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Colonic diverticular bleeding

INTRODUCTION

Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding in adults. In most cases, the bleeding will stop spontaneously. However, if the bleeding persists, endoscopic, radiologic, or surgical intervention may be required.

This topic will review colonic diverticular bleeding. The general approach to lower gastrointestinal bleeding, the causes of lower gastrointestinal bleeding, and the evaluation of obscure gastrointestinal bleeding are discussed elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults" and "Etiology of lower gastrointestinal bleeding in adults" and "Evaluation of obscure gastrointestinal bleeding".)

EPIDEMIOLOGY

Colon carcinoma is the most common source of lower gastrointestinal blood loss, but the bleeding is often occult (ie, no evidence of visible blood loss to the patient or clinician). On the other hand, colonic diverticular bleeding is the most common cause of brisk hematochezia (maroon or bright red blood), accounting for 30 to 50 percent of cases of massive rectal bleeding [1-3]. (See "Angiodysplasia of the gastrointestinal tract" and "Complications of hemodialysis in the older adult patient".)

Among patients with diverticulosis, bleeding will occur in approximately 15 percent and will be massive in a third [4]. Interestingly, obesity appears to increase the risk of diverticulitis and colonic diverticular bleeding [5].

PATHOGENESIS

A characteristic angioarchitecture is associated with bleeding colonic diverticula (figure 1) [6]. As a diverticulum herniates, the penetrating vessel responsible for the wall weakness at the point of herniation becomes draped over the dome of the diverticulum, separated from the bowel lumen only by mucosa (picture 1). Over time, the vasa recta is exposed to recurrent injury along its luminal aspect, leading to eccentric intimal thickening and thinning of the media. These changes may result in segmental weakness of the artery, predisposing to rupture into the lumen. It is rare for bleeding to coexist with diverticulitis [6]. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis".)

              

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Literature review current through: Jul 2014. | This topic last updated: Apr 28, 2014.
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References
Top
  1. Gostout CJ, Wang KK, Ahlquist DA, et al. Acute gastrointestinal bleeding. Experience of a specialized management team. J Clin Gastroenterol 1992; 14:260.
  2. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986; 204:530.
  3. Gayer C, Chino A, Lucas C, et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery 2009; 146:600.
  4. Imbembo AL, Bailey RW. Diverticular disease of the colon. In: Textbook of Surgery, 14th ed, Sabiston DC Jr (Ed), Churchill Livingstone, 1992. p.910.
  5. Strate LL, Liu YL, Aldoori WH, et al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 2009; 136:115.
  6. Meyers MA, Alonso DR, Gray GF, Baer JW. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976; 71:577.
  7. Casarella WJ, Kanter IE, Seaman WB. Right-sided colonic diverticula as a cause of acute rectal hemorrhage. N Engl J Med 1972; 286:450.
  8. Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40:344.
  9. Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.
  10. McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220:653.
  11. Udén P, Jiborn H, Jonsson K. Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage. A 15-year experience. Dis Colon Rectum 1986; 29:561.
  12. Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding. Am Fam Physician 2009; 80:977.
  13. Meyers MA, Volberg F, Katzen B, et al. The angioarchitecture of colonic diverticula. Significance in bleeding diverticulosis. Radiology 1973; 108:249.
  14. Richards RJ, Donica MB, Grayer D. Can the blood urea nitrogen/creatinine ratio distinguish upper from lower gastrointestinal bleeding? J Clin Gastroenterol 1990; 12:500.
  15. Mortensen PB, Nøhr M, Møller-Petersen JF, Balslev I. The diagnostic value of serum urea/creatinine ratio in distinguishing between upper and lower gastrointestinal bleeding. A prospective study. Dan Med Bull 1994; 41:237.
  16. Kim YI, Marcon NE. Injection therapy for colonic diverticular bleeding. A case study. J Clin Gastroenterol 1993; 17:46.
  17. Savides TJ, Jensen DM. Colonoscopic hemostasis for recurrent diverticular hemorrhage associated with a visible vessel: a report of three cases. Gastrointest Endosc 1994; 40:70.
  18. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342:78.
  19. Foutch PG, Zimmerman K. Diverticular bleeding and the pigmented protuberance (sentinel clot): clinical implications, histopathological correlation, and results of endoscopic intervention. Am J Gastroenterol 1996; 91:2589.
  20. Barker KB, Arnold HL, Fillman EP, et al. Safety of band ligator use in the small bowel and the colon. Gastrointest Endosc 2005; 62:224.
  21. Ishii N, Setoyama T, Deshpande GA, et al. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75:382.
  22. Simpson PW, Nguyen MH, Lim JK, Soetikno RM. Use of endoclips in the treatment of massive colonic diverticular bleeding. Gastrointest Endosc 2004; 59:433.
  23. Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding colonic diverticula by endoscopic band ligation: an in-vivo and ex-vivo pilot study. Endoscopy 2003; 35:823.
  24. Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol 1998; 93:1202.
  25. Fiorito JJ, Brandt LJ, Kozicky O, et al. The diagnostic yield of superior mesenteric angiography: correlation with the pattern of gastrointestinal bleeding. Am J Gastroenterol 1989; 84:878.
  26. Bokhari M, Vernava AM, Ure T, Longo WE. Diverticular hemorrhage in the elderly--is it well tolerated? Dis Colon Rectum 1996; 39:191.
  27. Parkes BM, Obeid FN, Sorensen VJ, et al. The management of massive lower gastrointestinal bleeding. Am Surg 1993; 59:676.
  28. Wagner HE, Stain SC, Gilg M, Gertsch P. Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract. Surg Gynecol Obstet 1992; 175:445.
  29. Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg 1992; 58:295.