Am Fam Physician. 2000 Jun 15;61(12):3700.
While endoscopy is frequently used to identify the site of upper gastrointestinal bleeding, it is rarely used to evaluate acute bleeding in the lower gastrointestinal tract. The standard of care for lower gastrointestinal bleeding is supportive therapy followed by elective colonoscopy when the bleeding has stopped. Only a few case reports describe the use of acute colonoscopy for the diagnosis and treatment of diverticular bleeding. Jensen and colleagues evaluated the role of urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage in patients presenting with hematochezia and diverticulosis.
The study was conducted in two parts. The first study included 73 consecutive patients seen from June 1986 to June 1992. These patients were treated medically and surgically, as necessary. The second part of the study was conducted from June 1994 to December 1998 and included 48 consecutive patients. These patients were treated medically, including therapeutic intervention at the time of colonoscopy, as necessary.
Urgent colonoscopy, performed within six to 12 hours after hospitalization and within one hour of clearance of the colon, was performed in each case. Only patients found to have a definite diagnosis of diverticulosis on colonoscopy were enrolled in the study. A diagnosis of diverticular bleeding was made if colonoscopy revealed active bleeding, a non-bleeding visible vessel or an adherent clot.
Seventeen (23 percent) of the 73 patients in the first group had definite diverticular hemorrhage; the remaining 56 patients (77 percent) had incidental diverticulosis, with bleeding in these patients caused by abnormalities other than a diverticulum. In the first part of the study, patients with diverticular hemorrhage were treated medically, including transfusions as required. Those with continued bleeding and those who had received at least three units of blood underwent emergency hemicolectomy. Nine of the 17 patients had recurrent bleeding, and six subsequently required hemicolectomy. Follow-up in these 17 patients was a median of 36 months (range: 24 to 54 months).
Ten (21 percent) of the 48 patients in the second part of the study had evidence of diverticular hemorrhage at the time of colonoscopy. Endoscopic hemostasis was performed in these patients. Epinephrine injections were administered at four quadrants around the bleeding site in patients with active bleeding or nonbleeding adherent clots. If a nonbleeding vessel was found, coagulation with a bipolar probe was performed. Patients were given a clear liquid diet for 24 hours after colonoscopy, and the diet was then advanced as tolerated. They were discharged with specific dietary instructions and were told to avoid aspirin, nonsteroidal anti-inflammatory drugs and anticoagulants, if possible. Iron supplements for residual iron deficiency anemia and stool softeners were also recommended. Follow-up in these 10 patients was a median of 30 months (range: 18 to 49 months).
None of the 10 patients treated endoscopically had recurrent bleeding or required surgery. The median time until discharge was two days, compared with five days in the 17 patients with diverticular hemorrhage in the first part of the study.
The authors conclude that urgent colonoscopy can be safely and effectively used to identify the type of diverticular bleeding and to implement treatment to stop the bleeding. The authors believe surgery should be reserved for use in patients who do not respond to colonoscopic treatment.
Jensen DM, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. January 13, 2000;342:78–82.
Copyright © 2000 by the American Academy of Family Physicians.
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