Severe acute diverticular bleeding: successful treatment with hemostatic powder

Abstract

A 50-year-old man was admitted to the intensive coronary care unit for acute myocardial infarction and was treated by coronary artery stenting and dual antiplatelet therapy. On postprocedure day 5, the patient presented with massive hematochezia, anemia (hemoglobin 10.4 g/dL), and hypovolemic shock. After hemodynamic stabilization, a mesenteric angiogram revealed a left-sided colonic hemorrhage highly suggestive of diverticular bleeding (A, white arrow). Selective embolization was ruled out because of the risk of bowel infarction. An urgent colonoscopy showed bright red blood and multiple diverticula in the left side of the colon. After profuse water irrigation, active arterial bleeding from a diverticulum was identified 35 cm from the anal verge (B). After the bleeding site was marked with an endoclip, hemostasis was attempted, but without success, by a combination of adrenaline injection followed by endoclip positioning. The bleeding vessel was within the dome of a deep diverticulum with a small orifice. Because of the massive bleeding, an endocap to evert the diverticulum and performance of clip deployment or band ligation was difficult. Therefore, a spray catheter application of 2 g topical hemostatic powder (EndoClot polysaccharide hemostatic system [PHS], EndoClot Plus, Inc., Santa Clara, Calif) inside the lumen of diverticulum was carried out (C). Hemostasis was rapidly achieved (D), and no rebleeding had occurred by a 30-day follow-up visit, even after the readministration of dual antiplatelet therapy.