What is the management of diverticular bleeding?

Management of Diverticular Bleeding

Patients with diverticular bleeding should undergo diagnostic colonoscopy within 24 hours of presentation, followed by appropriate endoscopic intervention for active bleeding, with angiographic embolization or surgery reserved for cases where endoscopic management fails. 1

Initial Assessment and Stabilization

1. Resuscitation and Hemodynamic Stabilization:

   • Maintain hemoglobin level ≥7 g/dL (target 7-9 g/dL) for most patients 2, 1
   • Consider higher transfusion threshold (>8 g/dL) in patients with cardiovascular disease 2
   • Provide intravenous fluid resuscitation with normal saline or lactated Ringer's solution 3
   • Ensure mean arterial pressure >65 mmHg while avoiding fluid overload 2
   • Correct any coagulopathy, especially in patients on anticoagulants 2, 1

2. Risk Assessment:

   • Evaluate for hemodynamic instability (tachycardia, hypotension)
   • Assess comorbidities that may complicate management
   • Monitor for signs of ongoing bleeding (continued hematochezia, hemodynamic instability)

Diagnostic Approach

1. Colonoscopy:

   • First-line diagnostic and therapeutic modality 1, 3
   • Perform within 24 hours of presentation after rapid bowel preparation 1, 3
   • Allows direct visualization of bleeding source and immediate intervention 1

2. If Colonoscopy is Negative or Not Feasible:

   • CT Angiography: Can detect bleeding at rates of 0.3-1.0 mL/min 1
   • Radionuclide imaging (technetium-99m-tagged red blood cell scan): Useful for intermittent bleeding 3
   • Mesenteric angiography: For active, brisk bleeding 1, 3
   • Video capsule endoscopy: If small bowel bleeding is suspected 1

Therapeutic Management

1. Endoscopic Intervention (First-line therapy):

   • Clipping: Direct placement of hemoclips on bleeding vessel 4, 5
   • Thermal therapy: Contact thermal coagulation for accessible lesions 1, 5
   • Injection therapy: Epinephrine injection or sclerosants 4, 5
   • Band ligation: Effective for recurrent bleeding 1, 4
   • Combination therapy: Epinephrine plus another modality (mechanical or thermal) for better outcomes 1

2. Interventional Radiology (If endoscopic management fails):

   • Angiographic embolization: Technical success rates of 93-100% 1
   • Intra-arterial vasopressin infusion: Alternative to embolization 3
   • Note: 10-50% risk of rebleeding after embolization 1

3. Surgical Management (Last resort):

   • Reserved for cases with:
     • Failed endoscopic and angiographic interventions
     • Hemodynamic instability despite resuscitation
     • Recurrent significant bleeding 6
   • Intraoperative endoscopy may help localize the bleeding site 6
   • Do not proceed to emergency laparotomy without attempting to localize bleeding by radiological and/or endoscopic modalities 1

Management Algorithm

1. Mild Bleeding (Hemodynamically stable):

   • Intravenous fluid replacement
   • Monitor hemoglobin levels
   • Prepare for colonoscopy within 24 hours
   • Correct coagulopathy if present

2. Severe Bleeding (Hemodynamically unstable):

   • Aggressive fluid resuscitation
   • Blood transfusion to maintain Hb ≥7 g/dL
   • Urgent colonoscopy after rapid bowel preparation
   • If bleeding persists or patient remains unstable:
     • Proceed to angiography with embolization
     • Consider surgery if other methods fail

Prevention of Recurrence

• Iron supplementation for patients discharged with anemia 1
• Avoid NSAIDs and other medications that increase bleeding risk
• Consider PPI therapy in patients requiring antiplatelet therapy 1
• Schedule follow-up within 2 weeks of discharge 1

Important Considerations

• Diverticular bleeding resolves spontaneously in approximately 80% of patients 3
• Early rebleeding is common but can be reduced with proper endoscopic therapies 5
• Patients with severe bleeding or significant comorbidities should be admitted to the intensive care unit 3
• For patients on antiplatelet therapy who develop bleeding, continue aspirin without interruption if possible, and temporarily discontinue P2Y12 receptor antagonists 1