Prospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 7, 2015; 21(37): 10697-10703
Published online Oct 7, 2015. doi: 10.3748/wjg.v21.i37.10697
Risk factors for adverse in-hospital outcomes in acute colonic diverticular hemorrhage
Naoyoshi Nagata, Ryota Niikura, Tomonori Aoki, Shiori Moriyasu, Toshiyuki Sakurai, Takuro Shimbo, Katsunori Sekine, Hidetaka Okubo, Kazuhiro Watanabe, Chizu Yokoi, Junichi Akiyama, Mikio Yanase, Masashi Mizokami, Kazuma Fujimoto, Naomi Uemura
Naoyoshi Nagata, Ryota Niikura, Tomonori Aoki, Shiori Moriyasu, Toshiyuki Sakurai, Katsunori Sekine, Hidetaka Okubo, Kazuhiro Watanabe, Chizu Yokoi, Junichi Akiyama, Mikio Yanase, Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo 162-8655, Japan
Takuro Shimbo, Department of Clinical Research and Informatics, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo 162-8655, Japan
Masashi Mizokami, Naomi Uemura, Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Kohnodai, Ichikawa City, Chiba 272-8516, Japan
Kazuma Fujimoto, Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, Saga City, Saga 849-8501, Japan
Author contributions: Nagata N designed the study and was the main author of the manuscript; Shimbo T performed statistical analysis; Niikura R, Aoki T, Moriyasu S, Sakurai T, Sekine K, and Watanabe K collected clinical information; Okubo H, Yokoi C and Akiyama J performed colonoscopy; and Mizokami M, Fujimoto K and Uemura N edited the initial manuscript and revised manuscript; all authors approved the final draft submitted.
Supported by Grant from the National Center for Global Health and Medicine (226A-201, in part).
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board at NCGM (approval No. 1575).
Informed consent statement: All patients gave informed written consent prior to enrolment.
Conflict-of-interest statement: The authors declare no conflict of interest. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Naoyoshi Nagata, MD, Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo 162-8655, Japan. nnagata_ncgm@yahoo.co.jp
Telephone: +81-3-32027181 Fax: +81-3-32071038
Received: January 7, 2015
Peer-review started: January 8, 2015
First decision: May 18, 2015
Revised: May 28, 2015
Accepted: August 31, 2015
Article in press: August 31, 2015
Published online: October 7, 2015
Processing time: 263 Days and 18.8 Hours
Abstract

AIM: To investigate the factors associated with transfusion, further bleeding, and prolonged length of stay.

METHODS: In total, 153 patients emergently hospitalized for diverticular bleeding who were examined by colonoscopy were prospectively enrolled. Patients in whom the bleeding source was identified received endoscopic treatment such as clipping or endoscopic ligation. After spontaneous cessation of bleeding with conservative treatment or hemostasis with endoscopic treatment, all patients were started on a liquid food diet and gradually progressed to a solid diet over 3 d, and were discharged. At enrollment, we assessed smoking, alcohol, medications [non-steroidal anti-inflammatory drugs (NSAIDs)], low-dose aspirin, and other antiplatelets, warfarin, acetaminophen, and oral corticosteroids), and co-morbidities [hypertension, diabetes mellitus, dyslipidemia, cerebro-cardiovascular disease, chronic liver disease, and chronic kidney disease (CKD)]. The in-hospital outcomes were need for transfusion, further bleeding after spontaneous cessation of hemorrhage, and length of hospital stay. The odds ratio (OR) for transfusion need, further bleeding, and prolonged length of stay were estimated by logistic regression analysis.

RESULTS: No patients required angiographic embolization or surgery. Stigmata of bleeding occurred in 18% of patients (27/153) and was treated by endoscopic procedures. During hospitalization, 40 patients (26%) received a median of 6 units of packed red blood cells. Multivariate analysis revealed that female sex (OR = 2.5, P = 0.02), warfarin use (OR = 9.3, P < 0.01), and CKD (OR = 5.9, P < 0.01) were independent risk factors for transfusion need. During hospitalization, 6 patients (3.9%) experienced further bleeding, and NSAID use (OR = 5.9, P = 0.04) and stigmata of bleeding (OR = 11, P < 0.01) were significant risk factors. Median length of hospital stay was 8 d. Multivariate analysis revealed that age > 70 years (OR = 2.1, P = 0.04) and NSAID use (OR = 2.7, P = 0.03) were independent risk factors for prolonged hospitalization (≥ 8 d).

CONCLUSION: In colonic diverticular bleeding, female sex, warfarin, and CKD increased the risk of transfusion requirement, while advanced age and NSAID increased the risk of prolonged hospitalization.

Keywords: In-hospital adverse clinical outcomes; Antithrombotic agents; Blood transfusion requirement; Lower gastrointestinal hemorrhage; Length of hospital stay

Core tip: Some patients with diverticular bleeding experience severe or massive bleeding, necessitating blood transfusion and prolonged hospitalization, which can consequently reduce their quality of life. This study focused on drugs and diseases associated with poor clinical outcome of diverticular bleeding during hospitalization. We found that patients hospitalized for diverticular bleeding could be treated endoscopically and conservatively. However, there was a substantial need for transfusion during hospitalization. Statistical analysis revealed that female sex, warfarin use, and chronic kidney disease were associated with a greater risk of transfusion need, while non-steroidal anti-inflammatory druguse was associated with further bleeding and prolonged hospitalization. This study presents new information on the risk of adverse outcomes in diverticular bleeding.