Colonic Diverticular Bleeding Research Articles

Mo1269 Long-Term Outcome After Conservative and Endoscopic Treatment of Colonic Diverticular Bleeding

the calculated index and Erythro-Sedimentation Rate (ESR) and C-Reactive Protein (CRP) expression. Correlation between the calculated index and the symptoms experienced by patients at the time of colonoscopy was assessed too. Finally, 50 videos of DD patients not involved in the development of DICA were reassessed in order to investigate the predictive role of DICA on the outcome of the disease. Results: A total of 960 ratings were performed by endoscopists involved. Overall agreement in using DICA was 0.847 (95% CI 0.812 to 0.893). It was 0.878 (95% CI 0.832 to 0.895) for DICA 1, 0.765 (95% CI 0.735 to 0.786) for DICA 2, and 0.891 (95% CI 0.845 to 0.7923) for DICA 3. Intra-observer agreement kappa was 0.91 (95% CI 0.886 to 0.947). A significant correlation was found between DICA score and both ESR (p=0.0001) and CRP values (p=0.0001), as well as between median pain score and DICA score (p=0.0001). With respect to the 50 patients retrospectively reassessed, recurrence or occurrence of disease complications were recorded in 29 (58%) patients: 10 (34.5%) were classified as DICA 1 and 19 (65.5%) as DICA 2 (p=0.036). Conclusions: Diverticular Inflammation and Complication Assessment (DICA) score is a simple, reproducible, validated, and easy-to-use endoscopic scoring system for diverticular disease of the colon.

Use a Cap for Colonic Diverticular Hemorrhage

Endoscopists are aware that treatment of bleeding colonic diverticula with endoscopic hemostasis clips, electrocautery, or rubber band ligation can effectively control diverticular bleeding. The problem is that the bleeding diverticulum is often not located in 75% or more of patients. In the current study, investigators evaluated whether use of a “hood method” could improve detection of bleeding diverticula. First, colonoscopy was performed using the Olympus disposable distal attachment on the end of the scope. This is a soft, short cap that can be used to inspect each …

Two cases of colonic diverticular bleeding in which the combination of a planned marking clip and dynamic computed tomography was useful for identification of the bleeding site

Two cases of colonic diverticular bleeding in which the combination of a planned marking clip and dynamic computed tomography was useful for identification of the bleeding site

Improving quality measures in colonoscopy and its therapeutic intervention

Colonoscopy with polypectomy has been shown to reduce the risk of colon cancer. The critical element in the quality of colonoscopy in terms of polyp detection and removal continues to be the performance of the endoscopist, independent of patient-related factors. Improved results in terms of polyp detection and complete removal have implications regarding the development of screening and surveillance intervals and the reduction of interval cancers after negative colonoscopy. Advances in colonoscopy techniques such as high-definition colonoscopy, hood-assisted colonoscopy and dye-based chromoendoscopy have improved the detection of small and flat-type colorectal polyps. Virtual chromoendoscopy has not proven to improve polyp detection but may be useful to predict polyp pathology. The majority of polyps can be removed endoscopically. Available polypectomy techniques include cold forceps polypectomy, cold snare polypectomy, conventional polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection. The preferred choice depends on the polyp size and characteristics. Other useful techniques include colonoscopic hemostasis for acute colonic diverticular bleeding, endoscopic decompression using colonoscopic stenting, and transanal tube placement for colorectal obstruction. Here we review the current knowledge concerning the improvement of quality measures in colonoscopy and colonoscopy-related therapeutic interventions.

Risk of recurrence and long-term outcomes after colonic diverticular bleeding

Diverticular disease is one of the most common causes of acute lower gastrointestinal bleeding. We aimed to evaluate the natural history, follow-up, and risk factors associated with re-bleeding (recurrence) in patients with colonic diverticular bleeding. We reviewed patients with proven colonic diverticular hemorrhage from September 1993 to June 2012 at our institution. Recurrence was the main outcome measure. We identified 78 out of 95 patients with proven diverticular bleed who were treated non-operatively and were followed up for a median of 57.1 months. Thirty-seven (47 %) of these patients with a median age of 67 years developed recurrent diverticular bleed after a median time of 8.1 months. The bleeding originated from the left colon in 78 (83 %) out of 95 patients in the first bleeding episode and 31(84 %) out of 37 patients during the recurrent bleeding episode. Thirty-six patients (97 %) with recurrent diverticular bleed required surgical intervention. Old age at the time of initial bleeding was associated with recurrence (p = 0.001). Patients with diverticulitis (p < 0.0001), peripheral vascular (p = 0.01), and chronic renal diseases (p = 0.047) were found to have an increased risk for recurrent colonic diverticular bleed. We only had one perioperative mortality due to postoperative sepsis. All other mortalities were not directly associated with surgery. Patients with a history of colonic diverticular bleed are prone to recur shortly thereafter. Certain risk factors including increased age, documented diverticulitis, history of peripheral vascular disease, and chronic renal failure may predispose to recurrence.

Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan

Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years. Twenty-eight thousand one hundred ninety-two patients who underwent colonoscopy at an emergency hospital were reviewed from an electronic endoscopy database. Diverticula were classified as right-sided, left-sided, and bilateral types, and time trends in the proportion in diverticulosis, type, and diverticular bleeding were determined. Associations of age (≤39, 40-59, and ≥60 years), sex, and year increase with disease and odds ratios were estimated using logistic regression. Diverticulosis was identified in 6,150 patients (20.3 %; mean age, 67.6 years) and was predominantly right-sided (48.0 %). Diverticular bleeding was found in 427 (1.5 %; mean age, 69.7 years) and was predominantly bilateral (47.0 %). Proportion of colonic diverticulosis increased significantly (P < 0.01 for trend) from 66.0 % (1,424/2,157) in 2003 to 70.1 % (2,914/4,159) in 2011 and was associated (P < 0.01) with an increased number of patients aged ≥60 years. Proportion of diverticular bleeding increased significantly (P < 0.01 for trend) from 1.02 % (22/2,157) in 2003 to 1.67 % (69/4,159) in 2011 and was associated (P = 0.04) with an increased number of patients aged 40-59 years. Diverticulosis, right and bilateral type, and diverticular bleeding were independently associated with the 9-year trend after adjustment by age and sex. Colonic diverticulosis and diverticular bleeding are prevalent and increasing in Japan. Given the significant association of age with this trend, both diseases can be expected to increase for decades to come.

Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis

Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30-40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case-control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86-3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I (2) = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63-3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31-2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.

Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis

Although colonic diverticular hemorrhage is a common cause of lower gastrointestinal bleeding, the low rate of detection of the diverticula responsible for bleeding, together with inadequate evaluation of endoscopic hemostasis, remain unsatisfactory. Over 3 years, we employed the hood method to diagnose diverticular hemorrhage in 53 patients and applied endoscopic band ligation (EBL) for hemostasis in 27 patients with responsible diverticula. The hood method revealed active bleeding in 13 patients (24.5%), nonbleeding visible vessels in 14 patients (26.4%), and presumptive diverticular hemorrhage in 26 patients (49.1%). The nonbleeding visible vessels were located in the diverticular dome in 13 patients and at the diverticular orifice in one patient. EBL was performed in 27 patients, and a hemostasis rate of 96.3% was achieved. In 9 of 12 patients treated with EBL, follow-up colonoscopy revealed resolution of the responsible diverticula. The hood method improves the detection rate of diverticula responsible for bleeding by revealing potential nonbleeding visible vessels in the diverticular dome. EBL may become an effective procedure for hemostasis of colonic diverticular hemorrhage.

The use of Ankaferd in diverticular bleeding: Two case reports

Bleeding from colonic diverticula is the most common cause of acute lower gastrointestinal bleeding. Using epinephrine injection, heater probe or bipolar coagulation, endoclips and endoscopic band ligation all have been shown in small case series to achievehemostasis. In the present two cases, we evaluated the effectiveness of Ankaferd Blood Stopper in colonic diverticular hemorrhage.

Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

Diverticular disease is the most frequent cause of lower gastrointestinal bleeding. Most of the times, bleeding stops without any intervention but in 10-20% of the cases it is necessary to treat the hemorrhage. Several modalities of endoscopic treatment have been described after purging the colon. We present five cases of severe diverticular bleeding treated with injection of epinephrine and hemoclips. All the colonoscopies were performed without purging of the colon in an emergency setting, with correct visualization of the point of bleeding. Patients recovered well avoiding other aggressive procedures such as angiography or surgery.

Risk factors for early re‐bleeding and associated hospitalization in patients with colonic diverticular bleeding

The annual incidence of colonic diverticular bleeding is increasing, but treatments are not yet well established. Here we aimed to identify the risk factors for early re-bleeding and to determine the associated duration of hospitalization. Records of 90 emergent patients with colonic diverticular bleeding between 1999 and May 2012 were retrospectively reviewed. They were divided into an early re-bleeding within 1 month group (n = 24) and a no re-bleeding group (n = 66) and we investigated the risk factors for early re-bleeding. In the former group, we calculated the time from the first haemostasis to early re-bleeding and the associated duration of hospitalization. Univariate analysis showed that there were significantly more patients with signs of shock (P = 0.00055) and active bleeding on the first colonoscopy after admission (P = 0.020) in the early re-bleeding group. Multivariate conditional logistic regression analysis using stepwise variable selection showed that signs of shock on admission (odds ratio, 5.23; 95% confidence interval, 1.84-14.90; P = 0.0019) remained statistically significant. All patients who re-bled without signs of shock (n = 7) and 16 of 17 with signs of shock re-bled within 126 h (5.25 days) of initial hospitalization. Shock was an independent risk factor for early re-bleeding. The associated duration of hospitalization was 6 days.

Multidetector CT Angiography for the Detection of Colonic Diverticular Bleeding: When, How, and Why?

Acute lower GI bleeding is responsible for 1–2 % of hospital emergencies, 15 % of which manifest as massive, lifethreatening bleeding. Initial clinical management focuses on identifying the site and cause of bleeding using scintigraphy, arteriography, and colonoscopy [1–3]. Although optical colonoscopy is the procedure of choice, its use poses challenges in the emergency setting [1]. Administration of bowel preparation, not always feasible in cases of massive bleeding, can delay the procedure for several hours; the presence of clots, blood, and stool in patients without preparation may hinder the visualization of the bleeding point, increasing the rate of incomplete studies when compared with nonemergent examinations. Furthermore, in 10–12 % of cases, the source of bleeding may be extracolonic [4]. Angiography is an invasive procedure usually reserved for therapeutic purposes in patients with more severe, life-threatening bleeding. Technetium 99labeled red blood cell scintigraphy is more sensitive than arteriography for identifying lower rate bleeding, although its emergency availability is variable, limiting its usefulness [4]. Computed tomography (CT) and, more specifically, CT enterography is commonly used as a second-line procedure in nonemergent patients with unexplained GI bleeding after negative upper and lower endoscopy examinations [5]. Since CT is rapid, noninvasive, and highly reproducible, it is commonly used in the acute setting for evaluating patients with lower GI bleeding emergencies, although optimal timing and patient characteristics for the diagnosis of colonic diverticular bleeding have not been established. In this issue, Obana et al. [6] prospectively explored the utility of contrast-enhanced CT in 52 patients with colonic diverticular bleeding testing the hypothesis that CT complements colonoscopy in this setting. Favorable patient characteristics, based on univariate analysis, included feasibility of examination within 2 h of the last hematochezia, re-bleeding in hospital, or past history of diverticular bleeding. Detection and localization of the bleeding source enable successful catheter-directed endovascular therapy. Although emergent colonoscopy remains the primary investigation in lower GI bleeding, it is often negative or impractical during the acute phase in hemodynamically unstable patients, as confirmed in the accompanying study [6]. In many centers, CT angiography is performed if endoscopy fails to identify the bleeding source with conventional mesenteric angiography reserved for patients with CT evidence of active contrast extravasatio or hemodynamic instability due to massive hemorrhage. CT may visualize acute lower GI bleeding at a bleeding rate less than the 0.5 ml/min limit cited for mesenteric angiography, perhaps as low as 0.2 ml/min [5]. The additional information provided by CT before attempted therapeutic angiographic procedures improves the preoperative localization and characterization of the bleeding source, expediting the selective catheterization of bleeding vessels, thereby significantly facilitating embolization. Relevant findings evaluated in this study were the presence and location of active or recent bleeding and the identification of the potential bleeding lesion [6]. Active bleeding from colonic diverticula was identified in only 15.4 % (8/52) of the patients included in the study, lower than in other series that included only massive or severe bleeding, probably because most patients were hemodynamically stable at the time CT was performed. In many R. Loffroy (&) Department of Vascular and Interventional Radiology, Bocage Teaching Hospital, University of Burgundy School of Medicine, Dijon, France e-mail: romaric.loffroy@chu-dijon.fr

Diagnosis and management of colonic diverticular bleeding

Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding representing 35% of cases. It is predominantly a disease of the elderly. Bleeding stops spontaneously in the majority of cases (90%), but sometimes it can be severe and requires specific treatment and blood transfusion. Diverticular bleeding can be life-threatening with a mortality rate of up to 5% of cases. Early colonoscopy is the main examination for diagnosis and treatment of diverticular bleeding. Recurrence occurs in up to 25% of cases within 4 years. Risk factors for recurrence are not clearly understood. Treatment of diverticular bleeding is not clearly codified: serum adrenaline injection, endoclips or endoscopic band ligation have been proposed with a high rate of initial success. Supra-selective embolization is an effective alternative treatment in case of failure of endoscopic treatment. Colectomy to control bleeding is uncommon and should be discussed if bleeding is uncontrolled by endoscopic treatment and/or radiological procedure and if possible after locating bleeding site.

Mo1616 Strategy of Endoscopic Treatment for Colonic Diverticular Hemorrhage: Is Endoscopic Band Ligation (EBL) Adequate As an Initial Therapy?

Mo1616 Strategy of Endoscopic Treatment for Colonic Diverticular Hemorrhage: Is Endoscopic Band Ligation (EBL) Adequate As an Initial Therapy?

586 Long-Term Outcomes of Endoscopic Band Ligation (EBL) for Colonic Diverticular Hemorrhage

586 Long-Term Outcomes of Endoscopic Band Ligation (EBL) for Colonic Diverticular Hemorrhage

Prospective Evaluation of Contrast-Enhanced Computed Tomography for the Detection of Colonic Diverticular Bleeding

To prospectively evaluate the role of contrast-enhanced computed tomography (CE-CT) in the detection of colonic diverticular bleeding (CDB). Consecutive patients who presented with hematochezia and were clinically suspected of CDB were prospectively enrolled. Those who could undergo both CE-CT and total colonoscopy, and who were finally diagnosed as CDB, were included in the analysis. Fifty-two cases were finally included in the analysis. The detection rate of CDB by CT was 15.4 % (8/52). Univariate analysis showed that the interval from the latest episode of hematochezia to the performance of CT and the presence of a past history of CDB were contributing factors for detection. The interval was 1.6 ± 4.6 h (mean ± SD) in patients detected by CT, and 3.4 ± 3.2 h in those without detection. The detection rate of CDB by total colonoscopy was 38.5 % (20/52). The overall detection rate was 46.2 % (24/52), which was superior to what CT or colonoscopy alone achieved. CE-CT may play a complementary role to colonoscopy in patients with suspected CDB, but is not recommended for all cases due to its low detection rate. Patients who can be examined within 2 h of last hematochezia would be candidates for urgent CT.

Differences in Clinical Characteristics between Right- and Left-Sided Colonic Diverticular Hemorrhage

Background: The number of patients with diverticular diseases has recently increased in Japan. Hemorrhage is a common manifestation of colonic diverticulosis, and the most frequent cause of lower gastrointestinal bleeding. Right- (RSD) and left- (LSD) sided diverticula are more predominant in Asian and in non-Asian populations, respectively. This retrospective study investigates differences in the clinical courses of hemorrhages arising from RSD and LSD. Methods: The clinical characteristics of 109 consecutive patients with colonic diverticular hemorrhage (from RSD, n=75; from LSD, n=34) selected from those admitted to Teikyo University Hospital (Tokyo, Japan) between January 2004 and August 2012 were compared. Results: Mean age was slightly lower and males were more predominant in the RSD than in the LSD group. All other background data were similar. Four and two patients in the RSD group required surgical resection and hemostasis using angiography, respectively, whereas none of the patients in the LSD group needed such invasive treatment. Endoscopic hemostasis was achieved in 21 (28%) of 75 and in 5 (14.7%) of 34 patients in the RSD and LSD groups, respectively, although the difference was not significant. The recurrence rates were essentially identical (RSD, 17.3%; LSD, 17.6%). Conclusion: Patients with hemorrhage from RSD tended to be more male-dominant than those from LSD. Serious bleeding is more likely to arise in patients with RSD, and endoscopic hemostasis is one choice of treatment when bleeding is suspected.

High-Dose Barium Impaction Therapy Is Useful for the Initial Hemostasis and for Preventing the Recurrence of Colonic Diverticular Bleeding Unresponsive to Endoscopic Clipping

Most cases of colonic diverticular bleeding stop spontaneously, but some patients experience massive bleeding that requires emergency treatment. Endoscopy can be useful when the bleeding source is identified. However, bleeding sometimes recurs within a short period despite the successful endoscopic treatment. Under such conditions, more invasive therapy such as interventional angiography or surgery is required and can prolong hospitalization and involve frequent blood transfusions. We report the case of a 68-year-old woman who presented with massive hematochezia. The patient was in hemorrhagic shock and required 16 units of blood transfusion to recover to general condition. We performed multidetector row computed tomography, but it showed no sites of bleeding. We conducted colonoscopy and identified the source of bleeding as colonic diverticula. We treated the bleeding with endoscopic hemoclips and achieved hemostasis, but bleeding recurred the next day. Four units of blood transfusion were required. We tried high-dose barium impaction therapy to avoid further blood transfusion and surgery. No complications or recurrent bleeding was observed for an 18-month period. Therapeutic barium enema is an option for colonic diverticular bleeding unresponsive to endoscopic clipping and may be effective for preventing recurrent bleeding.

Decreasing Mortality Rates from Colonic Diverticular Hemorrhage in the U.S.

Decreasing Mortality Rates from Colonic Diverticular Hemorrhage in the U.S.

Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping

Predictors of refractory colonic diverticular hemorrhage after endoscopic clipping (EC) remain unclear. To elucidate the predictors of uncontrolled bleeding after EC. Retrospective study. Two tertiary referral centers. Eighty-nine patients with colonic diverticular hemorrhage who underwent EC as a first-line treatment were included. If bleeding remained uncontrolled after 1 or 2 EC sessions, other interventions (transcatheter arterial embolization, endoscopic band ligation, or surgery) were performed. Patients were divided into EC-controlled and EC-uncontrolled groups; the characteristics of each group were compared. Comorbidities, location of bleeding diverticula, and EC technique (direct vs indirect placement). Initial treatment with EC was successful in 87 patients. Early rebleeding (primary failure) occurred in 30 of 87 patients (34%). Secondary failure occurred in 6 of 22 patients treated with reclipping (27%). Cumulatively, 78 patients were successfully managed with EC. Non-EC treatments were required in 11 patients. Location in the right side of the colon, particularly in the ascending colon, was significantly more common in the EC-uncontrolled group than in the EC-controlled group (P = .017 and P = .0029, respectively). Although the difference was not significant, bleeding was successfully managed in all 13 patients treated with direct placement. Bleeding remained uncontrolled after EC in 11 of 52 ascending cases (21%) treated with indirect placement. Diverticular hemorrhage in other locations was managed regardless of EC technique. Retrospective study. Location in the ascending colon is a significant predictor of refractory colonic diverticular hemorrhage after EC. Indirect placement of hemoclips in ascending lesions is ineffective.