Correspondence
Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage
N Engl J Med 2000; 342:1608-1611May 25, 2000
- Article
To the Editor:
Jensen et al. (Jan. 13 issue)1 report on 10 patients who had stigmata of diverticular hemorrhage and were treated endoscopically. None of the 10 had early or late episodes of recurrent bleeding (median follow-up period, 30 months). Unless diverticular hemorrhage is caused by inflammation or another reversible process, local treatment of a single diverticulum is unlikely to prevent bleeding from other diverticula (or even the index lesion). Diverticular hemorrhage appears to be caused by chronic injury of the vasa recta adjacent to the lumens of the diverticula,2 which is unlikely to be reversible. In their study, Jensen and colleagues instructed patients to ingest high-fiber foods and to avoid certain foods; there are no data suggesting that this approach prevents recurrent diverticular hemorrhage. Furthermore, although the study provides promising data on the value of colonoscopic hemostatic therapy to reduce the rate of early recurrent bleeding, the 0 percent rate of late recurrent bleeding may be unusual.
Although the risk of late recurrent bleeding after diverticular hemorrhage has not been established, it appears to be substantial. In a study by McGuire,3 late recurrent bleeding (i.e., recurrent hemorrhage after discharge from the hospital) occurred in 38 percent of 73 patients who had not received specific therapy. Although this retrospective study was subject to bias, the findings indicate that late recurrent bleeding is an important consideration in patients with diverticular hemorrhage.
Over a six-year period at our institution between 1994 and 1999, 12 patients with severe hematochezia were found unequivocally to have a specific diverticulum as a cause of bleeding. Stigmata of hemorrhage included an adherent clot, a visible vessel, and oozing blood in 3, 3, and 6 patients, respectively. All 12 patients underwent endoscopic therapy consisting of an injection of epinephrine or an injection of epinephrine plus bipolar coagulation. One patient had early recurrent bleeding that required surgery. Of the other 11 patients, 4 (36 percent) had late recurrent bleeding (which we defined as bleeding after discharge from the hospital), 1 week, 2 weeks, 11 months, and 14 months after the index colonoscopy (2 of these 4 patients required surgery).
The study reported by Jensen et al. represents an important advance in the management of colonic diverticular hemorrhage. However, caution is required in the use of endoscopic therapy for diverticular hemorrhage because of the small number of patients in whom this treatment has been studied, the limited availability of other data, and experiences such as ours.
3 ReferencesRichard S. Bloomfeld, M.D.
Michael Shetzline, M.D.
Don Rockey, M.D.
Duke University Medical Center, Durham, NC 277101
Jensen DM ,Machicado GA ,Jutabha R ,Kovacs TOG . Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78-82
Full Text | Web of Science | Medline2
Meyers MA ,Alonso DR ,Gray GF ,Baer JW . Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976;71:577-583
Web of Science | Medline3
McGuire HH Jr . Bleeding colonic diverticula: a reappraisal of natural history and management. Ann Surg 1994;220:653-656
CrossRef | Web of Science | Medline
To the Editor:
It is unusual that in 27 of 41 patients (66 percent), Jensen et al. identified the exact site of bleeding on the basis of an actively bleeding diverticulum, a nonbleeding visible vessel, or an adherent clot. Furthermore, 10 patients with a “definite” diagnosis were treated during endoscopy with an injection of epinephrine and by coapting the bleeding or visible vessel with the use of a bipolar probe.
We have been performing urgent colonoscopy in patients with hematochezia for 25 years.1 We have rarely seen a patient with a bleeding or visible vessel near the diverticulum, whether we used a purge or did not clean the colon. We have noticed increased bleeding with large-volume purges, which may dislodge a formed clot, resulting in more bleeding and requiring more aggressive treatment.
The outcome for patients with diverticular hemorrhage is good, with a low rate of recurrent bleeding and no risk of death due to bleeding over years of follow-up.2 In our experience, the bipolar probe, considered the safest of the heater probes, is not as safe as it is claimed to be, because of the potential for intestinal perforation.3 We recommend caution in the use of heater probes. Studies should be performed to determine whether large-volume purges contribute to the need for endoscopic or surgical treatment.
3 ReferencesMohammad Farivar, M.D.
Joseph L. Perrotto, M.D., J.D.
Caritas Norwood Hospital, Norwood, MA 020621
Farivar M ,Perrotto J . The efficacy of colonoscopy in acute renal bleeding. Gastrointest Endosc 1982;28:130-130 abstract.
Web of Science2
Gostout CJ . The role of endoscopy in managing acute lower gastrointestinal bleeding. N Engl J Med 2000;342:125-127
Full Text | Web of Science | Medline3
Farivar AS ,Farivar M . A retrospective review concerning the safety of colonoscopy in patients with acute uncomplicated diverticulitis. Gastrointest Endosc 1999;49:AB75-AB75 abstract.
Web of Science
To the Editor:
Jensen et al. cite my report1 to support their statement that high rates of recurrent bleeding are often used as the rationale for early surgery to prevent a recurrence. On the contrary, at our hospital, my colleagues and I rarely recommend surgery after bleeding has stopped, even if it has recurred and stopped again. The reasons are that only 8 percent of our patients have required surgery for subsequent bleeding and that almost 20 percent of patients discharged with diagnoses of diverticular bleeding have later been found to have sources of bleeding other than diverticula. These observations illustrate the rule that surgeons who operate to stop bleeding they cannot find are more often sorry than safe. The work of Jensen et al. will reduce the number of operations but will not completely eliminate the need for scintigraphy, arteriography, and surgery.
1 ReferencesHunter H. McGuire, Jr., M.D.
Virginia Commonwealth University, Richmond, VA 232981
McGuire HH Jr . Bleeding colonic diverticula: a reappraisal of natural history and management. Ann Surg 1994;220:653-656
CrossRef | Web of Science | Medline
To the Editor:
Jensen et al. report a presumptive diagnosis of diverticular hemorrhage in 14 of 48 patients in the group that received medical and colonoscopic treatment. Further evaluation with mesenteric angiography might have been helpful in identifying the site of hemorrhage. Mesenteric angiography has detected the cause of “obscure gastrointestinal bleeding” in over 50 percent of patients.1 Catheter-directed therapy has a success rate of more than 90 percent for the immediate control of hemorrhage.2 The use of vasopressin to halt bleeding allows surgery to be elective, with a concomitant reduction in morbidity and mortality.3
3 ReferencesManu Sehgal, M.D.
Michael C. Farner, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 191051
Thompson JN ,Salem RR ,Hemingway AP , et al. Specialist investigation of obscure gastrointestinal bleeding. Gut 1987;28:47-51
CrossRef | Web of Science | Medline2
Kudela SP ,Meler JD . Diagnostic evaluation and endovascular thera-py for lower gastrointestinal bleeding. Appl Radiol 1999;28:Suppl:19-253
Browder W ,Cerise EJ ,Litwin MS . Impact of emergency angiogra-phy in massive lower gastrointestinal bleeding. Ann Surg 1986;204:530-536
CrossRef | Web of Science | Medline
To the Editor:
Superselective embolization is an additional treatment option for colonic hemorrhage. Coaxial catheter systems with 3-French inner microcatheters, which are now widely available, allow superselective arterial catheterization and endovascular treatment to be performed. Either polyvinyl alcohol particles or microcoils can be injected through these catheters directly at the site of bleeding. Although definitive clinical trials have to be performed, the results of several studies support the safety and efficacy of this technique.1-5
Embolization has several advantages over endoscopic treatment. First, aggressive bowel preparation is unnecessary. Thus, embolization can be performed without delay. In the study by Jensen et al., “urgent” colonoscopy was performed 6 to 12 hours after admission, while high-volume bowel lavage was being performed. None of the patients apparently suffered any ill effects from this delay, but in general, earlier treatment of severe hemorrhage is preferable when possible. Second, embolization can effectively stop bleeding due to any cause, not just diverticular hemorrhage. Finally, angiography does not preclude endoscopy in the event that the site of bleeding is not identified. The main limitation of endovascular therapy is that the patient must have active bleeding at the time of the procedure to allow identification and treatment of the source. Colonoscopy may identify a source of bleeding by showing adherent clots, prominent vessels, or a mass. In general, these minimally invasive techniques should be regarded as complementary rather than alternative therapies.
Endoscopy should be performed in all patients, even after successful embolization to ascertain the cause of bleeding. Of course, endoscopy can be performed electively instead of urgently if the bleeding vessel is embolized.
5 ReferencesBrian Funaki, M.D.
Jeffrey A. Leef, M.D.
University of Chicago Hospitals, Chicago, IL 60615George X. Zaleski, M.D.
Racine Radiology Group, Racine, WI 534021
Peck DJ ,McLoughlin RF ,Hughson MN ,Rankin RN . Percutaneous embolotherapy of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 1998;9:747-751
CrossRef | Web of Science | Medline2
Ledermann HP ,Schoch E ,Jost R ,Zollikofer CL . Embolization of the vasa recta in acute lower gastrointestinal hemorrhage: a report of five cases. Cardiovasc Intervent Radiol 1999;22:315-320
CrossRef | Web of Science | Medline3
Ledermann HP ,Schoch E ,Jost R ,Decurtins M ,Zollikofer CL . Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature. J Vasc Interv Radiol 1998;9:753-760
CrossRef | Web of Science | Medline4
Guy GE ,Shetty PC ,Sharma RP ,Burke MW ,Burke TH . Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol 1992;159:521-526
Web of Science | Medline5
Gordon RL ,Ahl KL ,Kerlan RK , et al. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg 1997;174:24-28
CrossRef | Web of Science | Medline
To the Editor:
Jensen et al. assumed that the bleeding originated from diverticula in 29 percent of the patients in the second of their two sequential studies, because no other colonic lesions or sites of bleeding were identified on enteroscopy. However, the authors do not provide technical information on how they performed enteroscopy.
Push enteroscopy has been reported to identify probable bleeding lesions in 10 to 40 percent of patients with obscure bleeding. In the study by Descamps et al.,1 the overall diagnostic yield of push enteroscopy performed in patients with occult bleeding was 53 percent. In the prospective study by Belaiche et al.,2 the use of an enteroscope as a colonoscope in the management of occult bleeding was of little help. Finally, with the use of intraoperative enteroscopy in the study reported by Zaman et al., the terminal ileum was reached 93 percent of the time, but the diagnostic yield in patients with obscure bleeding was 58 percent.3 Jensen et al. may have overestimated the frequency of diverticula as a source of rectal bleeding.
3 ReferencesJean Louis Frossard, M.D.
Laurent Spahr, M.D.
Raymond de Peyer, M.D.
Geneva University Hospital, 1211 Geneva 14, Switzerland1
Descamps C ,Schmit A ,Van Gossum A . “Missed“ upper gastrointestinal tract lesions may explain “occult“ bleeding. Endoscopy 1999;31:452-455
CrossRef | Web of Science | Medline2
Belaiche J ,Van Kemseke C ,Louis E . Use of the enteroscope for colo-ileoscopy: low yield in unexplained lower gastrointestinal bleeding. Endoscopy 1999;31:298-301
CrossRef | Web of Science | Medline3
Zaman A ,Sheppard B ,Katon RM . Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome. Gastrointest Endosc 1999;50:506-510
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: In response to Bloomfeld et al.: it is not known why only one diverticulum among many bleeds. We hypothesize that nonsteroidal antiinflammatory drugs and ischemia from phleboliths may cause focal diverticular hemorrhage. In our study, long-term management (the elimination of nonsteroidal antiinflammatory drugs, a high-fiber diet, and so forth) was associated with a markedly lower rate of recurrent diverticular bleeding than the reported rates in surgical studies. The rate of recurrent bleeding over a follow-up period of 30 to 36 months was 3 percent (1 of 33 patients had rebleeding): none of the 19 patients with definitive diverticular bleeding (9 patients in the first study who did not undergo surgery and 10 in the second study) had recurrent bleeding, and 1 of 14 in the group with presumptive diverticular bleeding (second study) had a recurrence. In comparison, the rate of recurrent bleeding was 38 to 50 percent in retrospective surgical studies and in the report by Bloomfeld et al. on their patients who did not receive preventive medical therapy. We believe that effective endoscopic hemostasis obliterated small vessels that caused the diverticular bleeding. An injection of epinephrine alone may not be adequate therapy for diverticula with stigmata. Therapies such as hemoclipping1 or the use of tissue glues or fibrin2 may be superior. For each issue mentioned by Bloomfeld et al., further studies are warranted.
In response to Dr. McGuire: with careful colonoscopic studies, we identified nondiverticular sources of severe hematochezia in 50 to 77 percent of our patients. These problems were treatable with endoscopic hemostasis or nondiverticular surgery. Scintigraphy and angiography for the diagnosis of diverticular hemorrhage require further evaluation, since we found that these studies were infrequently helpful in diagnosing or treating severe hematochezia.3,4
In response to Sehgal and Farner and to Funaki et al.: emergency visceral angiography is limited by three factors. Skilled radiologists must be available for emergencies, active bleeding must be present during the study, and there may be complications of the procedure. In our previous prospective study, 22 patients with very severe, ongoing hematochezia underwent both angiography and urgent colonoscopy. The diagnostic yield was 13.6 percent for angiography and 90.9 percent for colonoscopy; the complication rate for angiography was 9 percent.3,4
In response to Frossard et al., we note that 29 percent of the patients in the second study had presumptive diverticular hemorrhage on the basis of the following findings: diverticulosis but no other findings on urgent colonoscopy, negative results of push enteroscopy (at a length of 180 or 220 cm), and recurrent bleeding in only 1 of 14 patients during 30 months of follow-up. On the basis of our recent experience with push enteroscopy in 250 patients with obscure sources of bleeding, the diagnostic yield of this approach is 78 percent. These 250 patients represent a different referral population, and unlike the patients with severe hematochezia in our study,5 some of them benefited from intraoperative enteroscopy.
In response to Farivar and Perrotto: our selection of high-risk patients with diverticulosis and severe hematochezia, diligent use of colonic preparation, timing of emergency colonoscopy, use of improved video colonoscopes, and experience all contributed to our success in finding diverticula with stigmata of hemorrhage and other sites of bleeding. There is no evidence that oral purges increase gastrointestinal bleeding; rather, they facilitate complete examinations.3,5 Studies in animals and humans have shown that bipolar electrocoagulation is safer than the use of a heater probe, monopolar coagulation, or an yttrium–aluminum–garnet laser.4 However, we agree that experience, caution, and further comparative studies are warranted. In conclusion, our data suggest that the use of safe techniques and carefully performed urgent colonoscopies have the potential to treat bleeding in patients with diverticular hemorrhage and to reduce hospital stays.
5 ReferencesDennis M. Jensen, M.D.
Gustavo A. Machicado, M.D.
Center for Ulcer Research and Education–, UCLA Hemostasis Research Group, Los Angeles, CA 900731
Hokama A ,Uehara T ,Nakayoshi T , et al. Utility of endoscopic hemoclipping for colonic diverticular bleeding. Am J Gastroenterol 1997;92:543-546
Web of Science | Medline2
Andress HJ ,Mewes A ,Lange V . Endoscopic hemostasis of a bleeding diverticulum of the sigma with fibrin sealant. Endoscopy 1993;25:193-193
CrossRef | Web of Science | Medline3
Jensen DM ,Machicado GA . Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge. Gastroenterology 1988;95:1569-1574
Web of Science | Medline4
Jensen DM ,Machicado GA . Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding: routine outcomes and cost analysis. Gastrointest Endosc Clin N Am 1997;7:477-498
Medline5
Jensen DM ,Machicado GA ,Jutabha R ,Kovacs TOG . Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78-82
Full Text | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
I. Jovanovic, K. Vormbrock, C. M. Wilcox, K. Mönkemüller. (2011) Therapeutic and interventional endoscopy for gastrointestinal bleeding. European Journal of Trauma and Emergency Surgery 37:4, 339-351
CrossRef2
Bryan T. Green, Don C. Rockey. (2005) Lower Gastrointestinal Bleeding—Management. Gastroenterology Clinics of North America 34:4, 665-678
CrossRef3
Bryan T. Green, Don C. Rockey, G. Portwood, Paul R. Tarnasky, Steve Guarisco, Malcolm S. Branch, Joseph Leung, Paul Jowell. (2005) Urgent Colonoscopy for Evaluation and Management of Acute Lower Gastrointestinal Hemorrhage: A Randomized Controlled Trial. The American Journal of Gastroenterology 100:11, 2395-2402
CrossRef
