Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association

Abstract

Colonic diverticular disease has been increasing in prevalence in Japan due to the rapidly aging population. Colonic diverticular bleeding can result in hemorrhagic shock requiring blood transfusion, and it carries a high risk of recurrence within 1 year. Colonic diverticulitis can cause abscess, fistula formation, and perforation of the colon that may require surgery, and it often recurs. As a result, patients with colonic diverticular disease are often bothered by required frequent examinations, re-hospitalization, and a consequent decrease in quality of life. However, the management of diverticular disease differs between Japan and Western countries. For example, computed tomography (CT) is readily accessible at Japanese hospitals, so urgent CT may be selected as the first diagnostic procedure for suspected diverticular disease. Endoscopic clipping or band ligation may be preferred as the first endoscopic procedure for diverticular bleeding. Administration of antibiotics and complete bowel rest may be considered as first-line therapy for colonic diverticulitis. In addition, diverticula occur mainly in the sigmoid colon in Western countries, whereas the right side or bilateral of the colon is more commonly involved in Japan. As such, diverticular disease in the right-side colon is more prevalent in Japan than in Western countries. Against this background, concern is growing about the management of colonic diverticular disease in Japan and there is currently no practice guideline available. To address this situation, the Japanese Gastroenterological Association decided to create a clinical guideline for colonic diverticular bleeding and colonic diverticulitis in collaboration with the Japanese Society of Gastroenterology, Japan Gastroenterological Endoscopy Society, and Japanese Society of Interventional Radiology. The steps taken to establish this guideline involved incorporating the concept of the GRADE system for rating clinical guidelines, developing clinical questions (CQs), accumulating evidence through a literature search and review, and developing the Statement and Explanation sections. This guideline includes 2CQs for colonic diverticulosis, 24 CQs for colonic diverticular bleeding, and 17 CQs for diverticulitis.

Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding

“…In Japan, the rising prevalence of both colonic diverticula and CDB has increased the associated clinical burden including medical costs. Accordingly, growing concern about the management of colonic diverticular disease promoted the development of practice guidelines, particularly given the East‐West paradox in disease prevalence, phenotype, and medical burden . The guidelines indicated a clinical flow chart (Fig.…”

“…Accordingly, growing concern about the management of colonic diverticular disease promoted the development of practice guidelines, particularly given the East-West paradox in disease prevalence, phenotype, and medical burden. 20 The guidelines indicated a clinical flow chart ( Fig. 1) and practical recommendations for the diagnosis and treatment of patients with CDB.…”

Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage

“…In Japan, colonic diverticular hemorrhage is increasingly common with aging population and westernization of dietary habits, and valuable treatment options should be fully discussed for the management of colonic diverticular hemorrhage. Currently, Japanese guidelines proposed early colonoscopy as the triage tool for patients with sustained bleeding although it remains controversial whether early colonoscopy would contribute to increase in identification of SRH or prevention of rebleeding [6]. On the contrary, our results in a real clinical setting suggested that colonic diverticular hemorrhage would stop spontaneously without any interventions, i.e., with only conservative treatment, except for the cases with shock based on vital signs and extravasation on CECT.…”

“…In Japanese guidelines for colonic diverticular hemorrhage, it is proposed that early colonoscopy would be preferably performed within 24 hours of hospital visit to identify the stigma of recent hemorrhage (SRH) [6], and several institutions have actively performed early colonoscopy. In addition, some new endoscopic techniques, which might contribute to increase in successful hemostasis and decrease in rebleeding, have been recently reported, such as endoscopic band ligation, endoscopic detachable snare ligation, and over-the-scope clip (OTSC ® , Ovesco Endoscopy, Tübingen, Germany) [7][8][9].…”

Colonic Diverticular Bleeding Associated with Bowel Cleansers before Colonoscopy

“…Again, colonic diverticular bleeding is shown to be significantly more common in males and elderly patients aged ≥60 years [12], and NSAID and LDA have been reported as risk factors [13]. Our patient had a history of LDA use and was ineligible for endoscopic hemostasis and underwent colectomy according to the current guidelines [14].…”