Background/Summary: Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is “preferable.” Key Messages: This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.

Keywords:
Colonic diverticular hemorrhage, Bowel preparation, Colonoscopy, CT angiography
1.
Fong SS, Tan EY, Foo A, Sim R, Cheong DM: The changing trend of diverticular disease in a developing nation. Colorectal Dis 2011; 13: 312–316.
2.
Gostout CJ, Wang KK, Ahlquist DA, Clain JE, Hughes RW, Larson MV, Petersen BT, Schroeder KW, Tremaine WJ, Viggiano TR, et al: Acute gastrointestinal bleeding. Experience of a specialized management team. J Clin Gastroenterol 1992; 14: 260–267.
3.
Browder W, Cerise EJ, Litwin MS: Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986; 204: 530–536.
4.
Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, Sugawa C: Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery 2009; 146: 600–606.
5.
Niikura R, Nagata N, Shimbo T, Aoki T, Yamada A, Hirata Y, Sekine K, Okubo H, Watanabe K, Sakurai T, Yokoi C, Mizokami M, Yanase M, Akiyama J, Koike K, Uemura N: Natural history of bleeding risk in colonic diverticulosis patients: a long-term colonoscopy-based cohort study. Aliment Pharmacol Ther 2015; 41: 888–894.
6.
Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL: Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 2009; 136: 115–122.e1.
7.
Meyers MA, Alonso DR, Gray GF, Baer JW: Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976; 71: 577–583.
8.
Casarella WJ, Kanter IE, Seaman WB: Right-sided colonic diverticula as a cause of acute rectal hemorrhage. N Engl J Med 1972; 286: 450–453.
9.
Wong SK, Ho YH, Leong AP, Seow-Choen F: Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40: 344–348.
10.
Rege RV, Nahrwold DL: Diverticular disease. Curr Probl Surg 1989; 26: 133–189.
11.
Imbembo AL, Baily RW: Diverticular disease of the colon; in Sabiston DC Jr (ed): Textbook of Surgery, ed 14. Philadelphia, Churchill Livingstone, 1992, p 910.
12.
McGuire HH Jr: Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220: 653–656.
13.
Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, Leung J, Jowell P: Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100: 2395–2402.
14.
ASGE Standards of Practice Committee, Pasha SF, Shergill A, Acosta RD, Chandrasekhara V, Chathadi KV, Early D, Evans JA, Fisher D, Fonkalsrud L, Hwang JH, Khashab MA, Lightdale JR, Muthusamy VR, Saltzman JR, Cash BD: The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79: 875–885.
15.
Strate LL, Gralnek IM: ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111: 755.
16.
Jensen DM, Machicado GA: Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988; 95: 1569–1574.
17.
Rossini FP, Ferrari A, Spandre M, Cavallero M, Gemme C, Loverci C, Bertone A, Pinna Pintor M: Emergency colonoscopy. World J Surg 1989; 13: 190–192.
18.
Caos A, Benner KG, Manier J, McCarthy DM, Blessing LD, Katon RM, Gogel HK: Colonoscopy after Golytely preparation in acute rectal bleeding. J Clin Gastroenterol 1986; 8: 46–49.
19.
Forde KA: Colonoscopy in acute rectal bleeding. Gastrointest Endosc 1981; 27: 219–220.
20.
Jensen DM, Machicado GA, Jutabha R, Kovacs TO: Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342: 78–82.
21.
Mizuki A, Tatemichi M, Hatogai K, Iwasaki H, Izumiya M, Maeda N, Nakazawa A, et al: Timely colonoscopy leads to faster identification of bleeding diverticulum (in Japanese). Nihon Shokakibyo Gakkai Zasshi 2013; 110: 1927–1933.
22.
Nagata N, Niikura R, Shimbo T, Ishizuka N, Yamano K, Mizuguchi K, Akiyama J, Yanase M, Mizokami M, Uemura N: High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding: a randomized controlled trial. Ann Surg 2015; 261: 269–275.
23.
Chaudhry V, Hyser MJ, Gracias VH, Gau FC: Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998; 64: 723–728.
24.
Schmulewitz N, Fisher DA, Rockey DC: Early colonoscopy for acute lower GI bleeding predicts shorter hospital stay: a retrospective study of experience in a single center. Gastrointest Endosc 2003; 58: 841–846.
25.
Strate LL, Syngal S: Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleeding. Am J Gastroenterol 2003; 98: 317–322.
26.
Repaka A, Atkinson MR, Faulx AL, Isenberg GA, Cooper GS, Chak A, Wong RC: Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study. Gastrointest Endosc 2012; 76: 367–373.
27.
Strate LL, Naumann CR: The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010; 8: 333–343.
28.
Jensen DM, Machicado GA: Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding. Routine outcomes and cost analysis. Gastrointest Endosc Clin N Am 1997; 7: 477–498.
29.
Smoot RL, Gostout CJ, Rajan E, Pardi DS, Schleck CD, Harmsen WS, Zinsmeister AR, Nolte T, Melton LJ: Is early colonoscopy after admission for acute diverticular bleeding needed? Am J Gastroenterol 2003; 98: 1996–1999.
30.
Strate LL, Syngal S: Predictors of utilization of early colonoscopy vs radiography for severe lower intestinal bleeding. Gastrointest Endosc 2005; 61: 46–52.
31.
Laine L, Shah A: Randomized trial of urgent vs elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105: 2636–2641.
32.
Lewis M: Bleeding colonic diverticula. J Clin Gastroenterol 2008; 42: 1156–1158.
33.
Schwab SJ, Hlatky MA, Pieper KS, Davidson CJ, Morris KG, Skelton TN, Bashore TM: Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic radiographic contrast agent. N Engl J Med 1989; 320: 149.
34.
Laing CJ, Tobias T, Rosenblum DI, Banker WL, Tseng L, Tamarkin SW: Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics 2007; 27: 1055–1070.
35.
Kominami Y, Ohe H, Kobayashi S, Uchida D, Numata N, Matsushita H, Morimoto Y, Nakarai A, Nanba S, Ohta S, Ogawa T, Kurome M, Ueki T, Nakagawa M, Araki Y, Mizuno M: Dynamic computed tomography is useful for the diagnosis and colonoscopic treatment of colonic diverticular bleeding (in Japanese). Nihon Shokakibyo Gakkai Zasshi 2011; 108: 223–230.
36.
Obana T, Fujita N, Sugita R, Hirasawa D, Su-gawara T, Harada Y, Oohira T, Maeda Y, Koike Y, Suzuki K, Yamagata T, Kusaka J, Masu K: Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding. Dig Dis Sci 2013; 58: 1985–1990.
37.
Thoeni RF, Cello JP: CT imaging of colitis. Radiology 2006; 240: 623–638.
38.
Wolff JH, Rubin A, Potter JD, Lattimore W, Resnick MB, Murphy BL, Moss SF: Clinical significance of colonoscopic findings associated with colonic thickening on computed tomography: is colonoscopy warranted when thickening is detected? J Clin Gastroenterol 2008; 42: 472–475.
39.
Yoon W, Jeong YY, Shin SS, Lim HS, Song SG, Jang NG, et al: Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 2006; 239: 160–167.
40.
Nakatsu S, Yasuda H, Maehata T, Nomoto M, Ohinata N, Hosoya K, Ishigooka S, Ozawa S, Ikeda Y, Sato Y, Suzuki M, Kiyokawa H, Yamamoto H, Itoh F: Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med 2015; 54: 553–558.
41.
Hjern F, Jonas E, Holmström B, Josephson T, Mellgren A, Johansson C: CT colonography versus colonoscopy in the follow-up of patients after diverticulitis – a prospective, comparative study. Clin Radiol 2007; 62: 645–650.
42.
Scheffel H, Pfammatter T, Wildi S, Bauerfeind P, Marincek B, Alkadhi H: Acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row CT. Eur Radiol 2007; 17: 1555–1565.
43.
Loffroy R, Cercueil JP, Guiu B, Krausé D: Detection and localization of acute lower gastrointestinal bleeding prior to therapeutic endovascular embolization: a challenge! Am J Gastroenterol 2009; 104: 3108–3109; author reply 3109–3110.
44.
Jairath V, Hearnshaw S, Brunskill SJ, Doree C, Hopewell S, Hyde C, Travis S, Murphy MF: Red cell transfusion for the management of upper gastrointestinal haemorrhage. Coch-rane Database Syst Rev 2010; 9:CD006613.
45.
Villanueva C, Colomo A, Bosch A: Transfusion for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368: 1362–1363.
46.
Jairath V, Kahan BC, Stanworth SJ, Logan RF, Hearnshaw SA, Travis SP, Palmer KR, Murphy MF: Prevalence, management, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding in the United Kingdom. Transfusion 2013; 53: 1069–1076.
47.
Wolf AT, Wasan SK, Saltzman JR: Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol 2007; 102: 290–296.
48.
Siegal DM: Managing target-specific oral anticoagulant associated bleeding including an update on pharmacological reversal agents. J Thromb Thrombolysis 2015; 39: 395–402.
49.
Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al; PROPPR Study Group: Transfusion of plasma, platelets, and red blood cells in a 1: 1: 1 versus a 1: 1: 2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015; 313: 471–482.
50.
Baron TH, Kamath PS, McBane RD: New anticoagulant and antiplatelet agents: a primer for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12: 187–195.
51.
ASGE Standards of Practice Committee, Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, Eloubeidi MA, et al: The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83: 3–16.
52.
Niikura R, Nagata N, Aoki T, et al: Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. J Clin Gastroentrol 2015; 49:e24–e30.
53.
Kaltenbach T, Watson R, Shah J, Friedland S, Sato T, Shergill A, McQuaid K, Soetikno R: Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol 2012; 10: 131–137.
54.
Bloomfeld RS, Rockey DC, Shetzline MA: Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol 2001; 96: 2367–2372.
55.
Kominami Y, Ohe H, Kobayashi S, Higashi R, Uchida D, Morimoto Y, Nakarai A, Numata N, Hirao K, Ogawa T, Ueki T, Nakagawa M, Araki Y, Mizuno M, Chayama K: Classification of the bleeding pattern in colonic diverticulum is useful to predict the risk of bleeding or re-bleeding after endoscopic treatment (in Japanese). Nihon Shokakibyo Gakkai Zasshi 2012; 109: 393–399.
56.
Setoyama T, Ishii N, Fujita Y: Endoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25: 3574–3578.
57.
Ishii N, Setoyama T, Deshpande GA, Omata F, Matsuda M, Suzuki S, Uemura M, Iizuka Y, Fukuda K, Suzuki K, Fujita Y: Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382–387.
© 2018 S. Karger AG, Basel
2018
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.