Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study

Naoyoshi Nagata^{1

2}, Katsumasa Kobayashi³, Atsushi Yamauchi⁴, Atsuo Yamada⁵, Jun Omori⁶, Takashi Ikeya⁷, Taiki Aoyama⁸, Naoyuki Tominaga⁹, Yoshinori Sato¹⁰, Takaaki Kishino¹¹, Naoki Ishii¹², Tsunaki Sawada¹³, Masaki Murata¹⁴, Akinari Takao¹⁵, Kazuhiro Mizukami¹⁶, Ken Kinjo¹⁷, Shunji Fujimori¹⁸, Takahiro Uotani¹⁹, Minoru Fujita²⁰, Hiroki Sato²¹, Sho Suzuki²², Toshiaki Narasaka^{23

24}, Junnosuke Hayasaka²⁵, Tomohiro Funabiki^{26

27}, Yuzuru Kinjo²⁸, Akira Mizuki²⁹, Shu Kiyotoki³⁰, Tatsuya Mikami³¹, Ryosuke Gushima³², Hiroyuki Fujii³³, Yuta Fuyuno³⁴, Naohiko Gunji³⁵, Yosuke Toya³⁶, Kazuyuki Narimatsu³⁷, Noriaki Manabe³⁸, Koji Nagaike³⁹, Tetsu Kinjo⁴⁰, Yorinobu Sumida⁴¹, Sadahiro Funakoshi⁴², Kana Kawagishi⁴³, Tamotsu Matsuhashi⁴⁴, Yuga Komaki⁴⁵, Kuniko Miki¹, Kazuhiro Watanabe², Masakatsu Fukuzawa⁴⁶, Takao Itoi⁴⁶, Naomi Uemura^{1

47}, Takashi Kawai¹, Mitsuru Kaise⁶

Affiliations

¹ Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.
² Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
³ Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
⁴ Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan.
⁵ Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
⁶ Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan.
⁷ Department of Gastroenterology, St. Luke's International University, Tokyo, Japan.
⁸ Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.
⁹ Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan.
¹⁰ Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.
¹¹ Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan.
¹² Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan.
¹³ Department of Endoscopy, Nagoya University Hospital, Aichi, Japan.
¹⁴ Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
¹⁵ Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
¹⁶ Department of Gastroenterology, Oita University, Oita, Japan.
¹⁷ Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan.
¹⁸ Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan.
¹⁹ Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan.
²⁰ Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan.
²¹ Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
²² Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan.
²³ Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan.
²⁴ Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki Japan.
²⁵ Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan.
²⁶ Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan.
²⁷ Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan.
²⁸ Department of Gastroenterology, Naha City Hospital, Okinawa, Japan.
²⁹ Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
³⁰ Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan.
³¹ Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan.
³² Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
³³ Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan.
³⁴ Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
³⁵ Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan.
³⁶ Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan.
³⁷ Department of Internal Medicine, National Defense Medical College, Saitama, Japan.
³⁸ Division of Endoscopy and UltrasonograPhy, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan.
³⁹ Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan.
⁴⁰ Department of Endoscopy, University of the Ryukyu Hospital, Okinawa, Japan.
⁴¹ Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
⁴² Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan.
⁴³ Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan.
⁴⁴ Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan.
⁴⁵ Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
⁴⁶ Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
⁴⁷ Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan.

PMID: 34388140
PMCID: PMC8560163
DOI: 10.14309/ajg.0000000000001413

Multicenter Study

Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study

Naoyoshi Nagata et al. Am J Gastroenterol. 2021.

. 2021 Nov 1;116(11):2222-2234.

doi: 10.14309/ajg.0000000000001413.

Authors

Affiliations

¹ Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.
² Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
³ Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
⁴ Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan.
⁵ Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
⁶ Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan.
⁷ Department of Gastroenterology, St. Luke's International University, Tokyo, Japan.
⁸ Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.
⁹ Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan.
¹⁰ Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.
¹¹ Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan.
¹² Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan.
¹³ Department of Endoscopy, Nagoya University Hospital, Aichi, Japan.
¹⁴ Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
¹⁵ Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
¹⁶ Department of Gastroenterology, Oita University, Oita, Japan.
¹⁷ Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan.
¹⁸ Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan.
¹⁹ Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan.
²⁰ Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan.
²¹ Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
²² Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan.
²³ Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan.
²⁴ Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki Japan.
²⁵ Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan.
²⁶ Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan.
²⁷ Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan.
²⁸ Department of Gastroenterology, Naha City Hospital, Okinawa, Japan.
²⁹ Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
³⁰ Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan.
³¹ Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan.
³² Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
³³ Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan.
³⁴ Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
³⁵ Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan.
³⁶ Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan.
³⁷ Department of Internal Medicine, National Defense Medical College, Saitama, Japan.
³⁸ Division of Endoscopy and UltrasonograPhy, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan.
³⁹ Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan.
⁴⁰ Department of Endoscopy, University of the Ryukyu Hospital, Okinawa, Japan.
⁴¹ Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
⁴² Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan.
⁴³ Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan.
⁴⁴ Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan.
⁴⁵ Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
⁴⁶ Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
⁴⁷ Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan.

PMID: 34388140
PMCID: PMC8560163
DOI: 10.14309/ajg.0000000000001413

Abstract

Introduction: The bleeding source of hematochezia is unknown without performing colonoscopy. We sought to identify whether colonoscopy is a risk-stratifying tool to identify etiology and predict outcomes and whether presenting symptoms can differentiate the etiologies in patients with hematochezia.

Methods: This multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia.

Results: Patients were mostly elderly population, and 29.5% had hemodynamic instability. Computed tomography was performed in 69.1% and colonoscopy in 87.7%. Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding. Thirty-day rebleeding rates were significantly higher with diverticulosis and small bowel bleeding than with other etiologies. In-hospital mortality was significantly higher with angioectasia, malignancy, rectal ulcer, and upper gastrointestinal bleeding. Colonoscopic treatment rates were significantly higher with diverticulosis, radiation colitis, angioectasia, rectal ulcer, and postendoscopy bleeding. More interventional radiology procedures were needed for diverticulosis and small bowel bleeding. Etiologies with favorable outcomes and low procedure rates were ischemic colitis and infectious colitis. Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis. The same was true in cases of hematochezia with diarrhea, fever, and hemodynamic instability.

Discussion: This nationwide data set of acute hematochezia highlights the importance of colonoscopy in accurately detecting bleeding etiologies that stratify patients at high or low risk of adverse outcomes and those who will likely require more procedures. Predicting different bleeding etiologies based on initial presentation would be challenging.

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Conflict of interest statement

Guarantor of the article: Naoyoshi Nagata, MD, PhD.

Specific author contributions: N.N.: was the principal investigator of this study. N.N.: designed and conducted the study, interpreted the data, and mainly wrote the article. K.K. (Bokuto hospital), A. Yamauchi, A. Yamada, J.O., T.I., T.A., N.T., Y. Sato, T. Kishino, N.I., T.S., M.M., A.T., K.M., K.K. (Fukuoka University Chikushi Hospital), S. Fujimori, T.U., M.F., H.S., S.S., T.N., J.H., T.F., Y. Kinjo, A.M., S.K., T.M., R.G., H.F., Y.F., N.G., Y.T., K. Narimatsu, N.M., K. Nagaike, T. Kinjo, Y.S., S. Funakoshi, K.K., T.M., Y. Komaki, K.M., K.W., and M.K.: designed the study, made decisions and definitions of survey items, and interpreted the data. N.N. and K.M.: performed the statistical analysis. M.F., T.I., N.U., T. Kinjo, and M.K.: provided corrections and advice on the preparation of the article.

Financial support: This work was partially supported by grants from the Ministry of Health, Labour and Welfare, Japan (grant number: 19HB1003), JSPS KAKENHI grant (JP17K09365 and 20K08366), Smoking Research Foundation, Takeda Science Foundation, Tokyo Medical University Cancer Research Foundation, Tokyo Medical University Research Foundation, Grants-in-Aid for Research from the National Center for Global Health and Medicine (29-2001, 29-2004, 19A1011, 19A1022, 19A-2015, 29-1025, and 30-1020). The funders played no role in the study design, analysis, and decision to publish the manuscript.

Potential competing interests: None to report.

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Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study

Affiliations

Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

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LinkOut - more resources

Full Text Sources

Medical