New Trends in Acute Management of Colonic Diverticular Bleeding

Abstract

Colonic diverticular disease is the most common cause of lower gastrointestinal bleeding. In the past, this condition was usually managed with urgent colectomy. Recently, the development of endoscopy and interventional radiology has led to a change in the management of colonic diverticular bleeding.The aim of this systematic review is to define the best treatment for colonic diverticular bleeding.A systematic bibliographic research was performed on the online databases for studies (randomized controlled trials [RCTs], observational trials, case series, and case reports) published between 2005 and 2014, concerning patients admitted with a diagnosis of diverticular bleeding according to the PRISMA methodology.The outcomes of interest were: diagnosis of diverticulosis as source of bleeding; incidence of self-limiting diverticular bleeding; management of non self-limiting bleeding (endoscopy, angiography, surgery); and recurrent diverticular bleeding.Fourteen studies were retrieved for analysis. No RCTs were found. Eleven non-randomized clinical controlled trials (NRCCTs) were included in this systematic review. In all studies, the definitive diagnosis of diverticular bleeding was always made by urgent colonoscopy. The colonic diverticular bleeding stopped spontaneously in over 80% of the patients, but a re-bleeding was not rare. Recently, interventional endoscopy and angiography became the first-line approach, thus relegating emergency colectomy to patients presenting with hemodynamic instability or as a second-line treatment after failure or complications of hemostasis with less invasive treatments.Colonoscopy is effective to diagnose diverticular bleeding. Nowadays, interventional endoscopy and angiographic treatment have gained a leading role and colectomy should only be entertained in case of failure of the former.

Lower GI Bleeding: An Update on Incidences and Causes

“…7 Most diverticular bleeds are self-limited with 75 to 90% resolving spontaneously. 8,[11][12][13][14] In a review article by Cirocchi et al, only 16% of patients with diverticula bleeding required any form of intervention (114 patients out of 700). Of the 114 patients that required intervention, endoscopic approach was used in 66% while transcatheter arterial embolization was performed 10.5% of the time.…”

Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature

“…1 Some patients still develop re-bleeding, or it may not be possible to stop hemodynamically significant bleeding by endoscopy. 15,16 In these cases there has been a paradigm shift from surgical treatment to interventional radiology in the last few years. 17 …”

“…Up to now, treatment with a hemoclip, with or without injection therapy, has been the preferred endoscopic procedure for the lower gastrointestinal tract, although only about 16% of patients with diverticular bleeding receive an endoscopic intervention. 15 Alternative hemostasis procedures such as ligation or electrocoagulation have not been sufficiently established yet for diverticular bleeding. 1 Some patients still develop re-bleeding, or it may not be possible to stop hemodynamically significant bleeding by endoscopy.…”

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

“…Agreement rate: 100% Explanation Due to recent technological advances in endoscopy and improved treatment outcomes in arterial embolization, colectomy is no longer the first-line treatment for colonic diverticular bleeding [34,118,119]. Therefore, indications for hemostasis by emergency colectomy include severe cases of colonic diverticular bleeding for which endoscopic therapy or arterial embolization is unsuccessful.…”