From the Guidelines
The patient with hemorrhagic diverticulitis should be immediately stabilized and transferred to a facility capable of CT angiography to localize the bleeding source and plan intervention. For this patient, initial management includes:
- Two large-bore IVs with crystalloid resuscitation
- Type and cross for 2 units PRBC
- NPO status
- IV antibiotics (e.g., ceftriaxone 1g IV q24h plus metronidazole 500mg IV q8h) 1 Laboratory studies and bedside ultrasound should be performed to assess the patient's condition, including hemoglobin levels, leukocytosis, and free fluid in the left lower quadrant. Given the limitations of our facility in performing CT angiography, transfer to a tertiary center is essential for further management, which may include interventional radiology embolization or surgical intervention if bleeding persists 1. It is crucial to prioritize the patient's transfer to a facility with CT angiography capabilities, as hemorrhagic diverticulitis can lead to significant blood loss and sepsis if not properly managed, making timely diagnosis and intervention critical for preventing complications like peritonitis or hypovolemic shock. The 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting suggests that patients with CT findings of distant free gas without diffuse intra-abdominal fluid may be treated with non-operative treatment in selected patients only if close follow-up can be performed, but this is not applicable in our case due to the patient's hemodynamic instability and the need for CT angiography 1. Therefore, the focus should be on stabilizing the patient and facilitating a prompt transfer to a facility equipped to provide the necessary diagnostic and therapeutic interventions.
From the Research
ISBAR Scenario: Hemorrhagic Episode of Diverticulitis
- I: Identify the patient: a patient admitted due to a hemorrhagic episode of diverticulitis.
- S: Situation: the patient is experiencing a severe hemorrhagic episode, but the center is not equipped to perform a CT angio.
- B: Background:
- The patient's symptoms are consistent with diverticular bleeding, which is a common cause of lower gastrointestinal hemorrhage 2, 3.
- Diverticular bleeding typically presents with massive and painless rectal hemorrhage 2.
- The recommended initial diagnostic test is colonoscopy, which can be performed within 12 to 48 hours of presentation 2.
- A: Assessment:
- The patient requires immediate resuscitative measures, including airway maintenance, oxygen supplementation, and intravenous fluid resuscitation with normal saline or lactated Ringer's solution 2.
- Blood typing and crossmatching should be performed, and transfusion of packed red blood cells may be necessary in the event of ongoing bleeding 2.
- The patient's condition should be closely monitored, and the possibility of complications such as hemodynamic instability should be considered 3, 4.
- R: Recommendation:
- Colonoscopy should be performed as soon as possible to identify the source of bleeding and potentially perform endoscopic therapeutic maneuvers 2, 3.
- If the bleeding source is not identified, radionuclide imaging or other diagnostic tests may be necessary to locate the source of bleeding 2, 3.
- The patient should be closely monitored and managed by a multidisciplinary team, including gastroenterologists, surgeons, and radiologists, to ensure the best possible outcome 3, 4, 5, 6.