What is the management approach for bleeding diverticulosis?

Management of Bleeding Diverticulosis

For patients with bleeding diverticulosis, perform urgent colonoscopy within 12-24 hours after hemodynamic stabilization as the first-line diagnostic and therapeutic approach, with endoscopic band ligation preferred over clipping for identified bleeding diverticula. 1, 2

Initial Resuscitation and Stabilization

Immediate hemodynamic assessment is critical as approximately 75% of diverticular bleeding episodes stop spontaneously, particularly in patients requiring <4 units of blood transfusion over 24 hours. 3, 2

• Establish two large-bore IV lines and begin crystalloid resuscitation targeting mean arterial pressure >65 mmHg while avoiding fluid overload 1
• Transfuse red blood cells to maintain hemoglobin >7 g/dL, targeting the 7-10 g/dL range 1
• Monitor hourly urine output targeting >30 mL/hour in severe cases 1
• Obtain complete blood count, coagulation parameters, blood typing and crossmatching 4

Key risk stratification factors include initial heart rate >100/min, systolic blood pressure <115 mmHg, syncope, bleeding during first 4 hours of evaluation, aspirin use, and >2 active comorbidities—these predict severe bleeding requiring intervention. 3

Diagnostic Approach

Colonoscopy is the recommended first-line investigation and should be performed within 12-24 hours of presentation after hemodynamic stabilization. 1, 2, 5

• Administer rapid bowel preparation with 4-6 liters of polyethylene glycol solution over 3-4 hours before colonoscopy 1
• Use CO2 insufflation to reduce gas explosion risk in poorly prepared colons 1
• Consider upper endoscopy first to exclude upper GI source, especially in hemodynamically unstable patients (up to 15% of serious hematochezia originates from upper GI tract) 2

For hemodynamically unstable patients with suspected active bleeding, perform CT angiography first to rapidly localize the bleeding site before attempting colonoscopy. 2, 4

Endoscopic Treatment

When a bleeding diverticulum is identified, endoscopic band ligation is superior to clipping, showing lower early rebleeding rates (6% vs 33%). 1

Available endoscopic options include:

• Endoscopic band ligation (preferred) 1
• Endoscopic clipping 1
• Injection therapy with epinephrine 1, 6
• Thermal therapies (electrocautery) 1, 6
• Hemostatic powders 1

The presence of endoscopic stigmata such as visible vessel or adherent clot within a diverticulum reliably indicates severe hemorrhage requiring intervention, while a clean-based ulcer suggests low rebleeding risk. 3

Angiographic Intervention

Angiography should be considered when endoscopic visualization or treatment fails, or when there is ongoing severe bleeding with hemodynamic instability. 1

• Angiography requires active bleeding at rates >0.5 mL/min to localize a bleeding site 1, 2
• Technical success rates for embolization are 93-100% regardless of embolic agent used 1
• Transcatheter embolization should immediately follow arteriography when extravasation is identified 3
• Use microcatheter for superselective embolization of single vasa recta to minimize ischemic complications 3
• Recurrent bleeding and ischemic complications are less frequent when embolization is distal to a marginal artery with devascularized bowel length of only a few centimeters 3

If radionuclide imaging is performed (detecting bleeding at 0.1-0.5 mL/min), angiography should only follow positive scintigraphy or be reserved for hemodynamically unstable patients with severe unremitting bleeding. 2

Surgical Management

Surgery is indicated for patients with ongoing bleeding despite endoscopic and angiographic interventions, or for those with recurrent severe diverticular bleeding episodes. 1

• Segmental colectomy is the preferred surgical option when the bleeding source is localized, with mortality rate of 5-10% and rebleeding rate of 14% at 1 year 1
• Subtotal colectomy is necessary when localization is not possible preoperatively 5
• Surgery is necessary when associated with hemodynamic instability after failed endoscopic or angiographic interventions 5

Risk Factors for Rebleeding

History of prior diverticular bleeding, chronic kidney disease, and failure to identify and treat the bleeding point are the primary risk factors for rebleeding. 1

Additional considerations:

• Use of anticoagulants and/or antiplatelets increases bleeding risk, particularly in elderly patients 7
• Approximately 18-53% of patients may require emergency surgery if rebleeding occurs 7

Critical Care Considerations

Patients with diverticular bleeding should be admitted to hospitals with 24/7 access to endoscopy, interventional radiology, abdominal surgery, and critical care, as lack of interventional radiology access is independently associated with mortality. 1

Common pitfall: Attempting colonoscopy in hemodynamically unstable patients without adequate resuscitation or in those with ongoing massive bleeding—CT angiography should be performed first in these cases to guide subsequent intervention. 2, 4