What is the management approach for a patient with a history of diverticulitis presenting with hematochezia (blood in stool)?

Management of Diverticulitis with Hematochezia

For patients with a history of diverticulitis presenting with hematochezia, urgent colonoscopy within 24 hours is recommended for diagnosis and potential endoscopic treatment, followed by appropriate medical management based on findings. 1, 2

Initial Assessment and Management

Immediate Steps

• Assess hemodynamic stability (blood pressure, heart rate)
• Maintain hemoglobin level >7 g/dL during resuscitation 1
• Maintain mean arterial pressure >65 mmHg without fluid overload 1
• Obtain CT scan with IV contrast to:
  • Confirm active bleeding
  • Rule out complications of diverticulitis
  • Assess disease severity 3

Diagnostic Approach

1. Urgent colonoscopy (within 24 hours) if patient is stable 1, 2

   • Allows direct visualization of bleeding source
   • Enables therapeutic intervention
   • Can identify definite signs of diverticular hemorrhage:
     • Active bleeding
     • Nonbleeding visible vessels
     • Adherent clots 2

2. Upper endoscopy should be considered if:

   • Clear diagnosis of bleeding source is not possible
   • Up to 15% of patients with serious hematochezia may have an upper GI source 1

Treatment Based on Findings

For Active Diverticular Bleeding

1. Endoscopic treatment options:

   • Epinephrine injections
   • Bipolar coagulation
   • Endoscopic band ligation 2, 4

   Note: Endoscopic treatment can prevent recurrent bleeding and decrease need for surgery. In one study, all patients with definite diverticular hemorrhage treated endoscopically avoided surgery and had no recurrent bleeding 2

2. If endoscopic treatment fails:

   • Consider angiographic embolization
   • Surgical intervention (hemicolectomy) for persistent bleeding 2, 5

For Diverticulitis Without Active Bleeding

1. Medical management:

   • Clear liquid diet during acute phase, advancing as symptoms improve 1, 3
   • Broad-spectrum antibiotics (7-day course) 3
     • First-line: Piperacillin/tazobactam 4g/0.5g q6h
     • Alternative: Ertapenem 1g q24h (if concern for ESBL-producing organisms)

2. For complicated diverticulitis:

   • Small abscesses: Antibiotic therapy alone for 7 days
   • Large abscesses: Percutaneous drainage plus antibiotics 3

Prevention of Recurrence

Dietary Recommendations

• High-fiber diet (25-35 grams daily) 3
• Psyllium fiber supplements (15g daily) can augment dietary intake 3
• No need to avoid nuts, seeds, corn, or popcorn 1, 3

Lifestyle Modifications

• Regular vigorous physical activity 1, 3
• Maintain normal BMI 1, 3
• Avoid smoking 1
• Limit non-aspirin NSAIDs and opioid analgesics 1, 3

Medications to Avoid

• 5-aminosalicylic acid, probiotics, or rifaximin are not recommended for prevention of recurrent diverticulitis 1
• NSAIDs increase risk of complications 3

Follow-up Care

• Colonoscopy 6-8 weeks after resolution of acute symptoms if not performed within the past year 3
• Earlier colonoscopy if alarm symptoms are present (change in stool caliber, iron deficiency anemia, weight loss) 1
• Monitor for recurrent symptoms, as approximately 20% of patients have recurrent episodes within 10 years 1

Important Considerations

• Right-sided colonic diverticular disease can also be a source of lower GI bleeding 5
• Complications from diverticulitis occur more commonly with first episode than with subsequent episodes 1
• Patients should be educated that approximately 50% of the risk for diverticulitis is attributable to genetic factors 1
• Endoscopic band ligation for diverticular hemorrhage may rarely lead to diverticulitis as a complication 4