What is the management for a patient with diverticulosis (diverticulosis) of the ascending colon presenting with hematochezia (rectal bleeding)?

Management of Ascending Colon Diverticulosis with Hematochezia

For patients with diverticulosis of the ascending colon presenting with hematochezia, urgent colonoscopy within 24 hours is the recommended first-line management approach for both diagnosis and potential therapeutic intervention. 1, 2

Initial Assessment and Stabilization

• Perform immediate hemodynamic assessment including vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 2
• For patients with severe bleeding, maintain hemoglobin level >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 3
• Provide intravenous fluid replacement and blood transfusions as necessary based on hemodynamic status 3
• Correct any coagulopathy before invasive procedures 1

Diagnostic Approach

• Perform urgent colonoscopy within 24 hours of presentation for patients with evidence of ongoing bleeding or high-risk features 3
• Ensure thorough bowel preparation to improve visualization, as poor preparation may lead to incomplete evaluation 1
• Consider upper endoscopy to exclude an upper GI source of bleeding, especially in patients with hemodynamic instability (up to 15% of patients with serious hematochezia have an upper GI source) 3, 2
• For hemodynamically unstable patients or those with suspected active bleeding, CT angiography (CTA) may be performed first to rapidly localize the bleeding site 2

Endoscopic Management

• During colonoscopy, look for definite signs of diverticular hemorrhage including active bleeding, nonbleeding visible vessels, or adherent clots 4
• For identified diverticular bleeding, endoscopic treatment options include:
  • Endoscopic band ligation 5
  • Hemoclip placement on and around visible vessels 6
  • Epinephrine injection or bipolar coagulation 4
• Endoscopic treatment has been shown to prevent recurrent bleeding and decrease the need for surgery 4

Risk Factors and Special Considerations

• Right-sided diverticulosis (including ascending colon) is an independent risk factor for massive recurrent diverticular hemorrhage requiring surgery (OR = 4.6) 7
• Be aware of potential complications after endoscopic band ligation, including colonic diverticulitis 5 and rare cases of delayed perforation 8
• Approximately 75% of episodes of acute lower GIB due to diverticulosis stop spontaneously, especially in patients requiring transfusions of <4 units of blood over a 24-hour period 3

Alternative Diagnostic Steps if Initial Colonoscopy is Inconclusive

• Consider repeat colonoscopy if the initial examination is inconclusive but suggests bleeding around the ileocecal valve 1
• If repeat colonoscopy fails to identify the source, consider radionuclide imaging with [99Tcm] pertechnetate-labeled red blood cells, which can detect active bleeding at rates of 0.1-0.5 mL/min 1
• Angiography should be performed only after positive scintigraphy or in patients with hemodynamic instability and severe unremitting bleeding 1

Surgical Management

• Consider surgical intervention for patients with recurrent or persistent bleeding despite endoscopic therapy, particularly those with right-sided diverticulosis 7
• Lower threshold for surgical intervention should be considered for patients with right colon diverticulosis due to higher risk of recurrent bleeding 7