What are the differences in managing Diverticular Disease versus Angiodysplasia of the Colon?

Management of Diverticular Disease vs Angiodysplasia of the Colon

Colonoscopy with targeted endoscopic therapy is the primary management approach for both diverticular disease and angiodysplasia, with specific techniques tailored to each condition based on their distinct pathophysiology and bleeding patterns. 1

Diagnostic Differences

Diverticular Disease

• Located predominantly in left colon (75% of cases), though bleeding is often from right-sided diverticula 1
• Presents as outpouchings of intestinal wall that may become inflamed or bleed
• Diagnosis via colonoscopy shows characteristic diverticular openings with possible stigmata of recent hemorrhage

Angiodysplasia

• Most common in cecum and proximal ascending colon (54%), followed by sigmoid (18%) and rectum (14%) 1
• Appears as red, fern-like flat lesions (2-10mm) with ectatic blood vessels radiating from a central feeding vessel
• Often has a pale mucosal halo around the lesion
• Sensitivity of colonoscopy exceeds 80% when colon is examined completely 1

Management Approaches

Angiodysplasia Management

1. Endoscopic Treatment:

   • Contact thermal probes are conventional first-line therapy 1
   • Technique: Cauterize large angiodysplasia from outer margin toward center to obliterate feeder vessels
   • Argon plasma coagulation (non-contact method) is increasingly preferred 1
   • Power settings: 10-16W for bipolar coagulation, 10-15J for heater probe with light pressure 1

2. Special Considerations:

   • Extra caution needed when treating lesions in cecum to avoid perforation 1
   • Narcotic sedation may decrease sensitivity for detecting angiodysplasia by reducing mucosal blood flow 1
   • Consider IV naloxone to enhance visualization of angiodysplasia if meperidine was used for sedation 1

3. For Persistent/Recurrent Bleeding:

   • Transcatheter embolization with success rates of 63-96% 1
   • N-Butyl cyanoacrylate (NBCA) shows high technical success (98%) and clinical success (86%) with low complications (6.1%) 1
   • Ethylene-vinyl alcohol copolymer is effective even in patients with coagulopathy 1

Diverticular Disease Management

1. Acute Bleeding Management:

   • Most cases (86.3%) can be managed with conservative treatment 2
   • For active bleeding, consider injection with 1:10000 adrenaline prior to endoscopic coagulation 1
   • Bipolar coagulation (12-16W) or heater probe (10-15J) with moderate pressure 1
   • Endpoint: flatten visible vessel and achieve coagulum 1

2. Non-Bleeding Management:

   • High-fiber diet to prevent complications and reduce symptom frequency 3, 4
   • Pharmacological options:
     • Rifaximin (poorly absorbable antibiotic) for symptomatic uncomplicated disease 5, 4
     • Mesalazine (anti-inflammatory) for reducing inflammation 4
     • Probiotics to modulate gut microbiota 3, 4

3. Surgical Considerations:

   • Urgent colectomy required in approximately 13.7% of bleeding cases 2
   • Risk factors for requiring urgent colectomy:
     • Presence of comorbidities (especially diabetes and gouty arthritis)
     • High daily maximum blood transfusion requirements 2
   • Consider early elective colectomy in patients with comorbidities to avoid high-risk urgent surgery 2

Key Differences in Management Approach

1. Bleeding Pattern:

   • Angiodysplasia: Often presents with chronic, intermittent bleeding; may cause iron-deficiency anemia
   • Diverticular disease: Can present with acute, sometimes massive bleeding requiring urgent intervention

2. Endoscopic Technique:

   • Angiodysplasia: Light pressure application during cautery, treating from periphery to center
   • Diverticular bleeding: Moderate pressure application, targeting visible vessels directly

3. Recurrence Management:

   • Angiodysplasia: Higher rebleeding rates (45%) compared to diverticular bleeding (15%) 1
   • Diverticular disease: Better response to definitive treatment with lower recurrence rates

4. Angiographic Intervention:

   • Angiodysplasia: Recognized by ectatic slow-emptying veins, vascular tufts, or early-filling small veins 1
   • Diverticular bleeding: Extravasation of contrast into the lumen is required for definitive diagnosis 1

Pitfalls to Avoid

1. For Angiodysplasia:

   • Avoid excessive cautery in cecum due to higher perforation risk
   • Don't rely solely on narcotic-sedated examinations which may mask lesions
   • Consider that rebleeding is common (up to 45%) even after successful initial treatment 1

2. For Diverticular Disease:

   • Don't assume left-sided bleeding based on diverticula location alone
   • Avoid unnecessary antibiotics in uncomplicated disease without inflammatory component 5
   • Don't delay surgical consultation in patients with comorbidities and significant bleeding 2

3. General Pitfalls:

   • Inadequate bowel preparation leading to missed lesions
   • Failure to recognize that 10-15% of presumed lower GI bleeding may actually be from upper GI sources 1
   • Delaying angiography in hemodynamically unstable patients with severe unremitting bleeding 1

By understanding these key differences in management approaches, clinicians can provide targeted, effective care for patients with either diverticular disease or angiodysplasia of the colon.