What are the options for endoscopic management of diverticular bleeding?

Endoscopic Management of Diverticular Bleeding

Primary Recommendation

Endoscopic band ligation (EBL) is the preferred first-line endoscopic therapy for diverticular bleeding when the bleeding source is identified, demonstrating superior outcomes with only 6% early rebleeding rates compared to 33% with clipping. 1

Diagnostic Approach and Timing

• Perform urgent colonoscopy within 12-24 hours of presentation after achieving hemodynamic stabilization 1
• Administer rapid bowel preparation with 4-6 liters of polyethylene glycol solution over 3-4 hours before colonoscopy 2, 1
• Use CO2 insufflation during colonoscopy to reduce gas explosion risk in poorly prepared colons, particularly when planning to use diathermy or argon plasma coagulation 2, 1

Endoscopic Treatment Options

First-Line Therapy: Endoscopic Band Ligation

• EBL achieves 100% immediate hemostasis with only 6% rebleeding within 30 days, significantly better than clipping's 33% rebleeding rate 2
• The main limitation is that EBL requires scope removal after marking the diverticulum with a clip, followed by banding device attachment and re-intubation 2

Second-Line Therapy: Endoscopic Clipping

• Through-the-scope clip therapy can be delivered immediately without scope removal, making it practical when rapid intervention is needed 2
• Direct clipping is most effective when the bleeding point is clearly visible and clips can be inserted into the diverticulum 3
• Indirect clipping serves as a third-choice option when direct clipping is not feasible 3

Additional Therapeutic Modalities

The following options are available but lack head-to-head comparative data 2, 1:

• Injection therapy with epinephrine (though should not be used as monotherapy)
• Thermal therapies including bipolar coagulation or argon plasma coagulation
• Endoloops for mechanical hemostasis
• Hemostatic powders as adjunctive therapy
• Over-the-scope clips (OTSC) for severe bleeding or rebleeding after conventional methods 4

Treatment Selection Algorithm

When the bleeding point is visible and accessible:

1. Attempt direct clipping first (median hemostasis time: 9 minutes) 3
2. If direct clipping is not feasible, proceed to EBL (median hemostasis time: 22 minutes) 3
3. If EBL cannot be performed, use indirect clipping 3

When endoscopic visualization or treatment fails:

• Proceed to angiographic embolization (technical success rates: 93-100%) 1
• Angiography requires active bleeding at rates >0.5 mL/min to localize the bleeding site 1

Critical Safety Considerations

• Do not place more than six bands per EBL session to reduce post-banding ulcer hemorrhage risk 5
• Be aware that EBL carries a risk of delayed perforation, though this is rare 3
• Clipping has demonstrated no complications in recent case series 3
• Avoid proceeding to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 2

Facility Requirements

Patients with diverticular bleeding must be admitted to hospitals with 24/7 access to:

• Endoscopy services
• Interventional radiology
• Abdominal surgery
• Critical care facilities

Lack of interventional radiology access is independently associated with increased mortality 1

Risk Factors for Rebleeding

The following factors predict higher rebleeding risk 1:

• History of prior diverticular bleeding
• Chronic kidney disease
• Failure to identify and treat the bleeding point endoscopically

When Endoscopic Therapy Fails

• Consider angiographic embolization when endoscopic treatment is unsuccessful or ongoing severe bleeding with hemodynamic instability persists 1
• Embolization achieves 93-100% technical success but carries 7-24% risk of bowel ischemia 2
• Short-term rebleeding after embolization ranges from 10-50% 2
• Surgical segmental colectomy is reserved for patients with ongoing bleeding despite endoscopic and angiographic interventions, with mortality rates of 5-10% and 14% rebleeding at 1 year 1