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Commentary on: Risk factors predictive of severe diverticular hemorrhage. International Journal of Surgery, in press
DISCUSSION International Journal of Surgery 9 (2011) 353e354
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Discussion
Commentary on: Risk factors predictive of severe diverticular hemorrhage. International Journal of Surgery, in press R. Justin Davies Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
a r t i c l e i n f o Article history: Received 25 January 2011 Accepted 26 January 2011 Available online 3 February 2011
Diverticular disease remains common in industrialized nations, with prevalence increasing with age. Thankfully, most patients with colonic diverticulosis remain asymptomatic. A proportion will present with complications, including inflammation, abscess, perforation, stricture, fistula formation or bleeding. Bleeding from colonic diverticulosis may be from the left or right colon, resolving without surgical intervention in around 90% of cases.1 Patients presenting as an emergency with gastrointestinal bleeding can pose difficult diagnostic and treatment dilemmas. When the bleeding is from the upper gastrointestinal tract, there are established scoring systems allowing risk stratification2 as well as triage to predict which patients are suitable for outpatient management.3 The concept of outpatient management of patients presenting as an emergency with bleeding of lower gastrointestinal tract origin has generally not been in use in clinical practice. A scoring system to help predict this may, therefore, be of value. The paper by Lee and colleagues4 in this issue of the International Journal of Surgery is a useful adjunct to the decision-making process for clinicians managing patients with severe bleeding from colonic diverticular disease. The authors have identified five factors predictive of a severe bleed (defined as a transfusion of 6 units of blood or more, the need for surgery or systolic blood pressure less than 90 mmHg within 24 h of admission). These factors are: initial hemoglobin level; INR > 1.5; diastolic blood pressure; heart rate; anti-hypertensive medication. Whilst many of these factors are intuitive, it does provide a checklist allowing the surgical admitting team to triage patients more effectively and provide appropriate levels of investigation and care to those in most need. However, there are several drawbacks to this study. The risk factors identified are only applicable to patients known to be
DOI of original article: 10.1016/j.ijsu.2010.09.011. E-mail address: [email protected].
bleeding from colonic diverticulosis. In clinical practice, this is infrequently the case. Patients admitted as an emergency with bleeding per anum may be bleeding from anywhere in the GI tract and need careful evaluation to localize the bleeding site if possible. In addition, the retrospective nature of the data, coupled with the small sample size, render it difficult to draw meaningful conclusions. Although the authors suggest that only 99 patients were included over an 11 year period due to strict inclusion criteria, one must wonder if there have been other patients admitted that have not been included due to omission from the dataset. The risk factors identified require examination in a large prospective patient cohort before firm conclusions can be drawn. Data from Japan5 and Germany6 suggest that NSAIDs and steroids are also significant risk factors for colonic diverticular hemorrhage, and it is perhaps the small sample size in the current study that means these factors were not found to be predictive. Finally, it is not clear why the authors chose 6 units of transfused blood as their cut-off point to define severe haemorrhage. Despite these limitations, the message provided by the paper from Lee et al does have potential for impacting on clinical practice, particularly if the findings are confirmed in a large, prospective study. Its use will likely be as a clinical tool to aid triage of patients, highlighting those likely to need a higher level of care and possible urgent colonoscopy, mesenteric angiography, CT angiography and/or surgery. At the other end of the severity spectrum, those predicted as low risk may be able to be managed safely in the outpatient setting, avoiding unnecessary hospital admission. This may also have financial benefits to the healthcare system. Ethical approval N/A. Funding None declared.
1743-9191/$ e see front matter Ó 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2011.01.010
DISCUSSION 354
R.J. Davies / International Journal of Surgery 9 (2011) 353e354
Conflict of interest None declared. Author contribution This article was written by RJD.
3.
4. 5.
References 1. Lewis M. Bleeding colonic diverticula. J Clin Gastroenterol 2008;42:1156e8. 2. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering
6.
committee and members of the National audit of acute upper gastrointestinal haemorrhage. BMJ 1995;311:222e6. Chan JC, Ayaru L. Analysis of risk factors for the outpatient management of acute upper gastrointestinal bleeding. Frontline Gastroenterol 2011;2: 19e25. Lee KK, Shah SM, Moser MA. Risk factors predictive of severe diverticular haemorrhage. Int J Surg 2011;9(1):83e5. Tsuruoka N, Iwakiri R, Hara M, Shirahama N, Sakata Y, Miyahara K, et al. NSAIDs is a significant risk factor for colonic diverticular haemorrhage in elder patients: evaluation by a case control study. J Gastroenterol Hepatol; 2010 Dec 28. doi:10.1111/j.1440-1746.2010.06610.x [Epub ahead of print]. Jansen A, Harenberg S, Greanda U, Elsing S. Risk factors for colonic diverticular bleeding: a westernized community based hospital study. World J Gastroenterol 2009;15:457e61.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.theijs.com
Discussion
Commentary on: Risk factors predictive of severe diverticular hemorrhage. International Journal of Surgery, in press R. Justin Davies Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
a r t i c l e i n f o Article history: Received 25 January 2011 Accepted 26 January 2011 Available online 3 February 2011
Diverticular disease remains common in industrialized nations, with prevalence increasing with age. Thankfully, most patients with colonic diverticulosis remain asymptomatic. A proportion will present with complications, including inflammation, abscess, perforation, stricture, fistula formation or bleeding. Bleeding from colonic diverticulosis may be from the left or right colon, resolving without surgical intervention in around 90% of cases.1 Patients presenting as an emergency with gastrointestinal bleeding can pose difficult diagnostic and treatment dilemmas. When the bleeding is from the upper gastrointestinal tract, there are established scoring systems allowing risk stratification2 as well as triage to predict which patients are suitable for outpatient management.3 The concept of outpatient management of patients presenting as an emergency with bleeding of lower gastrointestinal tract origin has generally not been in use in clinical practice. A scoring system to help predict this may, therefore, be of value. The paper by Lee and colleagues4 in this issue of the International Journal of Surgery is a useful adjunct to the decision-making process for clinicians managing patients with severe bleeding from colonic diverticular disease. The authors have identified five factors predictive of a severe bleed (defined as a transfusion of 6 units of blood or more, the need for surgery or systolic blood pressure less than 90 mmHg within 24 h of admission). These factors are: initial hemoglobin level; INR > 1.5; diastolic blood pressure; heart rate; anti-hypertensive medication. Whilst many of these factors are intuitive, it does provide a checklist allowing the surgical admitting team to triage patients more effectively and provide appropriate levels of investigation and care to those in most need. However, there are several drawbacks to this study. The risk factors identified are only applicable to patients known to be
DOI of original article: 10.1016/j.ijsu.2010.09.011. E-mail address: [email protected].
bleeding from colonic diverticulosis. In clinical practice, this is infrequently the case. Patients admitted as an emergency with bleeding per anum may be bleeding from anywhere in the GI tract and need careful evaluation to localize the bleeding site if possible. In addition, the retrospective nature of the data, coupled with the small sample size, render it difficult to draw meaningful conclusions. Although the authors suggest that only 99 patients were included over an 11 year period due to strict inclusion criteria, one must wonder if there have been other patients admitted that have not been included due to omission from the dataset. The risk factors identified require examination in a large prospective patient cohort before firm conclusions can be drawn. Data from Japan5 and Germany6 suggest that NSAIDs and steroids are also significant risk factors for colonic diverticular hemorrhage, and it is perhaps the small sample size in the current study that means these factors were not found to be predictive. Finally, it is not clear why the authors chose 6 units of transfused blood as their cut-off point to define severe haemorrhage. Despite these limitations, the message provided by the paper from Lee et al does have potential for impacting on clinical practice, particularly if the findings are confirmed in a large, prospective study. Its use will likely be as a clinical tool to aid triage of patients, highlighting those likely to need a higher level of care and possible urgent colonoscopy, mesenteric angiography, CT angiography and/or surgery. At the other end of the severity spectrum, those predicted as low risk may be able to be managed safely in the outpatient setting, avoiding unnecessary hospital admission. This may also have financial benefits to the healthcare system. Ethical approval N/A. Funding None declared.
1743-9191/$ e see front matter Ó 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2011.01.010
DISCUSSION 354
R.J. Davies / International Journal of Surgery 9 (2011) 353e354
Conflict of interest None declared. Author contribution This article was written by RJD.
3.
4. 5.
References 1. Lewis M. Bleeding colonic diverticula. J Clin Gastroenterol 2008;42:1156e8. 2. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering
6.
committee and members of the National audit of acute upper gastrointestinal haemorrhage. BMJ 1995;311:222e6. Chan JC, Ayaru L. Analysis of risk factors for the outpatient management of acute upper gastrointestinal bleeding. Frontline Gastroenterol 2011;2: 19e25. Lee KK, Shah SM, Moser MA. Risk factors predictive of severe diverticular haemorrhage. Int J Surg 2011;9(1):83e5. Tsuruoka N, Iwakiri R, Hara M, Shirahama N, Sakata Y, Miyahara K, et al. NSAIDs is a significant risk factor for colonic diverticular haemorrhage in elder patients: evaluation by a case control study. J Gastroenterol Hepatol; 2010 Dec 28. doi:10.1111/j.1440-1746.2010.06610.x [Epub ahead of print]. Jansen A, Harenberg S, Greanda U, Elsing S. Risk factors for colonic diverticular bleeding: a westernized community based hospital study. World J Gastroenterol 2009;15:457e61.