Advances in endoscopic management of colonic diverticular bleeding.

PURPOSE OF REVIEW: This review is focused on diagnostic and management strategies for colonic diverticular bleeding (CDB). It aims to present the current state of the field, highlighting the available techniques, and emphasizing findings that influence the choice of therapy. RECENT FINDINGS: Recent guidelines recommend nonurgent colonoscopy (>24 h) for CDB. However, factors such as a shock index ≥1, which may warrant an urgent colonoscopy, remain under investigation.The standard approach to detecting the source of CDB requires a water-jet scope equipped with a cap. Innovative diagnostic techniques, such as the long-cap and tapered-cap, have proven effective in identifying stigmata of recent hemorrhage (SRH). Furthermore, the water or gel immersion methods may aid in managing massive hemorrhage by improving the visualization and stabilization of the bleeding site for subsequent intervention. Innovations in endoscopic hemostasis have significantly improved the management of CDB. New therapeutic methods such as endoscopic band ligation and direct clipping have substantially diminished the incidence of recurrent bleeding. Recent reports also have demonstrated the efficacy of cutting-edge techniques such as over-the-scope clips, which have significantly improved outcomes in complex cases that have historically necessitated surgical intervention. SUMMARY: Currently available endoscopic diagnostic and hemostatic methods for CDB have evolved with improved outcomes. Further research is necessary to refine the criteria for urgent colonoscopy and to confirm the effectiveness of new endoscopic hemostasis techniques.

Endoscopic Ultrasound-Guided Choledochoduodenostomy With Lumen-Apposing Metal Stent Through Duodenal Stent, a Success Case, and a Salvage Case.

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) has become a feasible alternative technique in cases of malignant bile duct obstruction, especially when the endoscopic retrograde cholangiopancreatography is not feasible or has failed. In the case of duodenal obstruction, when a duodenal stent has been initially placed, performing endoscopic retrograde cholangiopancreatography could be quite difficult with a low success rate. Thus, EUS-CD could be a good alternative. In this study, we present 2 particularly challenging endoscopic cases in which EUS-CD was performed with a lumen-apposing metal stent inserted through a previously placed duodenal stent.

The burden of gastrointestinal diseases in Japan, 1990-2019, and projections for 2035.

Background and Aim: Disease burden estimation allows clinicians and policymakers to plan for future healthcare needs. Although advances have been made in gastroenterology, as Japan has an aging population, disease burden assessment is important. We aimed to report gastrointestinal disease burden in Japan since 1990 and project changes through to 2035. Methods: This descriptive study examined the crude and age-standardized rates of prevalence, mortality, and disability-adjusted life years (DALYs) of 22 gastrointestinal diseases between 1990 and 2019. We used data from the Global Burden of Disease study 2019. We calculated the expected disease burden of gastrointestinal diseases by 2035 using an autoregressive integrated moving average. Results: Since 1990, cancer has accounted for most gastrointestinal disease-related causes of mortality and DALYs in Japan (77.1% and 71.2% in 1990, 79.2% and 73.7% in 2019, respectively). Although cancer-associated age-standardized mortality rates and DALYs have shown a decreasing trend, the crude rates have increased, suggesting that an aging society has a significant impact on the disease burden in Japan. Therefore, the overall gastrointestinal disease burden is expected to increase by 2035. Noncancerous chronic diseases with a high burden included cirrhosis, biliary disease, ileus, gastroesophageal reflux disorder, hernia, inflammatory bowel disease, enteric infections, and vascular intestinal disorders. In cirrhosis, the DALYs for hepatitis C decreased and the prevalence of non-alcoholic steatohepatitis increased. Conclusion: In the super-aging Japanese society, the burden of gastrointestinal diseases is expected to increase in the coming years. Colorectal, gastric, pancreatic, and liver cancers are the focus of early detection and treatment.

Utility of Under-Gel Endoscopic Mucosal Resection with Partial Submucosal Injection and Under-Gel Precutting Endoscopic Mucosal Resection for Difficult Colorectal Polyp Cases.

BACKGROUND: Here, we evaluated the utility of under-gel endoscopic mucosal resection (EMR) with partial submucosal injection (PI) and under-gel precutting EMR for difficult-to-treat colorectal polyps. METHODS: A retrospective case series was conducted from April 1, 2020, to April 1, 2021, at St. Luke's International Hospital (Japan). We included all consecutive patients who underwent colonoscopy and subsequent under-gel EMR with PI and under-gel precutting EMR. Baseline and clinical data were obtained from electronic medical records. RESULTS: Under-gel EMR with PI was performed in 6 patients, treating a total of seven lesions. In this group, 50% (3/6) were women (mean age = 59.2 years). The mean procedure time and specimen size were 5.1 min and 12.1 mm, respectively, achieving a 100% (7/7) en bloc resection rate. Under-gel precutting EMR was performed in 8 patients. In this group, 50% (4/8) were women (mean age = 66.1 years). The mean procedure time and specimen size were 22.6 min and 23.0 mm, respectively; en bloc resection rate was 62.5% (5/8). Regarding lesions over 20 mm in diameter, the en bloc resection rate was 50% (3/6). No complications were observed. CONCLUSIONS: PI is potentially useful for colorectal polyps where the distal end is not visible; when PI cannot be used, precutting EMR may constitute another troubleshooting method for difficult-to-treat colorectal polyps. The gel immersion method is also a viable option when the use of water causes rapid mixing of blood and residual stool, resulting in poor visibility.

Timing of colonoscopy in acute lower GI bleeding: a multicenter retrospective cohort study.

BACKGROUND AND AIMS: We aimed to determine the optimal timing of colonoscopy and factors that benefit patients who undergo early colonoscopy for acute lower GI bleeding. METHODS: We identified 10,342 patients with acute hematochezia (CODE BLUE-J study) admitted to 49 hospitals in Japan. Of these, 6270 patients who underwent a colonoscopy within 120 hours were included in this study. The inverse probability of treatment weighting method was used to adjust for baseline characteristics among early (≤24 hours, n = 4133), elective (24-48 hours, n = 1137), and late (48-120 hours, n = 1000) colonoscopy. The average treatment effect was evaluated for outcomes. The primary outcome was 30-day rebleeding rate. RESULTS: The early group had a significantly higher rate of stigmata of recent hemorrhage (SRH) identification and a shorter length of stay than the elective and late groups. However, the 30-day rebleeding rate was significantly higher in the early group than in the elective and late groups. Interventional radiology (IVR) or surgery requirement and 30-day mortality did not significantly differ among groups. The interaction with heterogeneity of effects was observed between early and late colonoscopy and shock index (shock index <1, odds ratio [OR], 2.097; shock index ≥1, OR, 1.095; P for interaction = .038) and performance status (0-2, OR, 2.481; ≥3, OR, .458; P for interaction = .022) for 30-day rebleeding. Early colonoscopy had a significantly lower IVR or surgery requirement in the shock index ≥1 cohort (OR, .267; 95% confidence interval, .099-.721) compared with late colonoscopy. CONCLUSIONS: Early colonoscopy increased the rate of SRH identification and shortened the length of stay but involved an increased risk of rebleeding and did not improve mortality and IVR or surgery requirement. Early colonoscopy particularly benefited patients with a shock index ≥1 or performance status ≥3 at presentation.

Reevaluation of Gastric Cancer Screening by Levin's Equation.

INTRODUCTION: This study aimed to reevaluate the effectiveness of fluoroscopy and endoscopy in reducing gastric cancer mortality at the population level. METHODS: Crude and age-adjusted mortality rates of gastric cancer and the introduction rates of gastric cancer screening were extracted from the Cancer Registry and Statistics database. The population-attributable risk (PAR) percent of no screening for gastric cancer mortality was calculated using Levin's equation. The PAR of each mortality rate in the no-screening group was estimated as follows: mortality × PAR%. The Jonckheere-Terpstra test for trends and linear regression were performed to compare the PAR of gastric cancer mortality rates among the decades. RESULTS: The PAR of crude and age-adjusted mortality rates in the no-screening group significantly decreased in the total population ( P for trend <0.001), as well as individually in the male ( P for trend <0.001) and female ( P for trend <0.001) populations. The PAR of the crude mortality rate in the female population significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989. There was no significant difference in the PAR of crude mortality rate in the male population among the decades. The PAR of the age-adjusted mortality rate significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989, in the male and female populations. DISCUSSION: PAR% and PAR of no screening for gastric cancer mortality could be estimated using Levin's equation, and the effectiveness of the present gastric cancer screenings with fluoroscopy and endoscopy has been decreasing, especially in the female population.

Doppler probe method to reduce delayed bleeding after endoscopic submucosal dissection in the stomach: a propensity-score matched study (with video).

BACKGROUND: Prophylactic coagulation after gastric endoscopic submucosal dissection (ESD) decreases the rate of delayed bleeding; however, it cannot prevent bleeding completely, and delayed bleeding may occur from non-exposed vessels that were not detected immediately after ESD or where prophylactic coagulation was inadequate. Doppler monitoring systems which can evaluate vascular flow have been recently introduced in the endoscopic field. We developed the Doppler probe method (DOP) using the novel system and conducted a comparative study. METHODS: Data were retrospectively collected at a tertiary hospital between January 2017 and May 2021. Patients who underwent DOP were matched to those who did not (no-DOP, 1:3 ratio). After successful ESD, DOP was performed, and coagulation was additionally performed as necessary. The primary outcome was the rate of 30-day delayed bleeding. RESULTS: Fifty DOP patients were matched to 151 no-DOP patients. Although the differences were not statistically significant, the DOP group had lower rates of delayed bleeding (2.0% vs. 8.6%, P = 0.11; risk differences, 6.6%; 95% confidence interval [CI] 1.2-12.1%), readmission due to bleeding (0% vs. 2.7%), and blood transfusion (2.0% vs. 3.3%) compared to the no-DOP group. In the whole study population (n = 245), the log-rank test revealed that DOP was correlated to a lower incidence of delayed bleeding (P = 0.036). The Cox regression model revealed a marginally significant effect on delayed bleeding (hazard ratio = 0.17, 95% CI 0.022-1.26, P = 0.082). No procedure-related adverse events were observed. CONCLUSION: DOP is safe and may reduce delayed bleeding; however, further prospective studies are required to validate our findings.

Evaluation and management of esophageal varices by through-the-scope endoscopic Doppler probe method.

OBJECTIVES: Objective assessments of esophageal varices (EVs) are inadequate. The recurrence of variceal bleeding after endoscopic variceal ligation (EVL) is associated with residual blood flow underlying EVL or incomplete treatment of a perforating vein by EVL. We aimed to assess our novel through-the-scope endoscopic Doppler probe method (DOP) for the evaluation and management of EVs. METHODS: This study included 20 patients (54 varices) with a history of esophageal variceal rupture from June 2019 to May 2021 who underwent DOP at a tertiary hospital. Variceal velocities were compared based on the size and endoscopic variceal findings. Additionally, we performed EVL assisted by DOP (EVL + DOP) in nine patients. RESULTS: Doppler imaging of EVs was observed in all 20 patients. The velocity of varices was significantly higher in EVs with a larger size, greater form, blue color, and red color sign positive. Perforating veins connecting to the EVs were identified in six out of nine patients who underwent EVL + DOP. Eight out of nine patients underwent repeat EVL. Repeat EVL was performed until the variceal velocity reached absent. No recurrence of variceal bleeding occurred during the follow-up period (mean 8.7 ± 3.2 months). No adverse events associated with DOP were observed. CONCLUSION: The evaluation of EVs using DOP is feasible and accurate. EV velocities are related to the variceal size, form, blue color, and red color sign. EVL + DOP may be a more reliable treatment for EVs. Further large-scale, long-term comparative studies are warranted.

Combination of rubber band traction and partial injection for effective under-gel endoscopic mucosal resection of an ileocecal valve lesion.

Video 1A 25-mm protruding polyp was detected on the proximal lip of the ileocecal valve, extending into the terminal ileum. The tumor was treated effectively with under-gel EMR and a combination of the double-clip and rubber band traction method and partial submucosal injection.

Use of the NOBLADS Score to Predict Endoscopic Treatment in Patients with Colonic Diverticular Bleeding by Age Stratification.

Objective A high NOBLADS score reflecting the severity of lower gastrointestinal bleeding contributes to the identification of stigmata of recent hemorrhage (SRH) in colonic diverticular bleeding (CDB). The burden of colonoscopy is particularly high in elderly patients; therefore, we investigated the utility of the NOBLADS score for managing CDB by age stratification. The NOBLADS score performance in SRH prediction was estimated by the area under the receiver operating characteristic calculation and a multiple logistic regression model. Methods This was a single-center, retrospective cohort study. Patients who underwent initial colonoscopy with CDB between April 2008 and December 2019 were divided into a young group (<65 years old) and an elderly group (≥65 years old). We further categorized patients according to colonoscopy findings as SRH-positive, with successful endoscopic hemostasis performance, and SRH-negative, with suspected CDB. The main outcome measure was successful SRH identification. Results Four-hundred and seventeen CDB patients were included, of whom 250 (60.0%) were elderly. There were 72 (43.1%) SRH-positive patients in the young group and 94 (37.6%) in the elderly group. The areas under the receiver operating characteristic curves of the NOBLADS score predicting SRH identification were 0.76, 0.71, and 0.81 for all ages, young patients, and elderly patients, respectively. A multiple logistic regression analysis showed that SRH identification was significantly associated with NOBLADS scores in both groups. Eighty-one patients (32.4%) scored ≥4 in the elderly group, and 60 of those were SRH-positive (74.1%). All 27 patients (10.8%) who scored ≥4 with extravasation on computed tomography were found to have SRH. Conclusion The NOBLADS score is useful for predicting SRH identification, especially in elderly patients.

Comparison of conventional and new endoscopic band ligation devices for colonic diverticular bleeding.

BACKGROUND/AIMS: Endoscopic band ligation (EBL) is used to treat colonic diverticular bleeding (CDB). An endoscopic variceal ligation device for esophageal varices is used as a conventional EBL device (C-EBL). A new EBL device (N-EBL) was developed by Sumitomo Bakelite Co. in August 2018. We aimed to evaluate the clinical outcomes of N-EBL compared with those of C-EBL. METHODS: Seventy-nine patients who underwent EBL for CDB at St. Luke's International Hospital, Japan, between 2017 and 2020 were included in this retrospective study. Patients were divided into the C-EBL and N-EBL groups. Their clinical outcomes, including achieving initial hemostasis, early rebleeding, procedure time, and EBL-associated adverse events, were evaluated. RESULTS: Of the 79 patients, 36 (45.6%) were in the C-EBL group and 43 (54.4%) were in the N-EBL group. The rate of achieving initial hemostasis was 100% in the C-EBL group and 93.0% in the N-EBL group. No significant difference was noted in the early rebleeding rate between the groups (p=0.24). The N-EBL group achieved a shorter median EBL procedure time than the C-EBL group (18.2 minutes vs. 14.2 minutes, p=0.02). No adverse events were observed in either group. CONCLUSION: The N-EBL device is safe and useful and may reduce EBL procedure time.