Is colonoscopy indicated for diverticular bleed?

From the Guidelines

Colonoscopy is indicated for diverticular bleeding, as it serves both diagnostic and therapeutic purposes, allowing for the identification of the bleeding diverticulum and immediate intervention to achieve hemostasis. This recommendation is based on the evidence from studies published in the Alimentary Pharmacology and Therapeutics journal 1. The diagnostic accuracy of colonoscopy ranges from 72 to 86% in patients with lower gastrointestinal bleeding, making it a valuable tool in the management of diverticular bleeding.

When performing colonoscopy for diverticular bleeding, it is essential to consider the timing and preparation. The procedure should be performed after the patient is hemodynamically stable, ideally within 24-48 hours of presentation. Adequate bowel preparation is crucial to improve visualization and increase diagnostic yield, although this may need to be balanced with the urgency of the situation. In cases of severe, ongoing bleeding, other modalities like CT angiography or nuclear scintigraphy may be performed first to localize the bleeding site.

Some key points to consider when performing colonoscopy for diverticular bleeding include:

• The use of a sulphate or polyethylene glycol (PEG)-based purge to prepare the bowel for colonoscopy, if necessary 1
• The administration of metoclopramide to aid in bowel preparation and prevent nausea 1
• The use of conventional endoscopic treatment, such as contact thermal probes or argon plasma coagulation, to control bleeding from colonic angiodysplasia 1
• The importance of identifying the culprit diverticulum to allow for targeted therapy and prevention of recurrent bleeding episodes, as diverticular bleeding has a high recurrence rate of approximately 25% 1

Overall, colonoscopy is a valuable tool in the management of diverticular bleeding, and its use should be considered in all patients with this condition, taking into account the individual patient's needs and circumstances.

From the Research

Indications for Colonoscopy in Diverticular Bleed

• Colonoscopy is indicated for diverticular bleed as it can be used as a first-line diagnostic and therapeutic approach for patients with severe lower gastrointestinal bleeding 2, 3, 4.
• The procedure can help localize the bleed and deliver therapeutic interventions, such as endoscopic clipping, which can provide hemostasis of active diverticular bleeding 2, 5.
• Colonoscopy is recommended for patients with severe lower gastrointestinal tract bleeding, defined as instability of the circulation, persistent bleeding after 24 hours, drop of the hemoglobin level to ≥ 2 g/dl, or the necessity for transfusion 3.

Benefits of Colonoscopy in Diverticular Bleed

• Colonoscopy can be a safe and effective way to manage diverticular bleeding, with a high success rate in achieving primary hemostasis 2.
• The procedure can reduce the rate of early and late rebleeding, and most cases of recurrent bleeding can be retreated with endoscopic clipping 2, 6.
• Colonoscopy can also help identify patients who are at high risk of rebleeding, such as those with a history of diverticular bleeding or chronic kidney disease 6.

Diagnostic and Therapeutic Algorithms

• Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding 4.
• If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed 4.
• In cases where the bleeding source cannot be identified, intraoperative enteroscopy or surgery may be necessary 5, 4.