What is the management of diverticular (diverticulum-related) bleeding?

Management of Diverticular Bleeding

The management of diverticular bleeding should follow a stepwise approach beginning with resuscitation, followed by diagnostic colonoscopy within 24 hours of presentation, and appropriate endoscopic, angiographic, or surgical intervention based on findings and clinical status. 1

Initial Assessment and Resuscitation

• Hemodynamic Assessment:

  • Calculate shock index (heart rate divided by systolic blood pressure) - a score >1 indicates an unstable patient requiring immediate management 1
  • Assess for signs of ongoing bleeding: continued hematochezia, hemodynamic instability, dropping hemoglobin

• Immediate Interventions:

  • Secure airway and provide oxygen supplementation if needed
  • Establish large-bore IV access for fluid resuscitation
  • Draw blood for CBC, coagulation profile, and type and cross-match
  • Initiate IV fluid resuscitation with normal saline or lactated Ringer's solution
  • Transfuse packed red blood cells if hemoglobin <70 g/L (target 70-100 g/L) 2
  • Consider higher transfusion threshold for patients with cardiovascular disease 2

• Medication Management:

  • Immediately interrupt anticoagulant and antiplatelet therapy 1
  • Consider reversal agents (andexanet alfa for factor Xa inhibitors, idarucizumab for dabigatran) only for life-threatening hemorrhage 2, 1
  • Consult cardiology regarding timing of medication resumption, especially for patients with coronary stents 1

Diagnostic Approach

1. Upper GI Endoscopy:

   • Perform first, even with suspected lower GI bleeding, as 10-15% of severe hematochezia cases have upper GI sources 1

2. Colonoscopy:

   • First-line diagnostic and therapeutic approach for diverticular bleeding 2, 1
   • Perform within 12-48 hours after adequate bowel preparation 3
   • Look for stigmata of recent hemorrhage (active bleeding, visible vessel, adherent clot) 2

3. If Colonoscopy is Negative or Not Feasible:

   • CT Angiography (CTA): High sensitivity (80-90%) for detecting active bleeding at rates as low as 0.3-1.0 mL/min 1
   • Radionuclide imaging (tagged RBC scan): Consider for intermittent or slow bleeding 1
   • Mesenteric angiography: If active bleeding is detected on CTA or RBC scan 1

Therapeutic Interventions

Endoscopic Management

• Endoscopic Options (when source is identified):

  • Injection therapy (epinephrine)
  • Endoscopic clipping (through-the-scope or over-the-scope)
  • Thermal therapies (bipolar coagulation or argon plasma coagulation)
  • Endoscopic band ligation 2

• Technique Considerations:

  • Use CO2 insufflation to reduce gas explosion risk in poorly prepared colons 2
  • Consider marking the diverticulum with a clip if band ligation is planned 2
  • Endoscopic band ligation may have lower early rebleeding rates (6%) compared to clipping (33%) 2

Angiographic Management

• Indications: Active extravasation on angiography or failed endoscopic therapy 1

• Options:

  • Selective embolization using coils, liquid agents (N-butyl cyanoacrylate), or particles (polyvinyl alcohol) 2
  • Intra-arterial vasopressin infusion: Successful in up to 91% of patients with diverticular bleeding, but bleeding recurs in up to 50% after cessation 2

• Outcomes and Risks:

  • Technical success rates: 93-100% 2
  • Rebleeding risk: 10-50% short-term 2
  • Major complication: Bowel ischemia (7-24%) 2

Surgical Management

• Indications:

  • Persistent hemodynamic instability despite resuscitation
  • Transfusion requirement >6 units of blood
  • Failed endoscopic and angiographic interventions
  • Recurrent severe bleeding 1

• Approach:

  • Localize bleeding site before surgery whenever possible 2
  • Segmental colectomy if bleeding site is localized
  • Subtotal colectomy if bleeding site cannot be identified 4

Follow-up and Prevention

• Hospital Discharge Criteria:

  • Hemodynamic stability
  • No evidence of ongoing bleeding
  • Oakland score ≤8 points 1

• Outpatient Management:

  • Follow-up within 2 weeks for endoscopic evaluation if initial workup was incomplete 1
  • Iron supplementation for patients discharged with anemia 1
  • Consider age-appropriate cancer screening 1

• Prevention of Recurrence:

  • Optimize management of comorbidities
  • Judicious use of anticoagulants and antiplatelets
  • Consider prompt resumption of anticoagulation after major bleeding once safe to do so 2

Special Considerations

• Diverticular bleeding resolves spontaneously in approximately 80% of patients 3
• Early rebleeding is common without proper endoscopic therapy 5
• Intraoperative enteroscopy or colonoscopy may be valuable for localizing obscure bleeding sources during surgery 6