First-Line Endoscopic Therapy Effective for Severe Diverticular Bleeding

For acute diverticular bleeding, first-line diagnostic colonoscopy plus endoscopic clipping of actively bleeding diverticulum appears safe and efficacious and also reduces hospital stays, reported Dr. Tonya Kaltenbach and colleagues in the February issue of Clinical Gastroenterology and Hepatology.

The authors wrote that they hope this finding "may aid in the development of a management algorithm for patients with acute severe [lower gastrointestinal bleed]."

Dr. Kaltenbach of the Veterans Affairs Palo Alto (Calif.) Health Care System studied data from 250 patients from her facility as well as the VA San Francisco, who presented with signs and symptoms indicative of acute lower GI bleed over a 5-year period.

The symptoms included tachycardia, systolic hypotension, syncope, nontender abdominal examination, rectal bleeding during the first 4 hours of evaluation, aspirin use, and multiple comorbid illnesses, the investigators said.

According to a protocol developed by the GI section chiefs at these institutions, all patients presenting with lower GI bleed symptoms underwent a rapid purge of the bowel over 3 hours, followed by colonoscopy. The median time to colonoscopy was 24 hours. The procedures were performed by 12 different endoscopists.

"Throughout colonoscope insertion and withdrawal, we systematically irrigated diverticula and surveyed for diverticular stigmata of recent hemorrhage, including active bleeding, nonbleeding visible vessel, and adherent clot, as well as other potential (though unproven) stigmata such as pigmented spot or erosion," wrote the authors.

If diverticular stigmata of recent hemorrhage were discovered, the authors attempted to clip the diverticulum. Other patients were classified as having presumptive diverticular hemorrhage if a diverticulum with a spot or erosion was found and no other bleeding source was identified.

Overall, diverticular bleeding was diagnosed in 64 patients (61 male) with an average age of 76 years. Of these, 24 had diverticular stigmata of recent hemorrhage visible on colonoscopy, including active bleeding in 12 cases, nonbleeding visible vessels in 3 cases, and adherent clots in 9 cases.

Among the active bleeders, "We achieved primary hemostasis with endoscopic clip application in 9 of the 12 (75%)," wrote the authors. Clipping was unsuccessful in the other three patients, two of whom required emergent hemicolectomy; the remaining patient underwent angiographic embolization.

The 21 patients who were successfully clipped had a significantly shorter mean length of hospital stay than the 3 who were not treated successfully with clipping (6.4 days vs. 36.3 days; P less than .001).

"There were no perforations or episodes of early [less than 30 days post-procedure] rebleeding," noted Dr. Kaltenbach and colleagues (Clin. Gastro. Hepatol. 2012 [doi:10.1016/j.cgh.2011.10.029]).

And while the clipped patients had recurrent bleeding rates that were similar to those of their nonbleeding, nonclipped counterparts – about 20% – the 21 clipped patients had longer mean bleeding-free intervals (43 months vs. 15 months, respectively; P less than .001).

Among the patients who did rebleed, all were treated with the protocol again. Four of these patients underwent diverticulum clipping, and had an even shorter length of hospital stay compared to their index bleed, wrote the authors.

Throughout the study period, no patients died due to diverticular bleeding, wrote the authors, nor were there any complications arising from the colonoscopy itself.

"Currently, clinicians are faced with uncertainty as to the optimal diagnostic modality to choose in the management of patients with acute severe lower GI bleed," wrote the authors. "As such, other diagnostic modalities are used – often with high risk and low benefit."

And while the study is limited by its retrospective nature, as well as by differences in practice among endoscopists, it adds to what the authors called a paucity of data showing that first-line endoscopic therapy can reduce the incidence of further bleeding, "thereby preventing the need for emergent colectomy."

The authors reported no conflicts of interest relating to this study.

For acute diverticular bleeding, first-line diagnostic colonoscopy plus endoscopic clipping of actively bleeding diverticulum appears safe and efficacious and also reduces hospital stays, reported Dr. Tonya Kaltenbach and colleagues in the February issue of Clinical Gastroenterology and Hepatology.

The authors wrote that they hope this finding "may aid in the development of a management algorithm for patients with acute severe [lower gastrointestinal bleed]."

Dr. Kaltenbach of the Veterans Affairs Palo Alto (Calif.) Health Care System studied data from 250 patients from her facility as well as the VA San Francisco, who presented with signs and symptoms indicative of acute lower GI bleed over a 5-year period.

The symptoms included tachycardia, systolic hypotension, syncope, nontender abdominal examination, rectal bleeding during the first 4 hours of evaluation, aspirin use, and multiple comorbid illnesses, the investigators said.

According to a protocol developed by the GI section chiefs at these institutions, all patients presenting with lower GI bleed symptoms underwent a rapid purge of the bowel over 3 hours, followed by colonoscopy. The median time to colonoscopy was 24 hours. The procedures were performed by 12 different endoscopists.

"Throughout colonoscope insertion and withdrawal, we systematically irrigated diverticula and surveyed for diverticular stigmata of recent hemorrhage, including active bleeding, nonbleeding visible vessel, and adherent clot, as well as other potential (though unproven) stigmata such as pigmented spot or erosion," wrote the authors.

If diverticular stigmata of recent hemorrhage were discovered, the authors attempted to clip the diverticulum. Other patients were classified as having presumptive diverticular hemorrhage if a diverticulum with a spot or erosion was found and no other bleeding source was identified.

Overall, diverticular bleeding was diagnosed in 64 patients (61 male) with an average age of 76 years. Of these, 24 had diverticular stigmata of recent hemorrhage visible on colonoscopy, including active bleeding in 12 cases, nonbleeding visible vessels in 3 cases, and adherent clots in 9 cases.

Among the active bleeders, "We achieved primary hemostasis with endoscopic clip application in 9 of the 12 (75%)," wrote the authors. Clipping was unsuccessful in the other three patients, two of whom required emergent hemicolectomy; the remaining patient underwent angiographic embolization.

The 21 patients who were successfully clipped had a significantly shorter mean length of hospital stay than the 3 who were not treated successfully with clipping (6.4 days vs. 36.3 days; P less than .001).

"There were no perforations or episodes of early [less than 30 days post-procedure] rebleeding," noted Dr. Kaltenbach and colleagues (Clin. Gastro. Hepatol. 2012 [doi:10.1016/j.cgh.2011.10.029]).

And while the clipped patients had recurrent bleeding rates that were similar to those of their nonbleeding, nonclipped counterparts – about 20% – the 21 clipped patients had longer mean bleeding-free intervals (43 months vs. 15 months, respectively; P less than .001).

Among the patients who did rebleed, all were treated with the protocol again. Four of these patients underwent diverticulum clipping, and had an even shorter length of hospital stay compared to their index bleed, wrote the authors.

Throughout the study period, no patients died due to diverticular bleeding, wrote the authors, nor were there any complications arising from the colonoscopy itself.

"Currently, clinicians are faced with uncertainty as to the optimal diagnostic modality to choose in the management of patients with acute severe lower GI bleed," wrote the authors. "As such, other diagnostic modalities are used – often with high risk and low benefit."

And while the study is limited by its retrospective nature, as well as by differences in practice among endoscopists, it adds to what the authors called a paucity of data showing that first-line endoscopic therapy can reduce the incidence of further bleeding, "thereby preventing the need for emergent colectomy."

The authors reported no conflicts of interest relating to this study.

For acute diverticular bleeding, first-line diagnostic colonoscopy plus endoscopic clipping of actively bleeding diverticulum appears safe and efficacious and also reduces hospital stays, reported Dr. Tonya Kaltenbach and colleagues in the February issue of Clinical Gastroenterology and Hepatology.

The authors wrote that they hope this finding "may aid in the development of a management algorithm for patients with acute severe [lower gastrointestinal bleed]."

Dr. Kaltenbach of the Veterans Affairs Palo Alto (Calif.) Health Care System studied data from 250 patients from her facility as well as the VA San Francisco, who presented with signs and symptoms indicative of acute lower GI bleed over a 5-year period.

The symptoms included tachycardia, systolic hypotension, syncope, nontender abdominal examination, rectal bleeding during the first 4 hours of evaluation, aspirin use, and multiple comorbid illnesses, the investigators said.

According to a protocol developed by the GI section chiefs at these institutions, all patients presenting with lower GI bleed symptoms underwent a rapid purge of the bowel over 3 hours, followed by colonoscopy. The median time to colonoscopy was 24 hours. The procedures were performed by 12 different endoscopists.

"Throughout colonoscope insertion and withdrawal, we systematically irrigated diverticula and surveyed for diverticular stigmata of recent hemorrhage, including active bleeding, nonbleeding visible vessel, and adherent clot, as well as other potential (though unproven) stigmata such as pigmented spot or erosion," wrote the authors.

If diverticular stigmata of recent hemorrhage were discovered, the authors attempted to clip the diverticulum. Other patients were classified as having presumptive diverticular hemorrhage if a diverticulum with a spot or erosion was found and no other bleeding source was identified.

Overall, diverticular bleeding was diagnosed in 64 patients (61 male) with an average age of 76 years. Of these, 24 had diverticular stigmata of recent hemorrhage visible on colonoscopy, including active bleeding in 12 cases, nonbleeding visible vessels in 3 cases, and adherent clots in 9 cases.

Among the active bleeders, "We achieved primary hemostasis with endoscopic clip application in 9 of the 12 (75%)," wrote the authors. Clipping was unsuccessful in the other three patients, two of whom required emergent hemicolectomy; the remaining patient underwent angiographic embolization.

The 21 patients who were successfully clipped had a significantly shorter mean length of hospital stay than the 3 who were not treated successfully with clipping (6.4 days vs. 36.3 days; P less than .001).

"There were no perforations or episodes of early [less than 30 days post-procedure] rebleeding," noted Dr. Kaltenbach and colleagues (Clin. Gastro. Hepatol. 2012 [doi:10.1016/j.cgh.2011.10.029]).

And while the clipped patients had recurrent bleeding rates that were similar to those of their nonbleeding, nonclipped counterparts – about 20% – the 21 clipped patients had longer mean bleeding-free intervals (43 months vs. 15 months, respectively; P less than .001).

Among the patients who did rebleed, all were treated with the protocol again. Four of these patients underwent diverticulum clipping, and had an even shorter length of hospital stay compared to their index bleed, wrote the authors.

Throughout the study period, no patients died due to diverticular bleeding, wrote the authors, nor were there any complications arising from the colonoscopy itself.

"Currently, clinicians are faced with uncertainty as to the optimal diagnostic modality to choose in the management of patients with acute severe lower GI bleed," wrote the authors. "As such, other diagnostic modalities are used – often with high risk and low benefit."

And while the study is limited by its retrospective nature, as well as by differences in practice among endoscopists, it adds to what the authors called a paucity of data showing that first-line endoscopic therapy can reduce the incidence of further bleeding, "thereby preventing the need for emergent colectomy."

The authors reported no conflicts of interest relating to this study.