How is bleeding from rectosigmoid diverticular disease managed?

Management of Bleeding from Rectosigmoid Diverticular Disease

Bleeding from rectosigmoid diverticular disease should be managed with a stepwise approach beginning with hemodynamic assessment, followed by colonoscopy as the first-line diagnostic and therapeutic intervention in stable patients, with angiography or surgery reserved for refractory cases. 1

Initial Assessment and Stabilization

• Hemodynamic assessment: Calculate shock index (heart rate divided by systolic blood pressure) - a score >1 indicates an unstable patient requiring immediate management 1
• Resuscitation measures:
  • Airway maintenance and oxygen supplementation
  • Intravenous fluid resuscitation with normal saline or lactated Ringer's solution
  • Blood transfusion with a restrictive threshold (Hb trigger 70 g/L, target 70-90 g/L)
  • Higher transfusion threshold (Hb trigger 80 g/L, target 100 g/L) for patients with cardiovascular disease 1

Diagnostic Approach

1. Upper GI endoscopy should be performed first, even with suspected lower GI bleeding, as 10-15% of severe hematochezia cases have upper GI sources 1

2. Colonoscopy:

   • Timing: Perform within 12-48 hours of presentation 2
   • Preparation: Rapid bowel preparation with polyethylene glycol solutions
   • Benefits: Highest diagnostic yield and allows for therapeutic intervention 1

3. If bleeding source not identified or colonoscopy not feasible:

   • CT Angiography: High sensitivity (80-90%) for detecting active bleeding at rates as low as 0.3-1.0 mL/min 1
   • Radionuclide scanning (technetium-99m-tagged red blood cell scan): Most sensitive for intermittent or slow bleeding 2

Therapeutic Interventions

Endoscopic Management (First-line)

• Endoscopic therapy when stigmata of recent hemorrhage are identified:
  • Injection with epinephrine
  • Hemoclips application
  • Thermal therapy/electrocautery 2, 3

Angiographic Management (Second-line)

• Indications: Failed endoscopic therapy or ongoing bleeding
• Options:
  • Selective embolization (achieves immediate hemostasis in 40-100% of cases with 15% rebleeding rate)
  • Intra-arterial vasopressin infusion 4, 5
• Caution: Risk of bowel ischemia (1-4%) following embolization 4

Surgical Management (Third-line)

• Indications:
  • Hemodynamic instability despite resuscitation
  • Failed endoscopic and angiographic interventions
  • Requirement for >6 units of blood
  • Recurrent severe bleeding 1, 5
• Procedures:
  • Partial colectomy if bleeding site localized
  • Subtotal colectomy if localization not possible 5
  • Consider intraoperative colonoscopy to identify bleeding source 6

Management of Anticoagulant and Antiplatelet Therapy

• Immediate interruption of both anticoagulant and antiplatelet therapy is recommended
• Reversal agents should be considered only for life-threatening hemorrhage
• Consultation with cardiology regarding timing of medication resumption, especially for patients with coronary stents 1

Disposition and Follow-up

• Admission criteria: All patients with clinically suspected diverticular hemorrhage should be admitted 7
• Level of care: ICU admission for severe bleeding or significant comorbidities
• Follow-up: Outpatient follow-up within 2 weeks if discharged, with laboratory tests including CBC and coagulation profile 1

Key Points and Pitfalls

• Diverticular bleeding resolves spontaneously in approximately 80-90% of patients 2, 7
• Colonoscopy without purging can still achieve correct visualization of the bleeding point in emergency settings 3
• Failure to perform upper endoscopy may miss the true source of bleeding in 10-15% of cases 1
• Delaying intervention in unstable patients can lead to increased morbidity and mortality