Risk of colonic diverticular rebleeding according to endoscopic appearance

Abstract

Background and study aims Re-commencement of bleeding (rebleeding) of colonic diverticula after endoscopic hemostasis is a clinical problem. This study aimed to examine whether endoscopic visibility of colonic diverticular bleeding affects the risk of rebleeding after endoscopic hemostasis.

Patients and methods We performed a retrospective review of endoscopic images and medical charts of patients with colonic diverticular bleeding who underwent endoscopic hemostasis. Endoscopic visibility was classified into two types according to visibility of the source of bleeding; source invisibility due to bleeding or attached hematin (type 1), or endoscopically visible responsive vessels (type 2). Rebleeding rates within one year after initial hemostasis were examined.

Results Of 93 patients with successful endoscopic hemostasis, 38 (41 %) showed type 1 visibility, while the remaining presented type 2. All patients received hemostasis with clipping, rebleeding developed in 20 patients (22 %). Type 1 visibility was more likely to be observed in patients with rebleeding (65 % vs. 34 %, P = 0.013). Multivariate analysis revealed that after endoscopic hemostasis, type 1 visibility (invisible source) was the only independent risk factor for colonic diverticular rebleeding (odds ratio, 3.05; 95 % confidence interval, 1.03 – 9.59, P = 0.044). Kaplan-Meier curve showed the cumulative incidence of rebleeding was significantly higher in patients with type 1 visibility than those with type 2 visibility (P = 0.0033, log-rank test)

Conclusion Hemostasis by clipping for colonic diverticular bleeding without definite observation of the source of bleeding may not be sufficiently effective. Other hemostatic methods, including band ligation, should be considered when the source of bleeding is unclear.

• References

• 1 Strate LL, Liu YL, Huang ES. et al. Use of Aspirin or Nonsteroidal Anti-inflammatory Drugs Increases Risk for Diverticulitis and Diverticular Bleeding. Gastroenterology 2011; 140: 1427-1433
• 2 Niikura R, Nagata N, Akiyama J. et al. Hypertension and concomitant arteriosclerotic diseases are risk factors for colonic diverticular bleeding: a case control study. Int J Colorectal Dis 2012; 22: 1137-1143
• 3 Nagata N, Niikura R, Aoki T. et al. Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan. Int J Colorectal Dis 2014; 29: 379-385
• 4 Newman J, Fitzgerald JEF, Gupta S. et al. Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding. Color Dis 2012; 14: 1020-1026
• 5 Poncet G, Heluwaert F, Voirin D. et al. Natural history of acute colonic diverticular bleeding: a prospective study in 133 consecutive patients. Aliment Pharmacol Ther 2010; 32: 466-471
• 6 Jensen DM, Machicado GA, Jutabha R. et al. Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage. N Engl J Med 2000; 342: 78-82
• 7 Niikura R, Nagata N, Yamada A. et al. Recurrence of colonic diverticular bleeding and associated risk factors. Color Dis 2012; 14: 302-305
• 8 Gilshtein H, Kluger Y, Khoury A. et al. Massive and recurrent diverticular hemorrhage, risk factors and treatment. Int J Surg 2016; 33: 136-139
• 9 Watanabe S, Kodera S, Shimura H. Investigation of risk factors predicting recurrence of colonic diverticular hemorrhage and development of a recurrence risk score. Acta Gastroenterol Belg 2014; 77: 408-412
• 10 Fujino Y, Inoue Y, Onodera M. et al. Risk factors for early re-bleeding and associated hospitalization in patients with colonic diverticular bleeding. Color Dis 2013; 15: 982-986
• 11 Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111: 459-474
• 12 Ishii N, Hirata N, Omata F. et al. Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping. Gastrointest Endosc 2012; 76: 1175-1181
• 13 Chung I, Kim E, Lee M. et al. Endoscopic Factors Predisposing to Rebleeding Following Endoscopic Hemostasis in Bleeding Peptic Ulcers. Endoscopy 2001; 33: 969-975
• 14 Guglielmi A, Ruzzenente A, Sandri M. et al. Risk Assessment and Prediction of Rebleeding in Bleeding Gastroduodenal Ulcer. Endoscopy 2002; 34: 778-786
• 15 Elmunzer BJ, Young SD, Inadomi JM. et al. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol 2008; 103: 2625-2632
• 16 Akimoto T, Goto O, Sasaki M. et al. Hold-and-drag closure technique using repositionable clips for large mucosal defects after colonic endoscopic submucosal dissection. Endosc Int Open 2016; 4: E1068-E1072
• 17 Osada T, Sakamoto N, Ritsuno H. et al. Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection. Surg Endosc 2016; 30: 4438-4444
• 18 Suzuki S, Chino A, Kishihara T. et al. Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms. World J Gastroenterol 2014; 20: 1839-1845
• 19 Rustagi T, McCarty TR. Endoscopic management of diverticular bleeding. Gastroenterol Res Pract 2014; 9: 353508
• 20 Ishii N, Itoh T, Iizuka Y. et al. Endoscopic band ligation for colonic diverticular rebleeding after endoscopic clipping. Dig Endosc 2011; 23: 211
• 21 Schmulewitz N, Fisher DA, Rockey DC. Early colonoscopy for acute lower GI bleeding predicts shorter hospital stay: a retrospective study of experience in a single center. Gastrointest Endosc 2003; 58: 841-846
• 22 Kaltenbach T, Watson R, Shah J. et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol 2012; 10: 131-137
• 23 Shimamura Y, Ishii N, Omata F. et al. Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization. Endosc Int Open 2016; 15: E233-E237
• 24 Shibata S, Shigeno T, Fujimori K. et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis. Endoscopy 2013; 11: 66-69
• 25 Ishii N, Setoyama T, Deshpande GA. et al. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382-387
• 26 Jensen DM, Ohning GV, Kovacs TOG. et al. Natural history of definitive diverticular hemorrhage based on stigmata of recent hemorrhage and colonoscopic Doppler blood flow monitoring for risk stratification and definitive hemostasis. Gastrointest Endosc 2016; 83: 416-423