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Colonic Diverticular Bleeding
Dr. Stephen Ng
Queen Elizabeth Hospital
Colonic Diverticular Bleeding
One of the commonest cause of acute lower gastrointestinal bleeding
15% of patients with diverticulosis will bleed at some time in their lives
Bleeding is usually abrupt, painless, and large in volume
33% being massive, requiring emergency transfusion
1. Longstreth GF, Am J Gastroenterol 19972. K A Ghassemi, Current Gastroenterology
Reports, 2013
Colonic Diverticulosis
Diverticulum – sac-like protrusion from the wall of intestine
Diverticulosis – anatomical disorder characterized by false diverticula (mucosal protrusion through the muscle wall)
More frequent in elderly and low fiber intake
Geographical variationWestern – 90% distal bowel diseaseAfrica and Asia - predominantly right-colon
involvementHong Kong - 76% prevalence of right-sided
diverticulosis
Pathophysiology
Consistent angioarchitecture of colonic diverticulum
1. Meyers MA, Gastroenterology, 1976
Injurious factors within the lumen of diverticulum
Eccentric thickening of the intima of the vasa rectum and thinning of the media
Segmental weakening of the associated vasa rectum
Overlying mucosa ulcerated
Eccentric rupture of these vessels results in bleeding
1. Meyers MA, Gastroenterology, 1976
Absence of inflammation (diverticulitis) in diverticular bleeding
Right colon is the source of bleeding in 49–90% of patientsWider necks and domes. Vasa recta are therefore exposed over a greater
length to any injurious factors arising from the colon
1. Meyers MA, Gastroenterology, 1976
Risk Factors of Diverticular Bleeding
Non-steroidal anti-inflammatory drug (NSAID)
Steroid
Concomitant atheroscelerosis related diseases (eg. ischemic heart disease, DM, HT, obesity)
Smoking
Presence of bilateral diverticulosis
1. Niikura R, Int J Colorectal Dis. 20122. Strate LL, Dig Dis. 20123. Strate LL, Gastroenterology. 2011
Natural History
70-80% resolve spontaneously
Rebleeding in 25-30%
Third bleed after second episode ~50%
1. McGuire HH, Ann Surg 19942. McGuire HH, Ann Surg 1972
Management Challenges
Usual advanced age and medical comorbidities of patients
Often associated with massive lower GI bleeding
Challenges in localization of bleedingBleeding from diverticulum can occur from anywhere
in the colonOften bleeding is intermittent
Recurrence of diverticular bleeding
What to Do Next???
I: Resuscitation
Airway, Breathing, Circulation
Large-bore IV access with fluid resuscitation
Foley catheter to guide resuscitation
Blood testsComplete blood count, coagulation profile, basic
metabolic panel
Transfusion of blood products
Directed history and physical examination
Proctoscopy to rule out anorectal pathology
Excluding upper GI source of bleeding by nasogastric lavage or upper endoscopy
Differential Diagnosis of Lower GIB
1. T Wilkins, Am Fam Physician 2009
II: Localization and Treatment
Localization Modalities
Diagnostic Therapeutic
Nuclear scintigraphy
✓ ✗
Angiography ✓ ✓
Colonoscopy ✓ ✓
Nuclear Scintigraphy
Purely diagnostic
First introduced in early 1980s
Detect bleeding at a rate of 0.1ml/min
99Tc sulfur colloid scintigraphyHalf life 2-3 minsOnly useful for patients who are actively haemorrhaging
99Tc pertechnetate-tagged red blood cell scintigraphyHalf life in hrsAllow detection of active as well as intermittent bleeding
ProsNot invasive; low complication rateSensitive; Can detect slow or intermittent bleeding
ConsNo therapeutic roleVariable ability of localization
Accurate in 40-60% patient to isolate bleeding to left or right colon
1. Adams JB, Clin Colon Rectal Surg 2009
As a screening test to distinguish which patients with LGIB will benefit from invasive therapyGunderman et al
Increase in dianostic yield from 22 to 53% for mesenteric angiograms preceded by positive red cell scintigram
Ochsner Clinic Positive red cell scan within 2mins had a positive
predictive value of 77% on subsequent mesenteric angiography
Delayed bleeding (>2mins) had 90% negative angiography
1. Gunderman R, J Nucl Med 19982. Ng DA, Dis Colon Rectum 1997
Angiography
Introduced since 1960s
Requires bleeding rate of 0.5ml/min
Pros:Provides anatomic location and diagnosis
Contrast extravasation during arterial phase and intensify and form a rounded shape as the contrast fills the offending diverticulum
1. Adams JB, Clinc Colon Rectal Surg 2009
Allows therapeutic intervention
1.Mesenteric vasopressin infusionFirst described by Baum et al in 1973 Into either IMA or SMACausing colonic wall and arteriolar contraction Immediate success rate 92-100%Early recurrent bleeding 36-40%Major complication rate 0-21%
ABANDON
1. CA Athanasoulis, Am J Surg 1975
2. Mesenteric embolizationFirst described by Bookstein et al in 1974Less complication of bowel ischemia (<10%) with
development of newer microcatheters and thrombotic agents and superselective embolization
Immediate hemorrhagic control rate of 96% prolonged control rate of 81%
1. Adams JB, Clinc Colon Rectal Surg 2009
ConsMust be performed during active bleedingRisks of major complicationsRequires expertise from interventional radiology
departmentFailure rate of embolization 15%
1. Adams JB, Clinc Colon Rectal Surg 2009
CT AngiographyFirst reported in 1997 by Ettorre et al Detect bleeding at rate 0.5ml/minPros:
Faster Safe Precise localization Cause of bleeding Sensitivity 85.2% and specificity 92.1%
Cons Purely diagnostic Further angiography and embolization means double
contrast required and higher risk of nephrotoxicity1. Justin A, Clin Colon Rectal Surg
20042. García-Blázquez V, Eur Radiol
2013
Colonoscopy
Diagnostic and therapeutic
Stigmata of recent haemorrhageActive bleeding from diverticulumNon-bleeding visible vesselAdherent clot
83% of urgent colonoscopy are negative
Increase detection rate byPrior bowel preparation
28.2% versus 12.0%
Colonoscopy performed ≤18 hrs of final hematochezia 40.5% versus 10.5%
1. A Mizuki, Japanese Journal of Gastroenterology, 2013
2. N Schmulewiz, Gastrointestinal Endoscopy, 2003
Superior diagnostic modalityDetection rate of source of bleeding
Colonoscopy – 42% RBC scan and angiography if positive – 22%
Provides multitude of therapeutic options
Treatment to diverticulum with stigmata of recent hemorrhage reduces risk of rebleeding
1. BT Green, The American Journal of Gastroenterology, 2005
Timing of colonoscopyAmerican Society for Gastrointestinal Endoscopy
(ASGE) guidelines recommend early colonoscopy (<24hrs) Shorter length of hospital stay Less blood transfusion required Lower hospitalization costs No difference in mortality
1. U Navaneethan, Gastrointestinal Endoscopy, 2014
Endoscopic treatment optionsEpinephrine injectionElectrocauteryEndoscopic haemostatic clippingEndoscopic band ligation
Epinephrine injectionFour-quadrant submucosal injection of dilute
epinephrine (1:10000)Provides only temporary cessation of haemorrhage
with significant risk of early rebleeding (38%)As combination therapy
Electrocautery risk of full-thickness thermal injury
-> high risk of perforation
1. RS Bloomfeld, The American Journal of Gastroenterology, 2001
2. DM Jensen, The New England Journal of Medicine, 2000
Endoscopic haemostatic clippingDirect clipping of vessel is superior to clipping of the
entire diverticular orifice (reefing method)Lower risks compared to coagulation therapyClipping at ascending colon lesions usually
ineffectiveClips fall off after some timeSignificant risk of late recurrent bleeding (18% in
15mths)
1. Y Kominami, Journal of Japanese Society of Gastroenterology, 2012
2. EF Yen, Digestive Diseases and Sciences, 20083. N Ishii, Gastrointestinal Endoscopy, 2012
Endoscopic band ligationEversion of diverticulum with minimal suction, then
deploy band by single-band ligatorFew complicationsBetter visualization of SRHSuperior to haemoclips in
reduction of rebleeding
(6% vs 33%, P = 0.018)
1. T Setoyama, Surgical Endoscopy 2011
2. N Ishii, Digestive Endoscopy, 2010
Summary
1. T Wilkins, Am Fam Physician 2009
Surgery
Indications:Persistent haemodynamic instabilityTransfusion of ≥6 units of packed red blood cells in
24hrsFailed angiographic or endoscopic treatment
High morbidity and mortality
1. Maykel JA, Clinc Colon Rectal Surg 2004
Successful pre-op localization1. Segmental resection
Morbidity 8.6%; rebleeding 0-14%
Without localization1. Total abdominal colectomy
Morbidity 40%; Mortality rate 30%; rebleeding <1%
2. “Blind” segmental resection Morbidity 83%; Mortality 12-50%; rebleeding 42-63%
Every effort should be made to localize site of bleeding
1. Parkes BM, Am Surg 1993
Therapeutic Barium Enema
First reported in 1970
MechanismUnknownPotential factors
Tamponade of bleeding vessel through physical pressure by the barium solution
Direct hemostatic effect of barium sulfate
1. Adam JT, Arch Surg. 1970
Controversies
AgainstHinders further diagnostics (colonoscopy, abdominal
CT)
ForLow rate of SRH identification in colonoscopyComplications associated with enema are rareMay prevent from surgery, which has higher
complications and mortality
1. Adam JT, Arch Surg. 19702. Kenig J, PJS. 2013
Limitations:No large, prospective, and randomized studies Small sample sizeNo standardization on barium concentration
1. Kenig J, PJS. 2013
III: Prevention
Natural History
70-80% resolve spontaneously
Rebleeding in 25-30%
Third bleed after second episode ~50%
1. McGuire HH, Ann Surg 19942. McGuire HH, Ann Surg 1972
Lifestyle Modification
Diets high in fruit and vegetable fiberHealth Professional Follow-up Study (1998)
Prospective study 51,529 US male over 6 years Higher dietary fiber intake associates with lesser
symptomatic diverticulosis (relative risk 0.63, 95%CI 0.44-0.91)
Diverticula do not regress
1. WH Aldoori, J Nutr 1998
Medication
Avoid Nonsteroidal anti-inflammatory drug (NSAID)Known major risk factors (Odd ratio 15)Discontinuing NSAID associates with significant
reduction in recurrence at 12 month (9.4% vs. 77%, P<0.01)
1. Yamada A, Dis Colon Rectum 20082. Nagata N, World J Gastroenterol
2015
Surgery
HistoricallySigmoid myotomy (by Reilly, 1964)
Division of antimesenteric taeniae and underlying circular muscle from the rectosigmoid junction to whatever distance is necessary
Transverse taeniamyotomy (by Hodgson, 1973) Transverse incision at 2cm interval at the two
antimesenteric taeniae from rectosigmoid junction to normal colon proximally
Surgery
Prevent recurrent bleeding
Controversy in optimal time for surgical intervention
May consider after second episode of bleeding
Elective segmental resection for known bleeding source
Barium Impaction Therapy
Protection from intestinal fluids through the long-term presence of barium in the diverticula
1. Nagata N, Ann Surg 2015
Nagata N et alFirst Randomized controlled study Conducted in Japan54 patients with spontaneous cessation of
diverticular bleedingRebleeding at 1 year is lower in the barium group
than conservative (14.8% vs. 42.5%)After adjustment of risk factors, hazard ratio of
rebleeding in the barium group was 0.34 (95% confidence interval, 0.12-0.98)
1. Nagata N, Ann Surg 2015
Conclusion
Prevalence of diverticular disease and bleeding in Eastern countries has increased
Acute bleeding requires initial resuscitation and subsequent localization and haemostasis
Recurrence of bleeding is common and means of prevention should be considered
END