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Colonic Diverticular Bleeding: Causes, Pathophysiology, and Management

This article explores colonic diverticular bleeding, highlighting common causes, geographical variations, pathophysiology, risk factors, natural history, and management challenges. It also discusses diagnostic modalities, localization techniques, and treatment options.

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Colonic Diverticular Bleeding: Causes, Pathophysiology, and Management

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  1. Colonic Diverticular Bleeding Dr. Stephen Ng Queen Elizabeth Hospital

  2. 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 Longstreth GF, Am J Gastroenterol 1997 K A Ghassemi, Current Gastroenterology Reports, 2013

  3. Colonic Diverticulosis • Diverticulum – sac-like protrusion from the wall of intestine • Diverticulosis – anatomical disorder characterized by false diverticula (mucosal protrusion through the muscle wall)

  4. More frequent in elderly and low fiber intake • Geographical variation • Western – 90% distal bowel disease • Africa and Asia - predominantly right-colon involvement • Hong Kong - 76% prevalence of right-sided diverticulosis

  5. Pathophysiology • Consistent angioarchitecture of colonic diverticulum Meyers MA, Gastroenterology, 1976

  6. 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 Meyers MA, Gastroenterology, 1976

  7. Absence of inflammation (diverticulitis) in diverticular bleeding • Right colon is the source of bleeding in 49–90% of patients • Wider necks and domes. • Vasa recta are therefore exposed over a greater length to any injurious factors arising from the colon Meyers MA, Gastroenterology, 1976

  8. 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 Niikura R, Int J Colorectal Dis. 2012 Strate LL, Dig Dis. 2012 Strate LL, Gastroenterology. 2011

  9. Natural History • 70-80% resolve spontaneously • Rebleeding in 25-30% • Third bleed after second episode ~50% McGuire HH, Ann Surg 1994 McGuire HH, Ann Surg 1972

  10. Management Challenges • Usual advanced age and medical comorbidities of patients • Often associated with massive lower GI bleeding • Challenges in localization of bleeding • Bleeding from diverticulum can occur from anywhere in the colon • Often bleeding is intermittent • Recurrence of diverticular bleeding

  11. What to Do Next???

  12. I: Resuscitation

  13. Airway, Breathing, Circulation • Large-bore IV access with fluid resuscitation • Foley catheter to guide resuscitation • Blood tests • Complete blood count, coagulation profile, basic metabolic panel • Transfusion of blood products

  14. Directed history and physical examination • Proctoscopy to rule out anorectal pathology • Excluding upper GI source of bleeding by nasogastric lavage or upper endoscopy

  15. Differential Diagnosis of Lower GIB T Wilkins, Am Fam Physician 2009

  16. II: Localization and Treatment

  17. Localization Modalities

  18. Nuclear Scintigraphy • Purely diagnostic • First introduced in early 1980s • Detect bleeding at a rate of 0.1ml/min • 99Tc sulfur colloid scintigraphy • Half life 2-3 mins • Only useful for patients who are actively haemorrhaging • 99Tc pertechnetate-tagged red blood cell scintigraphy • Half life in hrs • Allow detection of active as well as intermittent bleeding

  19. Pros • Not invasive; low complication rate • Sensitive; Can detect slow or intermittent bleeding • Cons • No therapeutic role • Variable ability of localization • Accurate in 40-60% patient to isolate bleeding to left or right colon Adams JB, Clin Colon Rectal Surg 2009

  20. As a screening testto distinguish which patients with LGIB will benefit from invasive therapy • Gunderman 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 Gunderman R, J Nucl Med 1998 Ng DA, Dis Colon Rectum 1997

  21. 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 Adams JB, Clinc Colon Rectal Surg 2009

  22. Allows therapeutic intervention • Mesenteric vasopressin infusion • First described by Baum et al in 1973 • Into either IMA or SMA • Causing colonic wall and arteriolar contraction • Immediate success rate 92-100% • Early recurrent bleeding 36-40% • Major complication rate 0-21% ABANDON CA Athanasoulis, Am J Surg 1975

  23. Mesenteric embolization • First described by Bookstein et al in 1974 • Less 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% Adams JB, Clinc Colon Rectal Surg 2009

  24. Cons • Must be performed during active bleeding • Risks of major complications • Requires expertise from interventional radiology department • Failure rate of embolization 15% Adams JB, Clinc Colon Rectal Surg 2009

  25. CT Angiography • First reported in 1997 by Ettorre et al • Detect bleeding at rate 0.5ml/min • Pros: • 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 nephrotoxicity Justin A, Clin Colon Rectal Surg 2004 García-Blázquez V, Eur Radiol 2013

  26. Colonoscopy • Diagnostic and therapeutic • Stigmata of recent haemorrhage • Active bleeding from diverticulum • Non-bleeding visible vessel • Adherent clot

  27. 83% of urgent colonoscopy are negative • Increase detection rate by • Prior bowel preparation • 28.2% versus 12.0% • Colonoscopy performed ≤18 hrs of final hematochezia • 40.5% versus 10.5% A Mizuki, Japanese Journal of Gastroenterology, 2013 N Schmulewiz, Gastrointestinal Endoscopy, 2003

  28. Superior diagnostic modality • Detection 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 BT Green, The American Journal of Gastroenterology, 2005

  29. Timing of colonoscopy • American 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 U Navaneethan, Gastrointestinal Endoscopy, 2014

  30. Endoscopic treatment options • Epinephrine injection • Electrocautery • Endoscopic haemostatic clipping • Endoscopic band ligation

  31. Epinephrine injection • Four-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 RS Bloomfeld, The American Journal of Gastroenterology, 2001 DM Jensen, The New England Journal of Medicine, 2000

  32. Endoscopic haemostatic clipping • Direct clipping of vessel is superior to clipping of the entire diverticular orifice (reefing method) • Lower risks compared to coagulation therapy • Clipping at ascending colon lesions usually ineffective • Clips fall off after some time • Significant risk of late recurrent bleeding (18% in 15mths) Y Kominami, Journal of Japanese Society of Gastroenterology, 2012 EF Yen, Digestive Diseases and Sciences, 2008 N Ishii, Gastrointestinal Endoscopy, 2012

  33. Endoscopic band ligation • Eversion of diverticulum with minimal suction, then deploy band by single-band ligator • Few complications • Better visualization of SRH • Superior to haemoclips in reduction of rebleeding (6% vs 33%, P = 0.018) T Setoyama, Surgical Endoscopy 2011 N Ishii, Digestive Endoscopy, 2010

  34. Summary T Wilkins, Am Fam Physician 2009

  35. Surgery • Indications: • Persistent haemodynamic instability • Transfusion of ≥6 units of packed red blood cells in 24hrs • Failed angiographic or endoscopic treatment • High morbidity and mortality Maykel JA, Clinc Colon Rectal Surg 2004

  36. Successful pre-op localization • Segmental resection • Morbidity 8.6%; rebleeding 0-14% • Without localization • Total abdominal colectomy • Morbidity 40%; Mortality rate 30%; rebleeding <1% • “Blind” segmental resection • Morbidity 83%; Mortality 12-50%; rebleeding 42-63% Every effort should be made to localize site of bleeding Parkes BM, Am Surg 1993

  37. Therapeutic Barium Enema • First reported in 1970 • Mechanism • Unknown • Potential factors • Tamponade of bleeding vessel through physical pressure by the barium solution • Direct hemostatic effect of barium sulfate Adam JT, Arch Surg. 1970

  38. Controversies • Against • Hinders further diagnostics (colonoscopy, abdominal CT) • For • Low rate of SRH identification in colonoscopy • Complications associated with enema are rare • May prevent from surgery, which has higher complications and mortality Adam JT, Arch Surg. 1970 Kenig J, PJS. 2013

  39. Limitations: • No large, prospective, and randomized studies • Small sample size • No standardization on barium concentration Kenig J, PJS. 2013

  40. III: Prevention

  41. Natural History • 70-80% resolve spontaneously • Rebleeding in 25-30% • Third bleed after second episode ~50% McGuire HH, Ann Surg 1994 McGuire HH, Ann Surg 1972

  42. Lifestyle Modification • Diets high in fruit and vegetable fiber • Health 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 WH Aldoori, J Nutr 1998

  43. 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) Yamada A, Dis Colon Rectum 2008 Nagata N, World J Gastroenterol 2015

  44. Surgery • Historically • Sigmoid 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

  45. 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

  46. Barium Impaction Therapy • Protection from intestinal fluids through the long-term presence of barium in the diverticula Nagata N, Ann Surg 2015

  47. Nagata N et al • First Randomized controlled study • Conducted in Japan • 54 patients with spontaneous cessation of diverticular bleeding • Rebleeding 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) Nagata N, Ann Surg 2015

  48. 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

  49. END

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