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

Emergency medicine updates: Lower gastrointestinal bleeding

INTRODUCTION

Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician.

DISCUSSION

LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with LGIB.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Management of an undetectable Diverticular Bleed: A Case Report and Literature review

Diverticular bleeding is the most common cause of lower gastrointestinal bleeding and accounts for 20.8%-41.6% of cases in the Western world. Management involves initial resuscitation followed by diagnostic assessment. Colonoscopy is the investigation of choice as it localizes the bleed and has the potential to effectively deliver therapeutic interventions. Other diagnostic modalities include flexible sigmoidoscopy, a tagged red blood cell scan, or angiography. In cases where the bleeding source cannot be identified, intraoperative enteroscopy has emerged as a valuable tool for investigating obscure gastroenterology bleeds in specific patients. In this case report, we describe the management of a 77-year-old male with recently diagnosed pan-colonic diverticulosis who presented with multiple episodes of rectal bleeding and syncope. Due to his declining hemodynamic status and failed endoscopy and embolization, he was taken to surgery for a colectomy. Intraoperative colonoscopy was utilized to facilitate accurate identification of the pathology, assessment of anastomotic patency, and detection of surgical complications. This case report attempts to portray how the incorporation of endo-videoscopy into surgical planning has the potential to enhance patient outcomes and represent a significant advancement in the field of minimally invasive surgery.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Patient Outcomes of Definitive Diverticular Hemorrhage After Colonoscopic, Medical, Surgical, or Embolization Treatment

BACKGROUND

There are few reports of clinical outcomes or the natural history of definitive diverticular hemorrhage (DDH).

AIMS

To describe 1-year clinical outcomes of patients with documented DDH treated with colonoscopic hemostasis, angioembolization, surgery, or medical treatment.

METHODS

DDH was diagnosed when active bleeding or other stigmata of hemorrhage were found in a colonic diverticulum during urgent colonoscopy or extravasation on angiography or red blood cell (RBC) scanning. This was a retrospective analysis of prospectively collected data of DDH patients from two referral centers between 1993 and 2022. Outcomes were compared for the four treatment groups. The Kaplan-Meier analysis was for time-to-first diverticular rebleed.

RESULTS

162 patients with DDH were stratified based on their final treatment before discharge-104 colonoscopic hemostasis, 24 medical treatment alone, 19 colon surgery, and 15 angioembolization. There were no differences in baseline characteristics, except for a higher Glasgow-Blatchford score in the angioembolization group vs. the colonoscopic group. Post-treatment, the colonoscopic hemostasis group had the lowest rate of RBC transfusions and fewer hospital and ICU days compared to surgical and embolization groups. The medical group had significantly higher rates of rebleeding and reintervention. The surgical group had the highest postoperative complications.

CONCLUSIONS

Medically treated DDH patients had significantly higher 1-year rebleed and reintervention rates than the three other treatments. Those with colonoscopic hemostasis had significantly better clinical outcomes during the index hospitalization. Surgery and embolization are recommended as salvage therapies in case of failure of colonoscopic and medical treatments.

Colonic diverticular bleeding: An update on pathogenesis and management

Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.

Colonic stricture: A rare complication of ultraselective transcatheter arterial embolization with microcoils for transverse colonic diverticular hemorrhage

Ultraselective transcatheter arterial embolization with microcoils is a highly effective and safe treatment for lower gastrointestinal bleeding. Here we present a patient with a history of pandiverticulosis, who was hospitalized with acute hemorrhage in the mid-transverse colon. The patient underwent a successful embolization with a microcatheter and microcoils. Postembolization angiography demonstrated no residual flow to the areas of concern. One-month postembolization, however, the patient presented to the emergency department with nonspecific abdominal symptoms. After imaging and endoscopy studies, a colonic stricture-a rare complication of ultraselective embolization with microcoils- was found. The patient underwent partial colectomy of the mid-transverse colon; postcolectomy course was uneventful. The case suggests a rare but clinically significant complication of ultraselective embolization using microcoils for patients with diverticular hemorrhage. We therefore hope to assist clinicians in making the appropriate diagnosis and intervention when presented with similar clinical presentations and history of embolization.

To Bleed or Not to Bleed

The location of gastrointestinal (GI) bleeding can be characterized based on the characteristics of the bowel movements these patients present with. Bright red blood per rectum is usually associated with a lower bleed; if brisk and significant enough, however, upper bleeds can present similarly. Melenic or "tar-colored" bowel movements are more likely to occur from upper bleeds as the color is secondary to digestion of hemoglobin as it passes through the GI tract. At times, there can be a mix of the two which can make a clinical decision for intervention less obvious. To make matters more difficult, some of these patients can be on anticoagulation therapy for a myriad of reasons. Risks versus benefits at these times need to be weighed as holding this therapy may make the patients more prone to clotting while continuation would increase likelihood of bleeding. We present a case of a hypercoagulable patient who was started on rivaroxaban for history of pulmonary embolism; this led to the onset of an acute GI bleed from a duodenal diverticulum requiring endoscopic intervention. Although this can be a known effect of the therapy, the severity of bleed and changes in hemodynamics can warrant very different management strategies.

Analysis of the Epidemiological Trends on Inpatient Diverticulosis Admissions in the US: A Longitudinal Analysis From 1997-2018

Background Diverticulosis of the colon is characterized by outpouchings of mucosa and serosa through the muscular layer of the large intestinal wall. It is classically associated with increasing age with older individuals having a higher prevalence and greater density of diverticula secondary to its progressive disease nature. Also, diverticular disease is associated with dietary habits, low fiber intake in western society as well as obesity. The aim of this study was to investigate the epidemiological trends associated with diverticular disease in the United States in a 21-year interval from 1997 to 2018. Methods Using the Nationwide Inpatient Sample, all hospitalizations between 1997 and 2018 were analyzed. We examined annual data for hospitalization rate, the average length of stay (LOS), mean age and interval age groups, and hospital charges for inpatient admissions for diverticular disease (diverticulitis and diverticulosis). Results Between 1997 and 2018, the number of hospitalizations for patients with a primary discharge diagnosis of diverticular disease (diverticulosis and diverticulitis) increased 32% from 220,896 to 293,530 with 89.7 discharges per 100,000 persons in 2018 versus 81.0 discharges per 100,000 persons in 1997. Overall, the average age of patients decreased from 67.55 ± 0.15 years in 1997 to 64.59 ±0.08 in 2018, [t-value (t) 12.56, degrees of freedom (df) 514424, 95% confidence interval (CI) 2.497-3.423, P<0.0001]. On further evaluation, the mean average age in males decreased from 63.16±0.21 years in 1997 to 61.31±0.12 years in 2018, (t 8.16, df 217981, 95% CI 1.404-2.295 P<0.0001), while in females it decreased from 70.53±0.14 years to 67.15±0.10 years, (t 20.13, df 296422, 95% CI 3.050-3.709 P<0.0001), in the same interval time. While evaluating different subgroups of age in this time interval, the prevalence rate of diverticular disease diagnosis per 100,000 persons increased in the interval age between 18-44 years from 20.1 to 29.8, [relative risk (RR) 0.848, CI 95% 0.834-0.863, P< 0.0001) and 45-64 years from 107.1 to 125.3, (RR 0.761, CI 95% 0.754-0.769 P<0.0001) while it decreased in the interval age between 65-84 years from 357.6 to 259.7, (RR 1.211, CI 95% 1.206-1.226, P<0.0001) as well as > 85 years from 746.2 to 523.6, (RR 1.130, CI 95% 1.112-1.147, P<0.0001) The length of stay (LOS) mean average in days decreased from 5.8 ± 0.04 days in 1997 to 4.4±0.021 days in 2018, (t 33.08 df 514424, 95%CI 1.316-1.483, P< 0.0001). Hospital Inpatient National Statistics data over hospital mean charges, available from the period between 1997 to 2015, shows that the mean hospital charges in US dollars increased over 100%, from $19,735.17 in 1997 to $39,575 in 2015 (P<0.001) even after adjusting values to 2015 inflation. Conclusion There is an overall trend of decreased mean age of patients admitted with diverticular disease in the US over the past 21 years with a respective significant increased rate of disease in younger age groups. We postulate that these changes may be associated with poor dietary habits and obesity epidemics worsened in the last two decades in the US. In addition, despite the decreased length of stay over the same time period, the mean hospital charges more than double likely reflecting the increased access to expensive diagnostic methods such as computed tomography and colonoscopies.

How to manage lower gastrointestinal bleeding in 2022?

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.

Diverticular Disease—An Updated Management Review

Diverticular disease is highly prevalent in the Western world, placing an increased burden on healthcare systems. This review clarifies the consensus in the literature on the disease’s classification, etiology, and management. Diverticular disease, caused by sac-like protrusions of colonic mucosa through the muscular colonic wall, has a varied disease course. Multiple theories contribute to our understanding of the etiology of the disease, with pathogenesis affected by age, diet, environmental conditions, lifestyle, the microbiome, genetics, and motility. The subtypes of diverticular disease in this review include symptomatic uncomplicated diverticular disease, segmental colitis associated with diverticulosis, and uncomplicated and complicated diverticulitis. We discuss emerging treatments and outline management options, such as supportive care, conservative management with or without antibiotics, and surgical intervention.

A Case of Cecal Diverticulitis Complicated by Pseudoaneurysm in the Ileocolic Artery

Acute colonic diverticulitis is a common gastrointestinal illness. It has several complications, such as perforation, abscess, and fistula formation. In addition, pseudoaneurysm caused by diverticulitis has been reported. We report a case of cecal diverticulitis complicated by pseudoaneurysm in the ileocolic artery.

A 58-year-old Japanese man was referred to our hospital for abdominal pain. Abdominal examination revealed right lower quadrant pain. Computed tomography (CT) scans showed the presence of diverticula and pericolic fat stranding in the cecum. Following this, he was diagnosed with cecal diverticulitis. Despite antibiotic treatment, his abdominal pain and blood test results worsened. On the third hospital day, a CT scan was performed again, revealing a pseudoaneurysm with hematoma in the ileocolic artery. Interventional radiology (IVR) was conducted to treat the pseudoaneurysm. It was embolized with n-butyl-2-cyanoacrylate (NBCA) and lipiodol. After embolization, he had stable hemoglobin. His abdominal pain and blood test results improved.

Pseudoaneurysms have been reported as a rare complication for diverticulitis. When a rupture occurs, it has a high risk of mortality. Early diagnosis and treatment of pseudoaneurysms are essential, and we should consider pseudoaneurysms as a complication of acute colonic diverticulitis.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Utility of the Gel Immersion Method for Treating Massive Colonic Diverticular Bleeding

Background/Aims

In Asia, right-sided diverticular bleeding is more common than that of the left side. It often causes massive bleeding and difficulties in identifying the stigmata of recent hemorrhage (SRH) of colonic diverticular bleeding (CDB). This case series demonstrates the efficacy of the gel immersion method using OS-1 Jelly (Otsuka Pharmaceuticals Factory, Tokushima, Japan) in patients with CDB.

Methods

This retrospective case series analyzed data of patients with CDB who underwent the gel immersion method from April 2016 to February 2020 at St. Luke’s International Hospital, Japan. All patients diagnosed with CDB who underwent the gel immersion method were included. We collected data on the site of bleeding, identification of SRH, and efficacy of the method from the electronic medical records.

Results

A total of 9 patients (including 7 with right-sided CDB) underwent gel immersion method and were included in this study. SRH were successfully found in 66.7% (6/9) of patients. Moreover, effective hemostasis was achieved in 85.7% (6/7) of patients with right-sided CDB. There were no adverse events.

Conclusions

The gel immersion method was found to be effective, especially for massive right-sided CDB.

Colonic diverticular disease

Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.

The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon

Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.

Initial management for acute lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.