What is the initial management for a patient with diverticulosis (inflammation of diverticula) and an acute gastrointestinal (GI) bleed?

Initial Management of Diverticulosis with Acute GI Bleeding

For patients with diverticulosis and acute GI bleeding, the initial management should include risk stratification based on hemodynamic stability, followed by appropriate resuscitation and diagnostic procedures to localize the bleeding source, with CT angiography as the first-line imaging for unstable patients and colonoscopy for stable patients. 1

Initial Assessment and Resuscitation

Hemodynamic Assessment

• Stratify patients as unstable (shock index >1) or stable 1
• Place two large-bore venous cannulae (16-18G) for fluid resuscitation
• Start with 1-2 liters of normal saline for initial volume replacement

Blood Transfusion Strategy

• Use restrictive RBC transfusion thresholds:
  • Hemoglobin trigger of 70 g/L with target of 70-90 g/L after transfusion
  • For patients with cardiovascular disease: trigger of 80 g/L with target of 100 g/L 1

Coagulopathy Management

• Interrupt warfarin therapy at presentation
• Reverse anticoagulation with prothrombin complex concentrate and vitamin K in cases of unstable hemorrhage 1
• Consider resuming low molecular weight heparin at 48 hours after hemorrhage control in high thrombotic risk patients 1

Diagnostic Approach

For Hemodynamically Unstable Patients (Shock Index >1)

1. CT angiography is the first-line imaging modality

   • Provides fastest and least invasive means to localize bleeding site 1
   • Should be performed immediately after initial resuscitation

2. If CT angiography is negative but bleeding is suspected:

   • Perform immediate upper endoscopy to exclude upper GI source 1
   • Up to 15% of apparent lower GI bleeding cases may have an upper GI source 2

For Hemodynamically Stable Patients

1. Colonoscopy is the recommended first-line investigation

   • Should be performed within 24 hours after adequate bowel preparation 1, 3
   • Allows for both diagnosis and potential therapeutic intervention 4, 5

2. If colonoscopy is inconclusive or not feasible:

   • Consider radionuclide scanning (technetium-99m-tagged red blood cell scan) 5
   • Follow with angiography if bleeding persists 5

Therapeutic Interventions

Endoscopic Management

• For identified diverticular bleeding with high-risk stigmata:
  • Active bleeding
  • Non-bleeding visible vessel
  • Adherent clot 3
• Endoscopic treatment options:
  • Epinephrine injection
  • Thermal coagulation
  • Mechanical therapy (hemoclips)
  • Over-the-scope clip method for severe or recurrent bleeding 6, 4

Interventional Radiology

• If endoscopic therapy fails or is not feasible:
  • Proceed to catheter angiography with embolization
  • Should be performed within 60 minutes of positive CTA in unstable patients 1
  • Technical success rates range from 73% to 100% 1

Surgical Management

• Surgery should be considered only after failure of endoscopic and radiological interventions 1
• Indications for surgery:
  • Life-threatening bleeding with persistent hemodynamic instability
  • Failed endoscopic or angiographic interventions 1, 7
  • Significant recurrent bleeding 1

Follow-up and Prevention

• Avoid NSAIDs in patients with history of diverticular bleeding 3
• For patients on antiplatelets for secondary cardiovascular prevention:
  • Do not discontinue aspirin therapy permanently 3
  • Timing of resumption depends on bleeding severity and adequacy of hemostasis

Common Pitfalls to Avoid

• Delaying CT angiography in unstable patients
• Failing to consider upper GI source in apparent lower GI bleeding
• Inadequate initial resuscitation before interventions
• Neglecting to correct coagulopathy
• Proceeding directly to surgery without attempting endoscopic or radiological interventions first

Diverticular bleeding is the most common cause of lower GI bleeding, accounting for approximately 30% of cases 1, 6. While 80% of cases resolve spontaneously 5, proper management is essential to reduce morbidity and mortality, particularly in elderly patients and those on anticoagulants or antiplatelets who are at higher risk 6.