Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis

Abstract

BACKGROUND AND AIMS Few prospective reports describe the short term natural history of colon diverticular hemorrhage based upon stigmata of recent hemorrhage and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes are to report the 30 day natural history of definitive diverticular hemorrhage based upon stigmata and to describe Doppler probe blood flow detection and as a guide to definitive hemostasis. METHODS Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30 day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. Natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after washing away clots are reported. Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis is also reported in a recent cohort. RESULTS For natural history patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. Doppler probe detected arterial blood flow in 92% of major stigmata, none after hemostasis and no one rebled. CONCLUSIONS 1. Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. 2. Patients with clean diverticula or only flat spots had no rebleeding. 3. High rates of arterial blood flow were detected under major stigmata with Doppler probe but with obliteration by hemostasis no rebleeding occurred.

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

“…Presumptive diagnosis is based on fresh blood localized to colonic diverticula in the presence of a potential bleeding source on complete colonoscopy; or bright red blood per rectum confirmed by colonoscopy that demonstrates a single potential bleeding source in the colon, complemented by negative upper endoscopy or negative capsule endoscopy, or negative nasogastric tube. Previous cohort studies of patients with definitive diverticular bleeding [62,82] have shown a high rate (53-66%) of early rebleeding (≤30 days of treatment) in patients who underwent conservative therapy alone, but the rate decreased with endoscopic hemostasis. Also, in a prospective cohort study [62], early rebleeding (≤30 days) did not occur after conservative treatment without endoscopic hemostasis in patients with black or dark red flat spots in colonic diverticula that did not appear to be visible vessels or in patients whose colonic diverticula were clean when clots were removed.…”

“…3b), and adherent clots (Fig. 3c, d) that develop into active bleeding or non-bleeding visible vessels upon removal of clots are defined as SRH [82]. Definitive colonic diverticular bleeding is defined as colonoscopic visualization of colonic diverticulum with SRH.…”

Has an Observational Study of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Hemorrhage Answered Questions That Clinical Trials Could Not?

“…However, natural history studies of peptic ulcer and diverticular bleeding indicate that SRH are highly predictive of rebleeding in the absence of endoscopic therapy. 6 Therefore, inadequate endoscopic hemostasis is likely to play a role in the disappointing results of the Nagata study and others. The approach to endoscopic hemostasis in the colon has not been standardized, and there is general concern for treatment related complications in the thin-walled colon.…”

“…Studies of colonoscopy within 12 hours of presentation in patients with diverticular hemorrhage indicate that major stigmata of recent hemorrhage (i.e., active bleeding, non-bleeding visible vessel and adherent clot) portend a poor prognosis, and that treatment of these stigmata with epinephrine injection and bipolar coagulation or hemoclipping decreases rebleeding and the need for angiography or surgery. 5, 6 …”

“…Notably, outcomes in LGIB from specialized GI bleeding centers tend to be more favorable than those from other care settings. 5, 6 Lastly, early colonoscopy could contribute to suboptimal endoscopy conditions such as insufficient hemodynamic resuscitation, and/or colon preparation, and performance of endoscopy outside the endoscopy suite and without trained assistants. In the Nagata study, colon preparation quality was not reported, but there were no differences in the receipt of a full preparation, and definitive diagnoses were more frequent in the early vs. elective colonoscopy group suggesting that poor preparations do not account for the findings.…”