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