Charalampos Pilichos, Department of Digestive Endoscopy, Sismanogleion General Hospital, Athens 15126, Greece

Emmanouil Bobotis, Department of Surgery, Sismanogleion General Hospital, Athens 15126, Greece

Author contributions: Pilichos C and Bobotis E contributed equally to this work.

Correspondence to: Pilichos Charalampos, Department of Digestive Endoscopy, Sismanogleion General Hospital, Athens 15126, Greece. hpilichos@hotmail.com

Telephone: +30-210-8234515

Received: December 4, 2007     Revised: January 27, 2008

Abstract

Colonic diverticulosis is one of the most common causes of lower gastrointestinal bleeding. Endoscopy is not only a useful diagnostic tool for localizing the bleeding site, but also a therapeutic modality for its management. To date, haemostatic methods have included adrenaline injection, mechanical clipping, thermal and electrical coagulation or combinations of them. The results of all published data are herein reviewed.

© 2008 WJG. All rights reserved.

Key words: Diverticulosis; Colon; Bleeding; Endoscopy; Therapy

Peer reviewer: Shingo Tsuji, Professor, Department of Internal Medicine and Therapeutics, Osaka University Graduate School of Medicine (A8), 2-2 Yamadaoka, Suita, Osaka 5650871, Japan

Pilichos C, Bobotis E. Role of endoscopy in the management of acute diverticular bleeding. World J Gastroenterol 2008; 14(13): 1981-1983  Available from: URL: http://www.wjgnet.com/1007-9327/14/1981.asp  DOI: http://dx.doi.org/10.3748/wjg.14.1981

Forty percent of lower gastrointestinal bleeding (LGB) is due to colonic divertculae. Inversely, bleeding complicates only 5% of all cases of colonic diverticulosis^[1]. In most of cases, hemorrhage ceases spontaneously; however, in 20% it persists, thus imposing an emergency treatment^[2].

Endoscopic hemostasis is a proven therapy in some indications of LGB, such as in the post-polypectomy bleeding and the post-radiation rectitis^[3,4]. Nevertheless, any attempt of endoscopic treatment presupposes either a certain diagnosis or a strong presumption of the bleeding lesion, which may not always be evident. Since the end of 1980’s, the benefit of an emergency colonoscopy in this setting has been investigated, but yielded contradictory conclusions (Table 1). After adequate bowel preparation urgent colonoscopy is incomplete in 0%-45% of cases and the risk of complications does not exceed 11%. The method allows positive diagnosis in approximately two thirds of cases and hemostasis in one third and may result in a shorter duration of hospitalization^[5-13]. The timing of colonoscopy has little or no impact on the diagnostic yield, but when it is performed early (within 24 h following admission) it seems associated with a better clinical outcome^[12-14].

The criteria proposed by Zuckerman for attributing LGB to diverticulosis are inspired by the Forrest classification of bleeding gastro duodenal ulcers^[15]. They include typical endoscopic stigmata such as active bleeding, visible vessel and adherent clot and presumptive findings, such as presence of fresh blood within one or more bowel segments and diverticular erosions. Using these criteria, a lower bleeding could undoubtedly be attributed to diverticulosis in only 20% of cases. In all other cases, the diverticular origin of bleeding is either presumed indirectly by the absence of any other lesion or considered as incidental^[16].

Endoscopic treatment aims to stop active bleeding, reduce the risk of recurrence, diminish transfusion needs and avoid surgery. To date, haemostatic methods have included adrenaline injection, mechanical clipping, thermal and electrical coagulation or associations of them. All of them are of similar efficacy, but mechanical clipping also offers the theoretical advantage of marking the bleeding site, which might be useful in case of relapse^[17]. Beyond these traditional techniques, Farrell, based on the previous work of Witte et al, has reported 4 cases of diverticular bleeding treated by elastic band ligation and suggested that this might be a promising method not only for the hemostasis, but for diverticular reversion as well^[18,19]. Concerning APC, despite its excellent results in vascular malformations, it has never been tested in the setting of diverticular hemorrhage, to our knowledge.

Apart of three original studies including only one prospective trial, all other published data are limited to some case reports. In the first study, Jensen et al compared 10 endoscopically managed patients with certain diverticular bleeding to 17 non-treated historical controls. Endoscopic treatment included diluted adrenaline injections in cases of active bleeding, bipolar coagulation in cases of visible vessel and association of both methods in cases of an adherent clot. None of the treated patients relapsed during a 30 mo observation period, whereas 9 of the 17 controls (52%) presented a recurrence within 3 years and 6 of them (35%) failed to avoid surgery^[16]. In the study of Bloomfeld, although the haemostatic methodology was similar to the previous study, results were less encouraging. Of 13 patients with active diverticular bleeding endoscopically treated, 5 and 3 presented an early or a late recurrence (up to 35 mo), respectively, thus a success rate of 46%^[20]. Finally, in the most recent study of Smoot et al, endoscopic haemostasis carried out in 7 patients actively bleeding, was proven both effective and free of complications^[14]. The methodology and the results of all relevant studies and reports are presented in Table 2. Summarizing the above data, one could say that out of 63 patients endoscopically managed, 6 (9.5%) presented an early relapse of bleeding and none a method-related complication. However, the long-term efficacy of endoscopic therapies is not demonstrated and randomized trials including larger number of patients are needed to make safe conclusions.

Thus, based on the above data one can conclude that in cases of lower GI bleeding, urgent colonoscopy after an adequate bowel preparation should be attempted. Endoscopic hemostasis might help patients to avoid at least emergency surgery, if a diverticular origin seems certain or highly probable.

REFERENCES

1         Tudor RG, Farmakis N, Keighley MR. National audit of complicated diverticular disease: analysis of index cases. Br J     Surg 1994; 81: 730-732  PubMed

2         McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220:     653-656  PubMed

3         Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. Postpolypectomy lower GI bleeding: descriptive     analysis. Gastrointest Endosc 2000; 51: 690-696  PubMed

4         Canard JM, Vedrenne B, Bors G, Claude P, Bader R, Sondag D. Long term results of treatment of hemorrhagic     radiation proctitis by argon plasma coagulation. Gastroenterol Clin Biol 2003; 27: 455-459  PubMed

5         Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after     purge. Gastroenterology 1988; 95: 1569-1574  PubMed

6         Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of current technology in the diagnosis and     management of lower gastrointestinal hemorrhage. Gastrointest Endosc 1995; 41: 93-98  PubMed

7         Geller A, Mayoral W, Balm R, Geller N, Gostout C. Colonoscopy in acute lower gastrointestinal bleeding [abstract].     Gastrointest Endosc 1997; 45: AB107  

8         Kok KY, Kum CK, Goh PM. Colonoscopic evaluation of severe hematochezia in an Oriental population. Endoscopy 1998;     30: 675-680  PubMed

9         Prakash C, Zuckerman GR, Aliperti G, Walden DT, Royal HD, Willis J-R. Prospective analysis of work-up of acute lower     gastrointestinal bleeding. Can an optimal algorithm be designed? Gastrointest Endosc 1998; 47: AB102  

10      Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am    Surg 1998; 64: 723-728  PubMed

11      Ohyama T, Sakurai Y, Ito M, Daito K, Sezai S, Sato Y. Analysis of urgent colonoscopy for lower gastrointestinal tract    bleeding. Digestion 2000; 61: 189-192  PubMed

12      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  PubMed

13      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  PubMed

14      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  PubMed

15      Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest    Endosc 1998; 48: 606-617  PubMed

16      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  PubMed

17      Elta GH. Urgent colonoscopy for acute lower-GI bleeding. Gastrointest Endosc 2004; 59: 402-408  PubMed

18      Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding colonic diverticula by endoscopic band ligation: an in-vivo    and ex-vivo pilot study. Endoscopy 2003; 35: 823-829  PubMed

19      Witte JT. Band ligation for colonic bleeding: modification of multiband ligating devices for use with a colonoscope.    Gastrointest Endosc 2000; 52: 762-765  PubMed

20      Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol    2001; 96: 2367-2372  PubMed

21      Johnston J, Sones J. Endoscopic heater probe coagulation of the bleeding colonic diverticulum. Gastrointest Endosc    1986; 84: AB168  

22      Bertoni G, Conigliaro R, Ricci E, Mortilla MG, Bedogni G, Fornaciari G. Endoscopic injection hemostasis of colonic    diverticular bleeding: a case report. Endoscopy 1990; 22: 154-155  PubMed

23      Kim YI, Marcon NE. Injection therapy for colonic diverticular bleeding. A case study. J Clin Gastroenterol 1993; 17: 46-  48  PubMed

24      Savides TJ, Jensen DM. Colonoscopic hemostasis for recurrent diverticular hemorrhage associated with a visible    vessel: a report of three cases. Gastrointest Endosc 1994; 40: 70-73  PubMed

25      Foutch PG, Zimmerman K. Diverticular bleeding and the pigmented protuberance (sentinel clot): clinical implications,    histopathological correlation, and results of endoscopic intervention. Am J Gastroenterol 1996; 91: 2589-2593  PubMed

26      Ramirez FC, Johnson DA, Zierer ST, Walker GJ, Sanowski RA. Successful endoscopic hemostasis of bleeding colonic    diverticula with epinephrine injection. Gastrointest Endosc 1996; 43: 167-170  PubMed

27      Hokama A, Uehara T, Nakayoshi T, Uezu Y, Tokuyama K, Kinjo F, Saito A. Utility of endoscopic hemoclipping for    colonic diverticular bleeding. Am J Gastroenterol 1997; 92: 543-546  PubMed

28      Prakash C, Chokshi H, Walden DT, Aliperti G. Endoscopic hemostasis in acute diverticular bleeding. Endoscopy 1999;    31: 460-463  PubMed

29      Cuillerier E, Landi B, Berger A, Barbier JP, Marteau P. Endoscopic treatment of lower intestinal haemorrhage of    diverticular origin. Gastroenterol Clin Biol 2003; 27: 558-559  PubMed

30      Simpson PW, Nguyen MH, Lim JK, Soetikno RM. Use of endoclips in the treatment of massive colonic diverticular    bleeding. Gastrointest Endosc 2004; 59: 433-437  PubMed

            S- Editor  Zhong XY    L- Editor  Rippe RA    E- Editor  Lu W

Reviews	Add
more>>