What is the management plan for diverticular bleeding?

From the Guidelines

The management of diverticular bleeding involves a stepwise approach beginning with hemodynamic stabilization through intravenous fluid resuscitation and blood transfusions as needed, with a focus on minimizing morbidity, mortality, and improving quality of life. Initial assessment should include complete blood count, coagulation studies, and cross-matching for potential transfusion 1. Patients should be kept nil by mouth until bleeding stabilizes. Diagnostic evaluation typically starts with colonoscopy within 24 hours of presentation, which can both identify the bleeding source and potentially provide therapeutic intervention, such as endoscopic clipping, thermal coagulation, or epinephrine injection 1. If colonoscopy fails to identify the source or cannot control bleeding, CT angiography followed by interventional radiology embolization may be performed, with technical success rates ranging from 73% to 100% 1. For persistent or recurrent bleeding, nuclear medicine studies like tagged red blood cell scans can help localize the source. Medical management includes correction of coagulopathies, discontinuation of anticoagulants and NSAIDs when possible, and blood pressure control. Definitive treatment may involve endoscopic interventions, angiographic embolization using liquid embolic agents such as N-Butyl cyanoacrylate (NBCA) or ethylene-vinyl alcohol copolymer, or surgical resection of the affected bowel segment for severe or recurrent bleeding 1. Most diverticular bleeding (80-90%) resolves spontaneously, but recurrence rates are high (25-40%), necessitating close follow-up and consideration of preventive measures such as high-fiber diet and avoidance of NSAIDs after the acute episode resolves 1.

Some key points to consider in the management of diverticular bleeding include:

• The use of the BLEED classification system to triage patients into high and low risk of adverse in-hospital outcome 1
• The importance of correcting coagulopathy and discontinuing anticoagulants and NSAIDs when possible 1
• The role of endoscopic interventions, such as clipping, thermal coagulation, or epinephrine injection, in controlling bleeding 1
• The use of angiographic embolization, including liquid embolic agents such as NBCA or ethylene-vinyl alcohol copolymer, for persistent or recurrent bleeding 1
• The need for close follow-up and consideration of preventive measures to reduce the risk of recurrence 1.

Overall, the management of diverticular bleeding requires a multidisciplinary approach, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the Research

Management Plan for Diverticular Bleeding

The management plan for diverticular bleeding typically involves the following steps:

• Initial resuscitative measures, including airway maintenance, oxygen supplementation, and measurement of hemoglobin and hematocrit levels 2
• Intravenous fluid resuscitation with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells if necessary 2
• Diagnostic evaluation, with colonoscopy being the recommended first-line investigation 2, 3
• Endoscopic therapeutic maneuvers, such as injection with epinephrine or electrocautery therapy, if the bleeding source is identified 2
• Radionuclide imaging or arteriography if the bleeding source is not identified 2, 3
• Consideration of other therapeutic modalities, such as selective embolization, intra-arterial vasopressin infusion, or surgery, for ongoing diverticular hemorrhage 2, 3

Risk Factors for Re-bleeding

Several risk factors for re-bleeding have been identified, including:

• History of diverticular bleeding 4
• Chronic kidney disease 4
• Failure to identify the bleeding point during colonoscopy 4
• Extravasation on CT scan 4

Prevention of Re-bleeding

There is currently limited evidence on the prevention of diverticular re-bleeding, with no clear dietary or lifestyle interventions, pharmacological treatments, or endoscopic approaches shown to be effective 5

• Further studies are needed to determine the best strategies for preventing diverticular re-bleeding 5
• The timing of resumption of antiplatelet and anticoagulant therapy after an episode of diverticular bleeding also remains to be determined 5

Treatment Outcomes

The treatment outcomes for diverticular bleeding vary, with:

• Approximately 80% of patients experiencing spontaneous resolution of bleeding 2
• Around 50% of patients requiring a blood transfusion 6
• Between 18% and 53% of patients needing emergency surgery 6
• The over-the-scope clip method (OTSC) being a effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures 6