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Clin Colon Rectal Surg 2018; 31(04): 243-250
DOI: 10.1055/s-0037-1607963
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Diverticular Bleeding: Evaluation, Stabilization, Intervention, and Recurrence of Bleeding and Indications for Resection after Control of Bleeding

Mohammed Iyoob Mohammed Ilyas
1   Department of Colon and Rectal Surgery, Henry Ford Health System, Detroit, Michigan
,
Eric J. Szilagy
2   Department of Colon and Rectal Surgery, West Bloomfield Hospital, Henry Ford Health System, Detroit, Michigan
› Author Affiliations
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Publication History

Publication Date:
22 June 2018 (online)

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Abstract

Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.

Keywords

lower gastrointestinal bleeding - diverticular bleeding - angiography - embolization
 

  • References

  • 1 Hreinsson JP, Gumundsson S, Kalaitzakis E, Björnsson ES. Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013; 25 (01) 37-43
    CrossrefPubMedGoogle Scholar
  • 2 Nagata N, Niikura R, Aoki T. , et al. Impact of discontinuing non-steroidal antiinflammatory drugs on long-term recurrence in colonic diverticular bleeding. World J Gastroenterol 2015; 21 (04) 1292-1298
    CrossrefPubMedGoogle Scholar
  • 3 Peery AF, Dellon ES, Lund J. , et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143 (05) 1179-1187 .e1–e3
    CrossrefPubMedGoogle Scholar
  • 4 Adams JB, Margolin DA. Management of diverticular hemorrhage. Clin Colon Rectal Surg 2009; 22 (03) 181-185
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Gayer C, Chino A, Lucas C. , et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery 2009; 146 (04) 600-606 , discussion; 606–607
    CrossrefPubMedGoogle Scholar
  • 6 Wedel T, Böttner M. Anatomy and pathogenesis of diverticular disease [Article in German]. Chirurg 2014; 85 (04) 281-288
    CrossrefPubMedGoogle Scholar
  • 7 Ilyas MI, Zangbar B, Nfonsam VN. , et al. Are there differences in outcome after elective sigmoidectomy for diverticular disease and for cancer? A national inpatient study. Colorectal Dis 2017; 19 (03) 260-265
    CrossrefPubMedGoogle Scholar
  • 8 Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363 (9409): 631-639
    CrossrefPubMedGoogle Scholar
  • 9 Reinus JF, Brandt LJ. Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994; 23 (01) 1-20
    PubMedGoogle Scholar
  • 10 McGuire Jr HH, Haynes Jr BW. Massive hemorrhage for diverticulosis of the colon: guidelines for therapy based on bleeding patterns observed in fifty cases. Ann Surg 1972; 175 (06) 847-855
    CrossrefPubMedGoogle Scholar
  • 11 Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49 (02) 228-238
    CrossrefPubMedGoogle Scholar
  • 12 Kang JY, Melville D, Maxwell JD. Epidemiology and management of diverticular disease of the colon. Drugs Aging 2004; 21 (04) 211-228
    CrossrefPubMedGoogle Scholar
  • 13 Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. Dis Colon Rectum 2000; 43 (10) 1383-1389
    CrossrefPubMedGoogle Scholar
  • 14 Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342 (02) 78-82
    CrossrefPubMedGoogle Scholar
  • 15 Meyers MA, Alonso DR, Baer JW. Pathogenesis of massively bleeding colonic diverticulosis: new observations. AJR Am J Roentgenol 1976; 127 (06) 901-908
    CrossrefPubMedGoogle Scholar
  • 16 McGuire Jr HH. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220 (05) 653-656
    CrossrefPubMedGoogle Scholar
  • 17 Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40 (03) 344-348
    CrossrefPubMedGoogle Scholar
  • 18 Kollef MH, O'Brien JD, Zuckerman GR, Shannon W. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med 1997; 25 (07) 1125-1132
    CrossrefPubMedGoogle Scholar
  • 19 Rockall TA, Logan RF, Devlin HB, Northfield TC. ; National Audit of Acute Upper Gastrointestinal Haemorrhage. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet 1996; 347 (9009): 1138-1140
    CrossrefPubMedGoogle Scholar
  • 20 Bordley DR, Mushlin AI, Dolan JG. , et al. Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage. JAMA 1985; 253 (22) 3282-3285
    CrossrefPubMedGoogle Scholar
  • 21 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356 (9238): 1318-1321
    CrossrefPubMedGoogle Scholar
  • 22 Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003; 163 (07) 838-843
    CrossrefPubMedGoogle Scholar
  • 23 Patel R, Clancy R, Crowther E, Vannahme M, Pullyblank A. A rectal bleeding algorithm can successfully reduce emergency admissions. Colorectal Dis 2014; 16 (05) 377-381
    CrossrefPubMedGoogle Scholar
  • 24 Laine L, Connors LG, Reicin A. , et al. Serious lower gastrointestinal clinical events with nonselective NSAID or coxib use. Gastroenterology 2003; 124 (02) 288-292
    CrossrefPubMedGoogle Scholar
  • 25 Strate LL, Gralnek IM. ACG Clinical Guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111 (05) 755
    CrossrefPubMedGoogle Scholar
  • 26 Villanueva C, Colomo A, Bosch A. Transfusion for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368 (14) 1362-1363
    PubMedGoogle Scholar
  • 27 Jairath V, Kahan BC, Stanworth SJ. , et al. Prevalence, management, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding in the United Kingdom. Transfusion 2013; 53 (05) 1069-1076
    CrossrefPubMedGoogle Scholar
  • 28 Shingina A, Barkun AN, Razzaghi A, Martel M, Bardou M, Gralnek I. ; RUGBE Investigators. Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding. Aliment Pharmacol Ther 2011; 33 (09) 1010-1018
    CrossrefPubMedGoogle Scholar
  • 29 Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol 2007; 102 (02) 290-296
    CrossrefPubMedGoogle Scholar
  • 30 Eisen GM, Dominitz JA, Faigel DO. , et al; American Society for Gastrointestinal EndoscopY. Standards of Practice Committee. An annotated algorithmic approach to acute lower gastrointestinal bleeding. Gastrointest Endosc 2001; 53 (07) 859-863
    CrossrefPubMedGoogle Scholar
  • 31 Zuccaro Jr G. ; American College of Gastroenterology. Practice Parameters Committee. Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol 1998; 93 (08) 1202-1208
    CrossrefPubMedGoogle Scholar
  • 32 Strate LL, Saltzman JR, Ookubo R, Mutinga ML, Syngal S. Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Am J Gastroenterol 2005; 100 (08) 1821-1827
    CrossrefPubMedGoogle Scholar
  • 33 Davila RE, Rajan E, Adler DG. , et al; Standards of Practice Committee. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc 2005; 62 (05) 656-660
    CrossrefPubMedGoogle Scholar
  • 34 Green BT, Rockey DC, Portwood G. , et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100 (11) 2395-2402
    CrossrefPubMedGoogle Scholar
  • 35 Angtuaco TL, Reddy SK, Drapkin S, Harrell LE, Howden CW. The utility of urgent colonoscopy in the evaluation of acute lower gastrointestinal tract bleeding: a 2-year experience from a single center. Am J Gastroenterol 2001; 96 (06) 1782-1785
    CrossrefPubMedGoogle Scholar
  • 36 Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988; 95 (06) 1569-1574
    CrossrefPubMedGoogle Scholar
  • 37 Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol 2001; 96 (08) 2367-2372
    CrossrefPubMedGoogle Scholar
  • 38 Parra-Blanco A, Ruiz A, Alvarez-Lobos M. , et al. Achieving the best bowel preparation for colonoscopy. World J Gastroenterol 2014; 20 (47) 17709-17726
    CrossrefPubMedGoogle Scholar
  • 39 Lhewa DY, Strate LL. Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding. World J Gastroenterol 2012; 18 (11) 1185-1190
    CrossrefPubMedGoogle Scholar
  • 40 Navaneethan U, Njei B, Venkatesh PGK, Sanaka MR. Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study. Gastrointest Endosc 2014; 79 (02) 297-306.e12
    CrossrefPubMedGoogle Scholar
  • 41 Kaltenbach T, Watson R, Shah J. , et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol 2012; 10 (02) 131-137
    CrossrefPubMedGoogle Scholar
  • 42 Yamada A, Sugimoto T, Kondo S. , et al. Assessment of the risk factors for colonic diverticular hemorrhage. Dis Colon Rectum 2008; 51 (01) 116-120
    CrossrefPubMedGoogle Scholar
  • 43 Niikura R, Nagata N, Aoki T. , et al. Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. J Clin Gastroenterol 2015; 49 (03) e24-e30
    CrossrefPubMedGoogle Scholar
  • 44 Tada M, Shimizu S, Kawai K. Emergency colonoscopy for the diagnosis of lower intestinal bleeding. Gastroenterol Jpn 1991; 26 (Suppl. 03) 121-124
    CrossrefPubMedGoogle Scholar
  • 45 Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998; 64 (08) 723-728
    PubMedGoogle Scholar
  • 46 Ohyama T, Sakurai Y, Ito M, Daito K, Sezai S, Sato Y. Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding. Digestion 2000; 61 (03) 189-192
    CrossrefPubMedGoogle Scholar
  • 47 Wang CY, Won CW, Shieh MJ. Aggressive colonoscopic approaches to lower intestinal bleeding. Gastroenterol Jpn 1991; 26 (Suppl. 03) 125-128
    CrossrefPubMedGoogle Scholar
  • 48 Jensen DM, Ohning GV, Kovacs TO. , et al. Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis. Gastrointest Endosc 2016; 83 (02) 416-423
    CrossrefPubMedGoogle Scholar
  • 49 Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding colonic diverticula by endoscopic band ligation: an in-vivo and ex-vivo pilot study. Endoscopy 2003; 35 (10) 823-829
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Setoyama T, Ishii N, Fujita Y. Enodoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25 (11) 3574-3578
    CrossrefPubMedGoogle Scholar
  • 51 Ishii N, Setoyama T, Deshpande GA. , et al. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75 (02) 382-387
    CrossrefPubMedGoogle Scholar
  • 52 Shibata S, Shigeno T, Fujimori K, Kanai K, Yoshizawa K. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis. Endoscopy 2014; 46 (01) 66-69
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Olds GD, Cooper GS, Chak A, Sivak Jr MV, Chitale AA, Wong RC. The yield of bleeding scans in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol 2005; 39 (04) 273-277
    CrossrefPubMedGoogle Scholar
  • 54 Gunderman R, Leef JA, Lipton MJ, Reba RC. Diagnostic imaging and the outcome of acute lower gastrointestinal bleeding. Acad Radiol 1998; 5 (Suppl. 02) S303-S305
    CrossrefPubMedGoogle Scholar
  • 55 Funaki B, Kostelic JK, Lorenz J. , et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001; 177 (04) 829-836
    CrossrefPubMedGoogle Scholar
  • 56 Sanlı Y, Ozkan ZG, Kuyumcu S. , et al. Role of red blood cell scintigraphy for determining the localization of gastrointestinal bleeding. Ulus Travma Acil Cerrahi Derg 2012; 18 (03) 225-230
    CrossrefPubMedGoogle Scholar
  • 57 Al Qahtani AR, Satin R, Stern J, Gordon PH. Investigative modalities for massive lower gastrointestinal bleeding. World J Surg 2002; 26 (05) 620-625
    CrossrefPubMedGoogle Scholar
  • 58 Gunderman R, Leef J, Ong K, Reba R, Metz C. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998; 39 (06) 1081-1083
    PubMedGoogle Scholar
  • 59 Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology 2003; 228 (03) 743-752
    CrossrefPubMedGoogle Scholar
  • 60 García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J. ; EBM-Connect Collaboration. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2013; 23 (05) 1181-1190
    CrossrefPubMedGoogle Scholar
  • 61 Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology 2012; 262 (01) 109-116
    CrossrefPubMedGoogle Scholar
  • 62 Sun H, Jin Z, Li X. , et al. Detection and localization of active gastrointestinal bleeding with multidetector row computed tomography angiography: a 5-year prospective study in one medical center. J Clin Gastroenterol 2012; 46 (01) 31-41
    CrossrefPubMedGoogle Scholar
  • 63 Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol 2010; 16 (31) 3957-3963
    CrossrefPubMedGoogle Scholar
  • 64 Kennedy DW, Laing CJ, Tseng LH, Rosenblum DI, Tamarkin SW. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review. J Vasc Interv Radiol 2010; 21 (06) 848-855
    CrossrefPubMedGoogle Scholar
  • 65 Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2008; 52 (04) 333-338
    CrossrefPubMedGoogle Scholar
  • 66 Obana T, Fujita N, Sugita R. , et al. Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding. Dig Dis Sci 2013; 58 (07) 1985-1990
    CrossrefPubMedGoogle Scholar
  • 67 Rösch J, Keller FS, Kozak B, Niles N, Dotter CT. Gelfoam powder embolization of the left gastric artery in treatment of massive small-vessel gastric bleeding. Radiology 1984; 151 (02) 365-370
    CrossrefPubMedGoogle Scholar
  • 68 Clark RA, Colley DP, Eggers FM. Acute arterial gastrointestinal hemorrhage: efficacy of transcatheter control. AJR Am J Roentgenol 1981; 136 (06) 1185-1189
    CrossrefPubMedGoogle Scholar
  • 69 Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986; 204 (05) 530-536
    CrossrefPubMedGoogle Scholar
  • 70 Cherian MP, Mehta P, Kalyanpur TM, Hedgire SS, Narsinghpura KS. Arterial interventions in gastrointestinal bleeding. Semin Intervent Radiol 2009; 26 (03) 184-196
    Article in Thieme ConnectPubMedGoogle Scholar
  • 71 Eckstein MR, Kelemouridis V, Athanasoulis CA, Waltman AC, Feldman L, van Breda A. Gastric bleeding: therapy with intraarterial vasopressin and transcatheter embolization. Radiology 1984; 152 (03) 643-646
    CrossrefPubMedGoogle Scholar
  • 72 Sherman LM, Shenoy SS, Cerra FB. Selective intra-arterial vasopressin: clinical efficacy and complications. Ann Surg 1979; 189 (03) 298-302
    CrossrefPubMedGoogle Scholar
  • 73 Walker TG, Waltman AC. Vasoconstrictive infusion therapy for management of arterial gastrointestinal hemorrhage. Semin Intervent Radiol 1988; 5: 18
    Article in Thieme ConnectPubMedGoogle Scholar
  • 74 Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization. J Vasc Interv Radiol 2003; 14 (05) 535-543
    CrossrefPubMedGoogle Scholar
  • 75 Adams JT. Therapeutic barium enema for massive diverticular bleeding. Arch Surg 1970; 101 (04) 457-460
    CrossrefPubMedGoogle Scholar
  • 76 Niikura R, Nagata N, Yamano K, Shimbo T, Uemura N. High-dose barium impaction therapy is useful for the initial hemostasis and for preventing the recurrence of colonic diverticular bleeding unresponsive to endoscopic clipping. Case Rep Gastrointest Med 2013; 2013: 365954
    PubMedGoogle Scholar
  • 77 Pausawasdi N, Al-Hawary M, Higgins PD. Therapeutic high-density barium enema in a case of presumed diverticular hemorrhage. Case Rep Gastroenterol 2011; 5 (01) 88-94
    CrossrefPubMedGoogle Scholar
  • 78 Fujimoto A, Sato S, Kurakata H, Nakano S, Igarashi Y. Effectiveness of high-dose barium enema filling for colonic diverticular bleeding. Colorectal Dis 2011; 13 (08) 896-898
    CrossrefPubMedGoogle Scholar
  • 79 Iwamoto J, Mizokami Y, Shimokobe K, Matsuoka T, Matsuzaki Y. Therapeutic barium enema for bleeding colonic diverticula: four case series and review of the literature. World J Gastroenterol 2008; 14 (41) 6413-6417
    CrossrefPubMedGoogle Scholar
  • 80 Matsuhashi N, Akahane M, Nakajima A. Barium impaction therapy for refractory colonic diverticular bleeding. AJR Am J Roentgenol 2003; 180 (02) 490-492
    CrossrefPubMedGoogle Scholar
  • 81 Nagata N, Niikura R, Shimbo T. , et al. High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding: a randomized controlled trial. Ann Surg 2015; 261 (02) 269-275
    CrossrefPubMedGoogle Scholar
  • 82 Aytac E, Stocchi L, Gorgun E, Ozuner G. Risk of recurrence and long-term outcomes after colonic diverticular bleeding. Int J Colorectal Dis 2014; 29 (03) 373-378
    CrossrefPubMedGoogle Scholar
  • 83 Parkes BM, Obeid FN, Sorensen VJ, Horst HM, Fath JJ. The management of massive lower gastrointestinal bleeding. Am Surg 1993; 59 (10) 676-678
    PubMedGoogle Scholar
  • 84 Wagner HE, Stain SC, Gilg M, Gertsch P. Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract. Surg Gynecol Obstet 1992; 175 (05) 445-449
    PubMedGoogle Scholar
  • 85 Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986; 204 (05) 530-536
    CrossrefPubMedGoogle Scholar
  • 86 Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg 1992; 58 (05) 295-299
    PubMedGoogle Scholar