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Colonic diverticular bleeding

Colonic diverticular bleeding
Author:
John H Pemberton, MD
Section Editor:
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor:
Shilpa Grover, MD, MPH, AGAF
Literature review current through: Dec 2022. | This topic last updated: Nov 17, 2022.

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 suspected small bowel bleeding are discussed elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults" and "Etiology of lower gastrointestinal bleeding in adults" and "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal bleeding)".)

EPIDEMIOLOGY — Colon carcinoma is the most common source of slow occult lower gastrointestinal blood loss (ie, no evidence of visible blood loss to the patient or clinician) [1,2]. 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 [3-5]. (See "Angiodysplasia of the gastrointestinal tract".)

Among patients with diverticulosis, the risk of bleeding is approximately 0.5 per 1000 person-years [6]. In a study of 1514 asymptomatic patients with diverticulosis, the cumulative incidence of bleeding was 0.2 percent at 12 months, 2.2 percent at 60 months, and 9.5 percent at 120 months [6]. Risk factors for bleeding included age ≥70 years (adjusted hazard ratio [aHR] 3.7) and bilateral diverticulosis (aHR 2.4). Interestingly, obesity also appears to increase the risk of diverticulitis and colonic diverticular bleeding [7].

PATHOGENESIS — A characteristic angioarchitecture is associated with bleeding colonic diverticula (figure 1) [8]. 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 [8]. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis".)

Unlike diverticulitis, which occurs primarily in the left colon, the right colon is the source of colonic diverticular bleeding in 50 to 90 percent of patients [3,8-10]. This reflects a marked increase in propensity for right-sided diverticula to bleed since in Western countries only 25 percent of diverticula are right-sided [11]. A possible explanation for this is that right-sided diverticula have wider necks and domes, exposing a greater length of vasa recta to injury. Another contributing factor may be the thinner wall of the right colon [12].

NATURAL HISTORY — Bleeding stops spontaneously in 75 percent of patients overall and in 99 percent of patients who are transfused fewer than four units per day [13]. However, patients who have had an episode of diverticular bleeding have an appreciable risk of rebleeding (14 to 38 percent) [3,13]. After a second bleeding episode, the risk of further hemorrhage is 21 to 50 percent [13]. Surgery should be considered for patients who have had multiple episodes of diverticular bleeding and are good surgical candidates. (See 'Surgical intervention' below.)

Many patients with colonic diverticular bleeding are older adults and have comorbid conditions, and morbidity and mortality rates from colonic diverticular bleeding together are approximately 10 to 20 percent [3,4,14].

CLINICAL MANIFESTATIONS — Patients with colonic diverticular bleeding typically present with painless hematochezia that is self-limited. However, in some patients, massive, persistent hematochezia is seen.

Symptoms — Painless hematochezia is the typical presentation of a diverticular bleed [15]. Most patients who bleed have minor bleeding that is self-limited, and 50 percent have had a previous episode of hematochezia [9].

Blood originating from the left colon tends to be bright red in color, whereas bleeding from the right side of the colon usually appears dark or maroon-colored and may be mixed with stool. Rarely, melena may be seen in patients with bleeding originating from the right side of the colon.

Patients typically have few abdominal symptoms, which is a reflection of the noninflammatory pathogenesis of the bleeding. However, blood within the colon acts as a cathartic, and some patients report bloating, cramping, or the urge to defecate. Symptoms and signs of diverticulitis are not present since the two disorders rarely coexist [8,16].

Patients with bleeding that is severe enough to cause hemodynamic instability may report syncope, light-headedness, or postural dizziness.

Physical examination — On examination, patients may be normotensive if the bleeding has stopped. However, if the bleeding is severe and ongoing, patients may be tachycardic and hypotensive [15]. Poor skin turgor, dry skin, oliguria, and altered level of consciousness are late signs of severe bleeding.

The abdominal examination is typically normal, though some patients may have tenderness to palpation. Blood is usually seen on rectal examination and may be bright red, dark, or (rarely) melenic. Nasogastric lavage may be performed to exclude an upper gastrointestinal source of bleeding. In patients with colonic diverticular bleeding, the nasogastric lavage will be negative for blood. (See "Approach to acute upper gastrointestinal bleeding in adults", section on 'Nasogastric lavage'.)

Laboratory tests — The initial hemoglobin in patients with overt gastrointestinal bleeding will often be at the patient's baseline because the patient is losing whole blood. With time (typically after 24 hours or more), the hemoglobin will decline as the blood is diluted by the influx of extravascular fluid into the vascular space and by fluid administered during resuscitation. It should be kept in mind that overhydration can lead to a falsely low hemoglobin value.

Patients with acute bleeding should have normocytic red blood cells. Microcytic red blood cells or iron deficiency anemia suggest chronic bleeding. Unlike in patients with upper gastrointestinal bleeding, the blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio is not elevated in patients with colonic diverticular bleeding. (See 'Differential diagnosis' below.)

DIAGNOSIS — The diagnosis of colonic diverticular bleeding may be made with colonoscopy or radiographic imaging. Once initial resuscitation is complete and an upper gastrointestinal source for the bleeding has been excluded, the test of choice is colonoscopy (table 1). Colonoscopy can be used to localize the site of bleeding and provide endoscopic therapy. If colonoscopy fails to reveal a source, nuclear scintigraphy (tagged red blood cell scan) followed by angiography may be able to localize the bleeding site. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Fluid resuscitation'.)

The approach to the diagnostic evaluation of a patient with suspected lower gastrointestinal bleeding is discussed in detail elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies'.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of brisk hematochezia is broad and includes massive upper gastrointestinal bleeding, colon cancer, inflammatory bowel disease, ulcers, angiodysplasia, and severe hemorrhoidal bleeding (table 2). (See "Etiology of lower gastrointestinal bleeding in adults", section on 'Etiology'.)

Findings that suggest an upper gastrointestinal source include hemodynamic instability, melena, or an elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio (>20:1 or >100:1, respectively) [17,18]. The higher the ratio, the more likely the bleeding is from an upper gastrointestinal source [17]. Nasogastric lavage may reveal blood, but a negative lavage does not rule out an upper gastrointestinal bleed. Patients with findings that suggest a possible upper gastrointestinal bleed (even if a lower gastrointestinal bleed is still more likely) should undergo upper endoscopy. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies'.)

Other causes of lower gastrointestinal bleeding typically can be differentiated from colonic diverticular bleeding based on colonoscopic findings. However, colonic diverticula are common and thus may be seen in patients whose bleeding is from other sources. In a patient with multiple possible bleeding sources, it may not be possible to definitively identify the source if active bleeding is not visualized. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis", section on 'Epidemiology' and "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies'.)

Massive hemorrhoidal bleeding can be detected with anoscopy, and along with upper endoscopy, should be one of the first tests performed as it is simple to do. However, massive bleeding from hemorrhoids is rare, so unless significant active bleeding is seen coming from the hemorrhoids, brisk hematochezia should not be ascribed hemorrhoids until other causes have been excluded.

MANAGEMENT — The management of colonic diverticular bleeding includes resuscitation and, if the bleeding does not stop spontaneously, identification and treatment of the bleeding site.

Resuscitation — Resuscitation is initiated when the patient arrives at the hospital and should not be delayed pending a diagnostic workup. Resuscitation includes obtaining adequate intravenous access (eg, two large caliber peripheral catheters), assessing the patient's need for fluids and blood products, and correcting coagulopathies. Patients who are high risk for complications or who are hemodynamically unstable should be managed in an intensive care unit. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Fluid resuscitation'.)

Endoscopic therapy — Patients with suspected lower gastrointestinal bleeding should undergo colonoscopy (see "Approach to acute lower gastrointestinal bleeding in adults", section on 'Colonoscopy'). If active bleeding or a visible vessel (similar to stigmata of ulcer hemorrhage) can be localized to a particular diverticulum during colonoscopy, endoscopic therapy can be attempted [19-22]. However, it may be difficult to identify the specific diverticulum responsible for bleeding since diverticula often are numerous and bleeding may be intermittent. In addition, while the results of endoscopic therapy are good in the hands of endoscopists who are part of a dedicated gastrointestinal bleeding team [3], whether the results are as good when performed by endoscopists who are not part of a dedicated bleeding team is unclear.

The efficacy of endoscopic therapy in the hands of an endoscopic team that specializes in gastrointestinal bleeding was demonstrated in a study that included 48 patients with severe hematochezia and diverticulosis who underwent colonoscopy with endoscopic therapy if a bleeding source was identified:

A definite colonic diverticular bleeding source (defined by active bleeding from a diverticulum, a nonbleeding visible vessel, or an adherent clot) was identified in 10 patients (21 percent), all of whom were successfully treated with endoscopic therapy [21].

In patients with active bleeding, treatment included four-quadrant submucosal injection of epinephrine (1 to 2 mL aliquots, dilution 1:20,000) or endoscopic tamponade. In cases of a visualized nonbleeding diverticular vessel, the vessel was treated with bipolar coagulation at a setting of 10 to 15 watts of power with moderate appositional pressure directly on the vessel using one-second pulses until good coagulation and flattening of the vessel were achieved (picture 2). Nonbleeding adherent clots were injected with epinephrine and shaved down to 3 to 4 mm above the attachment with a polypectomy snare (without coagulation). The underlying stigmata (usually visible vessels) were then coagulated with a bipolar probe.

In the group that underwent endoscopic treatment, there were no episodes of recurrent bleeding after a median follow-up of 30 months, and no patient required emergency surgery. In a separate group of 17 patients with definite diverticular bleeding who did not receive endoscopic therapy, persistent bleeding after colonoscopy occurred in nine (53 percent). Six of the patients with persistent bleeding underwent surgery, and two suffered complications following surgery.

Other endoscopic approaches have been described, including banding the responsible diverticulum and using endoscopic clips to control bleeding [23-25]:

One group performed an ex vivo study on surgical specimens and described successfully "everting" and banding 11 diverticula in five of nine specimens [26]. While the authors describe having "everted" the diverticula, "inversion" would be a more accurate description. Examination of the specimens showed no evidence of muscularis propria or serosal involvement.

In a subsequent in vivo study, four patients were successfully banded. The safety of band ligation in the right colon was questioned in another report in which banding of ex-vivo colonic specimens showed gross serosal entrapment, raising concerns for possible subsequent ischemic perforation at that site [23].

In a study of 29 patients with 31 diverticula with stigmata of recent hemorrhage (17 of which were in the right colon), 27 diverticula were successfully banded with no complications during a mean follow-up of 11 months [24]. Diverticular "eversion" was noted in 25. Rebleeding occurred in three patients, two of whom were successfully treated with repeat banding or conservative therapy, though one patient required hemicolectomy.

These early experiences with diverticular banding require additional study, preferably in randomized trials, before widespread adoption.

Angiography — Angiography is an alternative to colonoscopy for treatment in cases where the bleeding site cannot be identified with colonoscopy, or if a bleeding site is identified but attempts to stop the bleeding endoscopically are unsuccessful [27]. Angiography can detect bleeding rates greater than 0.5 mL/min but must be performed during active bleeding (image 1). Typically, a tagged red blood cell scan is performed prior to angiography to aid with identification of the bleeding site; alternatively, if a site is identified during colonoscopy, an endoscopic clip can be placed near the bleeding site to help guide the radiologist. Angiography is 100 percent specific, but sensitivity varies with the pattern of bleeding, ranging in one series from 47 percent with acute bleeding to 30 percent with recurrent hemorrhage [28]. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies'.)

Once the site of bleeding is identified, angiographic therapy can be delivered. Angiographic therapies include the infusion of vasoconstricting medications or the delivery of agents to mechanically occlude the vascular supply of the bleeding lesion (embolization). While angiographic therapy achieves hemostasis in up to 95 percent of patients in whom it is technically feasible, rebleeding is a common problem, occurring in up to 56 percent of patients. However, in these patients, angiographic therapy may permit semielective rather than emergent surgery [4]. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults", section on 'Outcomes'.)

The techniques used for angiographic control of gastrointestinal bleeding are discussed in detail elsewhere. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults", section on 'Angiographic therapies'.)

Surgical intervention — If the bleeding does not stop spontaneously and cannot be controlled with endoscopic or angiographic therapy, surgery is typically required. In addition, instability despite aggressive resuscitation is another indication for surgery and is required in 18 to 25 percent of patients who need blood transfusions [13,29]. Finally, surgery should be considered for patients who are good surgical candidates and have recurrent episodes of bleeding. (See 'Natural history' above.)

Segmental colectomy is performed when the source of bleeding can be localized with colonoscopy or angiography and is associated with a rebleeding rate of 0 to 14 percent [4,13,30]. Generally, tagged red blood cell scans are not considered to be accurate enough for localizing a bleeding site and should not be relied on to direct a segmental resection. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Radionuclide imaging'.)

A segmental resection that removes the bleeding site is adequate in patients with extensive diverticular disease [4]. There is no need to remove all the diverticula. Preoperative localization of the site of bleeding and use of vasopressin as a temporizing measure have reduced the operative morbidity from segmental colectomy compared with subtotal colectomy. In one study, the morbidity rate was 8.6 percent for those who had preoperative localization and segmental colectomy, compared with 37 percent for those who underwent emergency subtotal colectomy [4]. If the source of bleeding cannot be identified prior to surgery, exploratory laparotomy may identify a source and may be aided by intraoperative colonoscopy. As an example, in a study that included nine patients who underwent exploratory laparotomy, a bleeding source was identified in seven (78 percent) [31].

Subtotal colectomy is reserved for patients who continue to bleed without a documented site of bleeding (including those with positive nuclear scintigraphy but negative angiography) and is typically performed with an end ileostomy and rectal stump as the patient is often too unstable to perform an anastomosis. It is associated with high morbidity and mortality rates (37 and 11 to 33 percent, respectively) [4,13,32]. However, the rebleeding rate is virtually nil [30].

Blind segmental resection is contraindicated. This procedure is associated with a high rebleeding rate (approximately 40 percent) leading to morbidity and mortality rates that may be as high as 83 and 57 percent, respectively [30].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colonic diverticular disease" and "Society guideline links: Gastrointestinal bleeding in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Diverticulitis (The Basics)" and "Patient education: Bloody stools (The Basics)")

Beyond the Basics topics (see "Patient education: Diverticular disease (Beyond the Basics)" and "Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Colonic diverticular bleeding is the most common cause of brisk hematochezia (maroon or bright red blood). It occurs in approximately 15 percent of patients with diverticulosis, and is massive in approximately a third. The right colon is the source of colonic diverticular bleeding in 50 to 90 percent of patients. (See 'Epidemiology' above.)

Bleeding stops spontaneously in 75 percent of patients, but the risk of rebleeding is high (up to 50 percent after two episodes). Since many patients with colonic diverticular bleeding are older adults and have comorbid conditions, morbidity and mortality rates from colonic diverticular bleeding together are approximately 10 to 20 percent. (See 'Natural history' above.)

Painless hematochezia is the typical presentation of a diverticular bleed, though some patients report bloating, cramping, or the urge to defecate. (See 'Symptoms' above.)

On examination, patients may be normotensive if the bleeding has stopped. However, if the bleeding is severe and ongoing, patients may be tachycardic and hypotensive. Poor skin turgor, dry skin, oliguria, and altered level of consciousness are late signs of severe bleeding. (See 'Physical examination' above.)

The initial hemoglobin in patients with overt gastrointestinal bleeding will often be at the patient's baseline because the patient is losing whole blood. With time (typically after 24 hours or more), the hemoglobin will decline as the blood is diluted by the influx of extravascular fluid into the vascular space and by fluid administered during resuscitation. (See 'Laboratory tests' above.)

The diagnosis of colonic diverticular bleeding may be made with a colonoscopy or radiographic imaging. Once initial resuscitation is complete and an upper gastrointestinal source for the bleeding has been excluded, the test of choice is a colonoscopy (table 1). Colonoscopy can be used to localize the site of bleeding and provide endoscopic therapy. If colonoscopy fails to reveal a source, nuclear scintigraphy (tagged red blood cell scan) followed by angiography may be able to localize the bleeding site. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies'.)

The management of colonic diverticular bleeding includes resuscitation and, if the bleeding does not stop spontaneously, treatment of the bleeding site. (See 'Resuscitation' above.)

If active bleeding or a visible vessel (similar to stigmata of ulcer hemorrhage) can be localized to a particular diverticulum during colonoscopy, endoscopic therapy can be attempted. (See 'Endoscopic therapy' above.)

Angiography is an alternative to colonoscopy for treatment in cases where the bleeding site cannot be identified with colonoscopy or if a bleeding site is identified but attempts to stop the bleeding endoscopically are unsuccessful. (See 'Angiography' above.)

If the bleeding cannot be controlled with endoscopic or angiographic therapy, or if there is persistent instability despite aggressive resuscitation, surgery is typically required. (See 'Surgical intervention' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Tonia Young-Fadok, MD, who contributed to an earlier version of this topic review.

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