What is the usual treatment for a diverticular bleed?

From the Guidelines

The usual treatment for a diverticular bleed typically involves initial stabilization with intravenous fluids and blood transfusions if necessary, followed by localization of the bleeding site, with most cases (about 80%) stopping spontaneously without specific intervention 1. For ongoing bleeding, colonoscopy is often performed to identify and potentially treat the source. Endoscopic treatments may include epinephrine injection, thermal coagulation, or clip placement. If endoscopic management fails, angiography with embolization may be used to stop the bleeding by blocking the affected blood vessels, with technical success rates ranging from 73% to 100% and clinical success rates ranging from 63% to 96% 1. In severe cases that don't respond to less invasive measures, surgical intervention may be necessary, which could involve segmental colectomy to remove the affected portion of the colon. After the acute bleeding resolves, patients are typically advised to follow a high-fiber diet (25-30g daily), maintain adequate hydration, and avoid NSAIDs which can increase bleeding risk. Antibiotics are not routinely needed unless there are signs of infection. The goal of treatment is to stop the active bleeding while minimizing the risk of recurrence, which occurs in approximately 25% of patients 1. Some key considerations in the management of diverticular bleeding include the use of embolization agents such as microcoils or liquid embolic agents like N-Butyl cyanoacrylate (NBCA), which have shown high technical and clinical success rates 1. Additionally, the BLEED classification system has been proposed as a means of triaging patients with acute lower gastrointestinal bleeding into those at high risk and those at low risk of adverse in-hospital outcome 1. Overall, the management of diverticular bleeding requires a multidisciplinary approach, with consideration of the patient's overall clinical condition, the severity of the bleeding, and the potential risks and benefits of different treatment options.

From the Research

Treatment Overview

The usual treatment for a diverticular bleed involves a combination of initial resuscitative measures, diagnostic tests, and therapeutic interventions.

• Initial resuscitative measures include airway maintenance, oxygen supplementation, measurement of hemoglobin and hematocrit levels, and blood typing and crossmatching 2.
• Patients may require intravenous fluid resuscitation with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells in the event of ongoing bleeding 2.

Diagnostic Tests

• The recommended initial diagnostic test is colonoscopy, performed within 12 to 48 hours of presentation and after a rapid bowel preparation with polyethylene glycol solutions 2.
• If the bleeding source is not identified by colonoscopy, radionuclide imaging (i.e., technetium-99m-tagged red blood cell scan) should be performed, usually followed by arteriography 2.
• Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding 3.

Therapeutic Interventions

• Endoscopic therapeutic maneuvers can be performed if the bleeding source is identified by colonoscopy, including injection with epinephrine or electrocautery therapy 2.
• Other therapeutic modalities such as selective embolization, intra-arterial vasopressin infusion, or surgery should be considered for ongoing diverticular hemorrhage 2.
• Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions 3.
• Endoscopic treatment with epinephrine and hemoclips is a effective and safe procedure for managing bleeding diverticular vessel 4, 5.