What is the treatment for diverticular bleeding?

Treatment of Diverticular Bleeding

For diverticular bleeding, initiate hemodynamic resuscitation targeting hemoglobin >7 g/dL (7-10 g/dL range), perform urgent colonoscopy within 12-24 hours after rapid bowel preparation, and apply endoscopic hemostasis if a bleeding source is identified—this approach significantly reduces rebleeding compared to conservative management alone. 1, 2

Initial Resuscitation and Stabilization

Hemodynamic Management:

• Establish two large-bore IV access immediately for fluid resuscitation 2
• Transfuse red blood cells to maintain hemoglobin >7 g/dL, targeting 7-10 g/dL range 1
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1
• Monitor hourly urine output targeting >30 mL/hour in severe cases 2

Coagulopathy Correction:

• Reverse anticoagulation in life-threatening hemorrhage 1
• For patients on DOACs with severe bleeding, use targeted reversal agents: andexanet alfa for factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) or idarucizumab for dabigatran 1
• Consider temporarily discontinuing antiplatelet agents during acute bleeding 2

Risk Stratification: Approximately 70-90% of diverticular bleeding stops spontaneously 3, 1. However, severe bleeding is defined by: hemodynamic instability, persistent bleeding after 24 hours, hemoglobin drop ≥2 g/dL, or transfusion requirement 3. These patients require urgent intervention.

Diagnostic Approach

Urgent Colonoscopy (First-Line):

• Perform colonoscopy within 12-24 hours of presentation after hemodynamic stabilization 1, 4
• Administer rapid bowel preparation with 4-6 liters of polyethylene glycol solution over 3-4 hours (may use nasogastric tube) 1, 4
• If bleeding source is in distal colon (known from CT), enema with copious washing may suffice 1
• Use CO2 insufflation to reduce gas explosion risk in poorly prepared colons 1

CT Angiography (When Indicated):

• Obtain contrast-enhanced CT before colonoscopy in hemodynamically unstable patients or when active bleeding is suspected 2, 5
• CT angiography detects bleeding at rates as low as 0.3 mL/min 1
• Extravasation on CT predicts 70% identification rate at urgent colonoscopy (compared to 11% overall) 5
• CT findings guide colonoscopy and increase diagnostic yield 1

Upper Endoscopy Consideration:

• Perform upper endoscopy to exclude upper GI source in 10-15% of patients presenting with severe hematochezia who have an upper GI bleeding source 2, 1

Endoscopic Treatment

Therapeutic Options for Identified Bleeding Diverticula: Multiple endoscopic techniques are available and all show effectiveness in case series 1:

• Endoscopic clipping (through-the-scope or over-the-scope clips)
• Injection therapy with epinephrine (diluted 1:10,000 to 1:20,000)
• Thermal therapies including bipolar coagulation or argon plasma coagulation
• Endoscopic band ligation
• Hemostatic powders

Comparative Effectiveness:

• Endoscopic band ligation shows lower early rebleeding rates (6%) compared to clipping (33%) in one retrospective study, though both achieve 100% immediate hemostasis 1
• However, band ligation requires scope removal, marking with clip, device attachment, and re-intubation, whereas through-the-scope clipping is immediately deliverable 1
• Endoscopic hemostasis significantly reduces rebleeding rates: identification and treatment of bleeding point reduces rebleeding by approximately 80% 5

Critical Point: Endoscopic therapy is strongly recommended when active bleeding or stigmata of recent hemorrhage (visible vessel, adherent clot) are identified, as it significantly decreases early and late rebleeding 3

Angiographic Intervention

When to Consider Angiography:

• Failed endoscopic visualization or treatment 1
• Ongoing severe bleeding with hemodynamic instability 2
• Requires bleeding rate ≥0.5-1.0 mL/min for detection 1, 2

Embolization Technique:

• Technical success rates: 93-100% regardless of embolic agent used 1
• Agents include platinum coils, N-butyl cyanoacrylate, or polyvinyl alcohol particles 1
• Major complication: Bowel ischemia occurs in 7-24% of cases 1
• Short-term rebleeding risk: 10-50% 1

Important Caveat: Empirical embolization without documented extravasation carries higher mortality (31% vs 9% with documented extravasation) and should be avoided except in exceptional circumstances 1

Surgical Management

Indications for Surgery:

• Ongoing bleeding despite endoscopic and angiographic interventions 1, 3
• Recurrent severe diverticular bleeding episodes 3
• Hemodynamic instability refractory to resuscitation 1

Critical Principle: No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 1. Blind segmental resection carries mortality rates of 30-57% and rebleeding rates up to 42%, compared to 5-10% mortality with localized resection 1.

Surgical Options:

• Segmental colectomy (preferred when bleeding source is localized): mortality 5-10%, rebleeding 14% at 1 year 1
• Total abdominal colectomy (when source cannot be localized): mortality 33%, but no rebleeding 1

Risk Factors for Rebleeding

Patients with the following factors have increased rebleeding risk and warrant closer monitoring 5:

• History of prior diverticular bleeding (OR 2.1)
• Chronic kidney disease (OR 2.3)
• Failure to identify and treat bleeding point (OR 5.0 for rebleeding)

Rebleeding Rates:

• After conservative management alone: 43% 6
• After endoscopic hemostasis: 9-25% at 1-4 years 1, 5
• After surgical resection: 0% 6

Management Algorithm Summary

1. Immediate resuscitation: Large-bore IV access, transfuse to Hb >7 g/dL, correct coagulopathy
2. Risk stratification: Identify severe bleeding (instability, persistent bleeding >24h, Hb drop ≥2 g/dL, transfusion need)
3. CT angiography if hemodynamically unstable or high suspicion of active bleeding
4. Urgent colonoscopy within 12-24 hours after rapid bowel prep
5. Endoscopic hemostasis if bleeding source identified (reduces rebleeding by 80%)
6. Angiographic embolization if endoscopy fails and active extravasation documented
7. Surgery only after failed interventional approaches, with every effort to localize source preoperatively

Common Pitfalls to Avoid

• Inadequate bowel preparation leading to poor colonoscopic visualization and missed bleeding sources 2
• Proceeding to blind surgical resection without localization attempts—this increases mortality from 5-10% to 30-57% 1
• Over-transfusion beyond hemoglobin targets, which wastes resources without improving outcomes 1
• Empirical angiographic embolization without documented extravasation, which carries 31% mortality versus 9% with documented bleeding 1
• Delaying colonoscopy beyond 24-48 hours, which reduces diagnostic yield and therapeutic success 4, 3