Endoscopic Technique for Successful Hemostasis in Massive Diverticular Bleed and the Importance of Rapid Bowel Prep

Abstract

SymbolIntroduction: An 88-year-old man presents with rectal hemorrhage and hemodynamic instability with orthostatic changes. His medical history is significant for hypertension, type 2 diabetes mellitus, coronary artery disease status post coronary artery bypass grafts, and cerebrovascular accident. He was maintained on full dose aspirin therapy. After resuscitation, the patient underwent a rapid bowel purge with polyethylene glycol and urgent colonoscopy was performed within 12 hours of presentation. During colonoscopy, severe right sided diverticulosis was seen with wide-mouthed diverticula, starting at the hepatic flexure. After careful irrigation, active bleeding with spurting was seen arising from a diverticulum in the mid-ascending colon. A total of 8 cc’s of epinephrine in a 1:10,000 concentation was injected into the diverticulum neck at the bleeding vessel. The bleeding slowed, but continued. Metallic hemoclips were then applied at the diverticulum neck at the site of the bleeding vessel with successful hemostasis. The patient did well and remained stable. Our video demonstrates the endoscopic techniques to achieve hemostasis in diverticular bleeding. This video also demonstrates the importance of rapid bowel prep and performing colonoscopy within 24 hours.SymbolConclusion: An 88-year-old man with multiple comorbid conditions presented with bright red blood pre-rectum and hemodynamic instability with orthostatic changes. After initial intravenous resuscitation, the patient underwent a rapid bowel purge with polyethylene glycol. An urgent colonoscopy was performed within 12 hours of presentation. During colonoscopy, severe right sided diverticulosis was seen with wide-mouthed diverticula, starting at the hepatic flexure. After careful irrigation, active bleeding with spurting was seen localized from a diverticulum in the mid-ascending colon. A total of 8 cc’s of epinephrine in a 1:10,000 concentration was injected into the diverticulum neck at the bleeding vessel site. The bleeding slowed, but continued. It was decided to proceed with mechanical hemostasis. A total of three metallic hemoclips were then applied at the diverticulum neck at the site of the bleeding vessel with successful hemostasis. After vigorous sterile water irrigation, no further bleeding was noted. The patient did well and remained stable. In summary, the tip for successful endotherapy in diverticular bleeding are: rapid bowel prep, vigorous sterile water irrigation (both improve localization of the lesion), epinephrine injection, and mechanical hemoclipping (or bipolar electrocautery).