor of diverticulitis.
Tu1185 Efficacy of Mesalamine in the Treatment of Symptomatic Uncomplicated Diverticular Disease (SUDD): Systemic Review and Meta Analysis Mikram Jafri, Javed N. Sadiq, Haroon Kamran, Sohaib A. Rana, Amit Bhanvadia, Frank G. Gress Background: Colonic Diverticular disease is the fifth most financially burdensome of digestive illness in the US. Inflammation has an important role in the pathophysiology of SUDD. Mesalamine is an anti-inflammatory agent actively used in other inflammatory diseases such as IBD. The aim of this study is to assess the efficacy of mesalamine in patients with SUDD through a systematic review and meta-analysis. Methods: A search of Medline, Pubmed, and Embase databases between 1992 to November 2012 for studies that assessed the therapeutic efficacy of Mesalamine in the treatment of SUDD. Search terms were: diverticulitis, colonic diverticula,diverticular disease; medical interventions evaluated mesalamine, mesalazine. Patients were required to have colonic diverticular disease identified by radiology and/or endoscopy. Studies were prospective trials or RCT and required use of mesalamine as 1 treatment arm. Studies were not differentiated based on schedule dosing or use of alternative therapies (e.g. Rifaxamin, Probiotics etc). Exclusion criteria included: studies not in English, those with less than 10 patients, and case series/reports. Schedule of mesalamine dosing was not taken into account when analyzing potential studies. A random effects model was used for this analysis. The data on pain relief was subsequently extracted, pooled, and analyzed. Results: Our initial review resulted in 52 potential articles. 41 studies were excluded as they did not meet our inclusion criteria.11 studies were identified for inclusion, however, 2 studies were excluded on further review as the symptom scale used was not uniform. Our final analysis included nine studies (5 RCTs, 4 Prospective trials) comprising 876 patients (575 in mesalamine group and 301 in the Control Group). Relapse of diverticulitis in the Mesalamine group vs control was lower (7% vs 15% respectively, odds ratio 0.54 (95%CI 0.34 to 0.86 P=0.0095) at a median follow up of 12 months. Symptomatic relief was greater in the Mesalamine group vs Control (79% vs 58% respectively), which was found to be statistically significant (P=,0.0001). Chi Square was used to analyze the data was found to be significant (P=0.0034). Conclusion: Mesalamine is an effective anti inflammatory agent used in the treatment of SUDD. Patients treated with mesalamine not only have less symptoms but also fewer recurrences of acute diverticulitis. Larger, well-designed studies are needed to confirm these results.
Tu1183 Incidence and Outcomes of Patients Presenting to the Emergency Department With Acute Lower Gastrointestinal Hemorrhage Deanne S. Soares, Kheng-Seong Ng, Natasha Nassar, Marc A. Gladman Introduction: Intuitively, acute lower gastrointestinal hemorrhage (LGIH) is a common reason for Emergency Department (ED) presentation, although there is a paucity of epidemiological data to support this. The aims of this study were to determine the incidence and outcomes of patients presenting to the ED with LGIH and to identify clinicopathological factors associated with admission and outcome. Methods: A retrospective observational cohort study of consecutive patients presenting with acute LGIH to a tertiary hospital between 2008 and 2011 was performed. Clinicopathological features of patients were examined including age, underlying etiology and use of antiplatelet and/or anti-coagulation therapy. Outcomes studied included mortality, rates of hospital and high dependency unit (HDU) admission, as well as rates of radiologic investigation, angiographic embolization and surgical intervention. Factors associated with hospital admission and outcome were determined. Results: LGIH accounted for 949 (512M, age 67 yrs) of 130,262 (0.73%) ED presentations. Etiologies included: diverticular disease (12.1%), hemorrhoids (11.6%), colitis (8.6%) post-operative bleeding (7.8%), neoplastic bleeding (6.6%). No definitive cause was established in almost half of all presentations. Anti-platelet or anti-coagulant therapy was present in 30% of patients. There were 5 deaths (0.5%), all in patients with significant comorbidities. Overall, 498 patients (52.5%) required admission, of which 30% required blood products and 3.8% required HDU monitoring. Of those admitted, 263 (52.8%) were managed supportively. A total of 63 patients (12.7%) required CT angiography, 13 of whom underwent mesenteric angiography; 9 of these required embolization. Colonoscopy and/or flexible sigmoidoscopy was performed in 173 patients (34.7%), 20 of whom underwent therapeutic intervention. Surgical intervention was necessary in only 24 (4.8%) patients. Patients requiring admission were more likely to be older (P ,0.0001), have lower systolic (P ,0.05) and diastolic (P,0.0001) blood pressures and higher heart rates (P ,0.01). Admitted patients were twice as likely to be on anti-platelet or anti-coagulant therapy (OR 2.3, 95%CI 1.2-4.3), whilst every increase by 1g/L in initial hemoglobin level decreased risk of admission by 3%. Admission was also significantly associated with etiology, with patients with diverticular or neoplastic bleeding most likely to be admitted (P ,0.0001). Conclusion: LGIH accounted for 1% of ED presentations, of which half required admission. Overall, mortality and surgical intervention rates were low. Hemodynamic parameters and anti-platelet/anti-coagulant therapy were significantly associated with admission. Whilst the etiology is heterogeneous, most
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AGA Abstracts
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patients can be managed supportively, although access to interventional radiology and endoscopy is important.
The Risk of Colorectal Cancer Is Not Increased in Patients After an Attack of Diverticulitis Bjarki T. Alexandersson, Johann P. Hreinsson, Tryggvi Stefánsson, Einar Bjornsson Background: According to clinical guidelines a colonoscopy is recommended after an attack of diverticulitis in order to exclude colorectal cancer (CRC). This recommendation is based on studies performed more than 20 years ago when the diagnosis of diverticulitis was in most cases made clinically and not confirmed with an abdominal computerized tomography (CT). We aimed to investigate the findings of a subsequent colonoscopy after an attack of diverticulitis in order to determine the frequency of CRC in these patients. Methods: The study was retrospective and population based. The cohort consisted of all patients with the diagnosis of diverticulitis who underwent a subsequent colonoscopy 6-8 weeks after the attack during a six year period in a European teaching hospital catchment area (population: 238.000 inhabitants). The diagnosis of diverticulitis was based on clinical symptoms such as abdominal pain with tenderness, compatible with diverticulitis, verified with a CT of the abdomen showing diverticulosis as well as thickening of the colonic wall and/or inflammation in the surrounding fat tissue. Relevant clinical information was obtained from medical records. Results: A total of 212 patients underwent endoscopy after the episode of diverticulitis, 93 males and 119 females, median age 59 (IQR 50-67) years. A total of 197/212 (93.4%) were examined with a full colonoscopy whereas 14/212 (6.6%) underwent a flexible sigmoidoscopy. Among those who underwent a full colonoscopy 181/197 (92%) had a successful colonoscopy examination of the whole colon including the cecum. One patient (0.47%), who did not recover clinically and developed iron-deficiency anemia was found to have colorectal cancer whereas all other patients recovered clinically before the colonoscopy was performed. A total of 34/212 (16%) had colonic polyps. In 19/34 (56%) cases the histology demonstrated hyperplastic polyps and in 14/34 (41%) adenoma with mild dysplasia and one with normal histology. Only 1/34 (2.9%) of the colonic polyps were more than 1 cm in size. During the attack of diverticulitis the median hemoglobin value was 135 (IQR 125145), white cell count 11.7 (9.6-13.8) and CRP 73 (49-118). Conclusions: Among patients experiencing an attack of diverticulitis where the diagnosis was verified by a CT investigation the frequency of CRC was equal to what could be expected compared to the average risk in the population. In these patients a routine colonoscopy in the absence of other clinical signs of CRC seems hardly necessary, especially if the clinical course is uneventful and the patient recovers.
Tu1182 Gender Difference in Acute Colonic Diverticulitis: Large Retrospective Multicenter Study in Japan Eiji Yamada, Takuma Higurashi, Hidenori Ohkubo, Eiji Sakai, Hiroki Endo, Hirokazu Takahashi, Noriaki Manabe, Atsushi Nakajima, Ken Haruma Background and Aims: Diverticulosis of the colon has been increasing in Japan as well as in Western countries. About 10-25% of patients with diverticulosis will develop diverticular disease, such as diverticulitis. However, pathogenic mechanism and risk factor of diverticulitis is still unclear. In recent years, gender-specific medicine is now attracting attention. For diseases with gender differences, comparing the patient backgrounds by gender provide some information about risk factor of disease. However, gender difference in colonic diverticulitis has not been discussed in detail. Therefore, the aim of this multicenter retrospective study was to assess the gender difference in diverticulitis in Japanese general population and to clarify the factor which influences this difference. Methods: This study was conducted in 20 flagship hospital in Japan. Study subjects were consecutive Japanese 1,100 patients with acute colonic diverticulitis (mean age 51.8 years) who were diagnosed by ultrasonography or computed tomography between January 2006 and May 2011. Patients were divided into two groups based on gender and compared with respect to patient background. Results: Male-to-female ratio of diverticulitis was (1.43:1) in total and (1.73:1) in under age of 50. The strongest male-to-female ratio was (2.45:1) in 40s which was peak age of diverticulitis. Mean age of diverticulitis was significantly higher in female compared to male (50.6±15.7 vs. 53.1±17.9, P=0.0138). Multiple regression analysis showed smoking rate (OR, 2.73; 95% CI, 1.94-3.84), drinking rate (OR, 2.18; 95% CI, 1.59-2.97), obesity rate (OR, 2.09; 95% CI, 1.50-2.90), and low-dose aspirin users rate (OR, 3.03; 95% CI, 1.35-6.84) was significantly greater in male compared to female. Discussion/Conclusions: Diverticulitis was more common among male than female in Japan. In diverticulitis, there is the possibility that difference of drinking, obesity, low-dose aspirin use and smoking caused male patient predominance in Japan. In other words, these factors could be considered as a risk factor of diverticulitis. Interestingly, previous reports showed that male-to-female ratio of diverticulitis varies greatly by countries (0.64~1.3:1). Difference in lifestyle, study period and race could be considered as a reason. However, the precise reason is unclear. Therefore, it is necessary to conduct a similar study in each region. Then, it'll lead to a greater understanding about risk factor of diverticulitis.
Tu1185 Efficacy of Mesalamine in the Treatment of Symptomatic Uncomplicated Diverticular Disease (SUDD): Systemic Review and Meta Analysis Mikram Jafri, Javed N. Sadiq, Haroon Kamran, Sohaib A. Rana, Amit Bhanvadia, Frank G. Gress Background: Colonic Diverticular disease is the fifth most financially burdensome of digestive illness in the US. Inflammation has an important role in the pathophysiology of SUDD. Mesalamine is an anti-inflammatory agent actively used in other inflammatory diseases such as IBD. The aim of this study is to assess the efficacy of mesalamine in patients with SUDD through a systematic review and meta-analysis. Methods: A search of Medline, Pubmed, and Embase databases between 1992 to November 2012 for studies that assessed the therapeutic efficacy of Mesalamine in the treatment of SUDD. Search terms were: diverticulitis, colonic diverticula,diverticular disease; medical interventions evaluated mesalamine, mesalazine. Patients were required to have colonic diverticular disease identified by radiology and/or endoscopy. Studies were prospective trials or RCT and required use of mesalamine as 1 treatment arm. Studies were not differentiated based on schedule dosing or use of alternative therapies (e.g. Rifaxamin, Probiotics etc). Exclusion criteria included: studies not in English, those with less than 10 patients, and case series/reports. Schedule of mesalamine dosing was not taken into account when analyzing potential studies. A random effects model was used for this analysis. The data on pain relief was subsequently extracted, pooled, and analyzed. Results: Our initial review resulted in 52 potential articles. 41 studies were excluded as they did not meet our inclusion criteria.11 studies were identified for inclusion, however, 2 studies were excluded on further review as the symptom scale used was not uniform. Our final analysis included nine studies (5 RCTs, 4 Prospective trials) comprising 876 patients (575 in mesalamine group and 301 in the Control Group). Relapse of diverticulitis in the Mesalamine group vs control was lower (7% vs 15% respectively, odds ratio 0.54 (95%CI 0.34 to 0.86 P=0.0095) at a median follow up of 12 months. Symptomatic relief was greater in the Mesalamine group vs Control (79% vs 58% respectively), which was found to be statistically significant (P=,0.0001). Chi Square was used to analyze the data was found to be significant (P=0.0034). Conclusion: Mesalamine is an effective anti inflammatory agent used in the treatment of SUDD. Patients treated with mesalamine not only have less symptoms but also fewer recurrences of acute diverticulitis. Larger, well-designed studies are needed to confirm these results.
Tu1183 Incidence and Outcomes of Patients Presenting to the Emergency Department With Acute Lower Gastrointestinal Hemorrhage Deanne S. Soares, Kheng-Seong Ng, Natasha Nassar, Marc A. Gladman Introduction: Intuitively, acute lower gastrointestinal hemorrhage (LGIH) is a common reason for Emergency Department (ED) presentation, although there is a paucity of epidemiological data to support this. The aims of this study were to determine the incidence and outcomes of patients presenting to the ED with LGIH and to identify clinicopathological factors associated with admission and outcome. Methods: A retrospective observational cohort study of consecutive patients presenting with acute LGIH to a tertiary hospital between 2008 and 2011 was performed. Clinicopathological features of patients were examined including age, underlying etiology and use of antiplatelet and/or anti-coagulation therapy. Outcomes studied included mortality, rates of hospital and high dependency unit (HDU) admission, as well as rates of radiologic investigation, angiographic embolization and surgical intervention. Factors associated with hospital admission and outcome were determined. Results: LGIH accounted for 949 (512M, age 67 yrs) of 130,262 (0.73%) ED presentations. Etiologies included: diverticular disease (12.1%), hemorrhoids (11.6%), colitis (8.6%) post-operative bleeding (7.8%), neoplastic bleeding (6.6%). No definitive cause was established in almost half of all presentations. Anti-platelet or anti-coagulant therapy was present in 30% of patients. There were 5 deaths (0.5%), all in patients with significant comorbidities. Overall, 498 patients (52.5%) required admission, of which 30% required blood products and 3.8% required HDU monitoring. Of those admitted, 263 (52.8%) were managed supportively. A total of 63 patients (12.7%) required CT angiography, 13 of whom underwent mesenteric angiography; 9 of these required embolization. Colonoscopy and/or flexible sigmoidoscopy was performed in 173 patients (34.7%), 20 of whom underwent therapeutic intervention. Surgical intervention was necessary in only 24 (4.8%) patients. Patients requiring admission were more likely to be older (P ,0.0001), have lower systolic (P ,0.05) and diastolic (P,0.0001) blood pressures and higher heart rates (P ,0.01). Admitted patients were twice as likely to be on anti-platelet or anti-coagulant therapy (OR 2.3, 95%CI 1.2-4.3), whilst every increase by 1g/L in initial hemoglobin level decreased risk of admission by 3%. Admission was also significantly associated with etiology, with patients with diverticular or neoplastic bleeding most likely to be admitted (P ,0.0001). Conclusion: LGIH accounted for 1% of ED presentations, of which half required admission. Overall, mortality and surgical intervention rates were low. Hemodynamic parameters and anti-platelet/anti-coagulant therapy were significantly associated with admission. Whilst the etiology is heterogeneous, most
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AGA Abstracts
Tu1184