Diverticular disease-associated hemorrhage in the elderly

Abstract

Lower gastrointestinal bleeding is frequent in the elderly secondary to diverticular disease and occurs in about 10-30%. It is the most frequent cause of lower gastrointestinal hemorrhage (about 40% of cases) followed by angiodysplasia (up to 20% of cases). The incidence of both diseases increase with age, but the patient's general condition and state of health decrease. Often cardiovascular morbidity coexists, resulting in an eventual risk of ischemic consequences. The intensity of bleeding varies from massive to occult. In diverticular disease, hemorrhage is caused by rupture or erosion of the vasa recti stretched by diverticula. Classically inflammation is absent. Although most diverticula (> 90%) are located in the sigmoid colon, bleeding originates more frequently from the right (> 50%) than the left colon. The preferred diagnostic tool following resuscitation is colonoscopy with an ability to locate the site of bleeding in up to 90% of cases. Additionally, injections and thermocoagulation are available to control bleeding endoscopically with a success rate of about 27%. Angiography is considerably variable concerning positive results (13.6-86%), has a complication rate of about 10% and is expensive. Hence, it is a second-line diagnostic method. Diverticular hemorrhage will cease spontaneously in about 90% of cases. Therefore, conservative treatment is preferred. Patients with persistent, massive or recurrent bleeding despite active conservative measures require surgical treatment. If surgical intervention is necessary, the site of hemorrhage must be sought to allow segmental resection. However, if the source of blood loss cannot be located, a subtotal colectomy is justified.

Risk factors for severity and recurrence of colonic diverticular bleeding

“…This is in accordance with previous studies that report that diverticular hemorrhage ceases spontaneously in about 90% of cases (32). Also the effective use of colonoscopy for hemostasis has been identified as a determinant factor for fewer operative interventions (3).…”

The use of Ankaferd in diverticular bleeding: Two case reports

“…The incidence of bleeding ranges from 5 to 50% in patients with diverticulosis (8,9). Bleeding is arterial and can occur either at the dome or at the neck of the diverticulum.…”

Subtotal colectomy with primary ileorectostomy is effective for unlocalized, diverticular hemorrhage

“…The vast majority of patients (90%) experience spontaneous cessation of bleeding [1,3,4,5], but without definitive therapy the rebleeding rate at 4 years may reach 25% [2]. The present study reviewed the minority of patients presenting with acute diverticular bleeding requiring emergency surgery for hemodynamic instability or the need for continued transfusions.…”