What is the treatment for acute diverticular bleed during diverticulitis?

From the Guidelines

The treatment for acute diverticular bleeding during diverticulitis should prioritize a conservative management approach, as approximately 75% of episodes due to diverticulosis stop spontaneously, especially in patients requiring transfusions of <4 units of blood over a 24-hour period 1.

Initial Management

The initial management of acute diverticular bleeding during diverticulitis involves hemodynamic stabilization with intravenous fluids and blood transfusions if necessary. This approach is crucial in preventing shock and ensuring the patient's vital signs are stable.

Diagnostic and Therapeutic Interventions

For active bleeding, colonoscopy is considered a first-line diagnostic and therapeutic intervention, allowing for direct visualization and potential endoscopic treatment such as epinephrine injection, thermal coagulation, or clip placement. If colonoscopy fails to control bleeding, angiography with embolization may be performed, where interventional radiologists can identify and block the bleeding vessel, as discussed in the management of lower gastrointestinal tract bleeding 1.

Surgical Intervention

For severe, persistent bleeding unresponsive to these measures, surgical intervention may be required, ranging from segmental colectomy to more extensive resection depending on the location and severity of bleeding. However, this should be considered a last resort due to the associated morbidity and mortality.

Antibiotic Treatment

Concurrently, antibiotics are administered to treat the underlying diverticulitis, typically including coverage for gram-negative and anaerobic bacteria. The choice of antibiotics, such as a combination of ciprofloxacin and metronidazole, should be based on local resistance patterns and patient-specific factors.

Dietary Management

Bowel rest is recommended during acute bleeding, progressing from clear liquids to a low-residue diet as bleeding subsides. This approach helps in reducing the risk of rebleeding and complications associated with diverticulitis.

Key Considerations

• The management of acute diverticular bleeding during diverticulitis should be individualized based on the patient's clinical presentation, hemodynamic stability, and response to initial treatments.
• The decision to proceed with more invasive interventions, such as angiography or surgery, should be made on a case-by-case basis, considering the risks and benefits in the context of the patient's overall health status and the severity of the bleeding episode, as outlined in the appropriateness criteria for radiologic management of lower gastrointestinal tract bleeding 1.

From the Research

Treatment of Acute Diverticular Bleed during Diverticulitis

• The treatment for acute diverticular bleed during diverticulitis depends on the severity of the condition and the presence of complications 2.
• For patients with severe and complicated diverticulitis, antibiotics such as ampicillin, gentamicin, metronidazole, piperacillin, and tazobactam are used in clinical practice 3.
• In cases of diverticular hemorrhage, endoscopic therapy such as epinephrine injection and/or multipolar electrocoagulation can be effective in achieving early hemostasis 4.
• However, the value of endoscopic therapy in preventing subsequent diverticular bleeding is unclear 4.
• Hospitalization is recommended for patients with signs of peritonitis or suspected complicated diverticulitis, and inpatient management includes intravenous fluid resuscitation and intravenous antibiotics 2.
• For patients with uncomplicated diverticulitis, outpatient treatment with oral antibiotics can be a viable option, with studies showing similar efficacy and safety to inpatient treatment with intravenous antibiotics 5.

Management of Diverticulitis

• The therapeutic measures for diverticulitis aim to put the intestine 'at rest', resolving the infection, and preventing or limiting complications 3.
• Mesalazine and probiotics are newer therapies that have been developed for the treatment of diverticulitis, with mesalazine showing significant superiority in improving symptoms and preventing recurrence when combined with antibiotics 3.
• Probiotics may also be effective in preventing recurrence of the disease, especially when used with salycilates 3.
• Increased intake of dietary fiber, exercise, cessation of smoking, and weight loss in obese individuals may help prevent recurrences of diverticulitis 2.