Redefining Hemorrhage in Diverticulitis: Complicated Diverticulitis or Exacerbation of Diverticular Bleeding?

Abstract

AIM: Lower gastrointestinal hemorrhage in a patient presenting with diverticulitis shifts the diagnosis from uncomplicated to complicated diverticulitis leading to more aggressive treatment measures. This study sought to determine the demographic characteristics of patients hospitalized with diverticular bleeding and diverticulitis with a focus on identifying factors that predispose to hemorrhage. We aim to use demographic information to elucidate whether hemorrhage in the setting of diverticulitis is more similar mechanistically to diverticular bleeding or diverticulitis. MATERIALS AND METHODS: Inpatient data collected by the Pennsylvania Health Care Cost Containment Council was used to analyze 29,479 hospitalizations spanning from 2002 to 2018 at Philadelphia healthcare institutions where the primary diagnosis for admission was diverticulitis or diverticular bleeding. Age, race, and gender were collected for patients hospitalized with diverticular bleeding, di-verticulitis, and diverticulitis complications. Demographic data from the 2010 US Census was used for comparison. RESULTS: Diverticulitis (n = 20,260) disproportionately affects White individuals (p < 0.0001) while diverticular bleeding (n = 9,219) disproportionately affects Black individuals (p < 0.0001). Of all diverticulitis complications, hemorrhage (n = 1,429) had the highest proportion of Black individuals. Patients admitted for diverticular bleeding tend to be older (75.0 ± 12.1) than patients admitted for diverticulitis (60.2 ± 15.9; p < 0.00001). Among those with complicated diverticulitis, patients with hemorrhage are the oldest (70.2 ± 14.7). CONCLUSION: Patients admitted with diverticulitis complicated by hemorrhage were more similar demographically to patients admitted with diverticular bleeding than those admitted with other forms of diverticulitis. Reframing diverticulitis complicated by hemorrhage as uncomplicated diverticulitis with diverticular bleeding could prompt more appropriate treatment with avoidance of potentially unnecessary antibiotics and imaging.Synopsis: An epidemiological assessment of diverticular bleeding and diverticulitis found that patients admitted with diverticulitis complicated by hemorrhage were more similar demographically to patients admitted with diverticular bleeding than those admitted with other forms of diverticulitis. Because prior studies have suggested that demographic differences between diverticular bleeding and diverticulitis suggest distinct etiologies, we conclude that hemorrhage in the setting of diverticulitis should be treated as a diverticular bleed and not as a complication of diverticulitis itself.

Acute diverticulitis complicated by massive lower gastrointestinal bleeding: a rare diagnostic challenge

“…Diverticulitis is thought to be secondary to a diverticular microperforation leading to inflammation, infection and possibly frank perforation. Diverticular bleeding is thought to be of separate aetiology that includes outpouching and subsequent thinning of the colonic wall and erosion into the vasa recta 3. These two entities are attributed to two separate processes, and concurrent manifestation is rare.…”