Diverticular bleeding: An appraisal based on stigmata of recent hemorrhage

Diverticular Bleeding: An Appraisal Based On Stigmata of Recent Hemorrhage Dennis M. Jensen, MD

Diverticulosis of the colon is often diagnosed as the bleeding site in patients who are hospitalized with severe hematochezia and anemia. In the past, indirect evidence, such as the presence of diverticula on barium enema or elective colonoscopy, was used to make a diagnosis and plan therapy. Surgery was considered definitive management. Various investigators are now recommending a change in this approach because of reports of the success of thoroughly cleansing the colon of blood and clots, the safety and efficacy of urgent colonoscopy, the recognition of incidental diverticulosis, and finding of stigmata of diverticular hemorrhage. Also, there are reports that the outcomes of definitive diverticular hemorrhage are significantly improved by endoscopic treatment, compared with medical-surgical therapy, for active bleeding or nonbleeding visibte vessels or adherent clots. Furthermore, long-term medical therapy of patients with definitive diverticular hemorrhage (after endoscopic hemostasis) and presumed diverticular hemorrhage appears to prevent most recurrences of colonic diverticular hemorrhage. In other words, surgery to prevent an inevitable recurrence of diverticulosis is not required. A standardized approach to patients with severe hematochezia and colonic diverticulosis is discussed and recommended. Copyright 9 2001 by W.B. Saunders Company

major medical centers, most gastroenterologists do not perform urgent colonoscopy for patients with severe hematochezia. They have been taught to perform elective colonoscopy after the patient stops bleeding. Alternatively, emergency visceral angiography or surgery (eg, hemicolectomy or subtotal colectomy) is favored for patients with recurrent or ongoing severe colonic bleeding that is presumed to be from diverticulosis. *-6 In contrast, there are reports that urgent colonoscopy after bowel purge to thoroughly cleanse the colon of blood, clots, and stool is the most accurate, effective, and efficient method for diagnosis and treatment of severe colonic bleeding and diverticular hemorrhage. 1-3 The purposes of this report are to (1) define diverticular hemorrhage according to major stigmata of recent hemorrhage, (2) describe different stigmata of diverticular hemorrhage, (3) discuss colonoscopic techniques for treatment of definitive diverticular hemorrhage, (4) describe outcomes of patients with definitive diverticular hemorrhage who are managed with medical-surgical therapy versus medical-colonoscopic treatment, and (5) discuss long-term management for prevention of recurrent diverticular hemorrhage.

Methods D

iverticulosis of the colon is often diagnosed as the bleeding site in patients who are hospitalized for severe hematochezia and anemia, t2 In most reports, the diagnosis is based on the indirect evidence of finding diverticulosis on elective colonoscopy, barium enema, or computerized tomography (CT) with oral contrast. However, the CURE Hemostasis Research Group has recommended that the diagnosis of diverticular hemorrhage be based on finding stigmata of recent hemorrhage on a diverticulum (such as active bleeding, a nonbleeding visible vessel [NBVV], or an adherent clot), as with the diagnosis of ulcer hemorrhage, which is diagnosed when stigmata of hemorrhage are found on peptic ulcers in the face of severe upper gastrointestinal (UGI) hemorrhage. 2,3 Whereas emergency endoscopic diagnosis and treatment for UGI hemorrhage has become standard over the last 10 years in From CURE: Digestive Disease Research Center, UCLA Center for the Health Sciences, and the VA Greater Los Angeles Healthcare Center, Los Angeles, CA. The clinical research was supported in part by NIH K24-DK 02650, the Center for Ulcer Research and Education (CURE) NIH-DK 41301-Human Studies CORE, and UCLA CRC NIH MO1-RR 00865. Address reprint requests to Dennis M. Jensen, MD, CURE Digestive Disease Research Center, BIdg 115, Rm. 318, VA Greater Los Angeles Healthcare Center, 11301 Wilshire BIvd, Los Angeles, CA 90073-1003. E-mail: [email protected] Copyright 9 2001 by W.B. Saunders Company 1096-2883/01/0304-0003535.00/0 doi:l 0.1053/tgie.2001.27860

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Definition of Diverticular Hemorrhage Definitive diverticular hemorrhage is diagnosed when there are stigmata of recent hemorrhage found in diverticula on colonoscopy or at surgery (Table 1). Adequate cleansing of the colon with purge and target water jet irrigation facilitate identification of stigmata at urgent colonoscopy. Presumptive diverticular hemorrhageis defined when only colonic diverticulosis is found and no other potentially bleeding lesions (including large internal hemorrhoids, angiomas, or peptic ulcers) are found on colonoscopy, anoscopy, and enteroscopy. Incidental diverticulosis is described when colonic diverticulosis is evident, but another site of bleeding is diagnosed as the cause of severe hematochezia.3 For patients hospitalized with colonic diverticulosis and severe hematochezia who were studied prospectively with urgent colonoscopy after purge, approximately 50% were bleeding from nondiverticular sources. They had incidental diverticulosis (Fig 1). By contrast, about 30% had presumed diverticular hemorrhage, and 20% had definitive diverticular hemorrhage. The acute and long-term treatments of the patients in these 3 subgroups differ substantially and are discussed below.

General Recommendationsfor Acute Management of Severe (Presumed) Diverticular Bleeding The CURE Hemostasis Research Group has prospectively evaluated a large number of patients who were hospitalized with

Techniques in Gastrointestinal Endoscopy, Vol 3, No 4 (October), 2001: pp 192-198

TABLE 1. Definitions of Diverticular Hemorrhage Definitive diverticular bleed--major stigmata on a diverticulum found on urgent coIonoscopy or s~rgery Presumptive diverticular bleed--diverticulosis wathout stigmata or other lesions found by colonoscopy, anoscopy, and enteroscopy Incidental diverticulosis--diverticulosis present, but another site of bleeding is identified

severe hematochezial, 2 (see the report byJensen 7 in this issue of the journal). For all patients who have presumed colonic bleeding sites, the colon is prepared with a sulfate purge prior to urgent colonoscopy (Table 2). Usually 6 L to 8 L of purge are required over 3 to 4 hours, either orally or via nasogastric (NG) tube. to cleanse the colon of stool, clots, and blood. Urgent colonoscopy is defined as colonoscopy that is performed 6 to 12 hours after hospitalization or consul Lation for severe hematochezia and within 1 to 2 hours after a physician witnesses clearance of the colon of blood, clots, and stool. Resuscitation and monitoring are continued during the preparation and colonoscopy. A video colonoscope with a 3.8 mm (or larger) suction channel and a separate target water jet irrigation port facilitates urgent target colonoscopy with washing and suctioning of residual fluids, stool, blood, or clots.

Endoscopic Treatment Techniques Because of high rates of further hemorrhage, transfusion, and surgery of patients with definitive diverticular hemorrhage who are treated with medical therapy, endoscopic hemostasis has been applied in an attempt to improve initial hemostasis. We based colonoscopic treatment on previous laboratory studies of coagulation in the right colon 8 and a pilot study in patients with definitive diverticular hemorrhage and NBVVs. 9 Colonoscopic treatments have not been standardized among U.S. gastroenterologists, but tlre CURE Hemostasis Research Group does have current recommendations (listed in Table 3). These guidelines are similar to our current recommendations for ulcers with the same stigmata of hemorrhage; however, for diverticular hemorrhage, we use a lower concentration of epinephrine (1:20,000 v 1:10,000), lower power settings (10 to 12 W v 14 to 20 W), shorter treatment pulses (1 to 2 sec v 5 to 10 sec), and less tamponade pressure (moderate v firm to very firm). The small diameter probe is more commonly used for hemostasis of definitive diverticular hemorrhage than for peptic ulcer hemorrhage.

India Ink Tattooing After endoscopic hemostasis, the diverticulum with the stigma of hemorrhage is tattooed with India lnk in 3 to 4 areas near the

Definitive TI Bleed 20%

Incidental Diverticulosis 50%

Presumptive TIC Bleed 30% Fig 1. Prevalence of incidental diverticulosis, presumptive, and definitive diverticular. DIVERTICULAR BLEEDING

TABLE 2. General Recommendations for Acute Management of (Presumed) Severe Diverticular Bleeding Resuscitate patients and correct coagu!opathies Purge patients and have medical doctor check rectal effluent Use large channel colonoscope with separate water jet port Target wash and suction fluids, blood, and clots Use combination therapy for definitive diverticular hemorrhage and tattoo area (India ink) Source: CURE Hemostasis Research Group

diverticulum. 2,3a~ This facilitates localization of the diverticulum with repeat colonoscopy, for surgical resection should severe rebleeding or a complication occur, and for histopathology, if resection is done (Fig 2).

Natural History by Stigmata of Hemorrhage and Treatment Recommendations Stigmata of Diverticular Hemorrhage The CURE Hemostasis Research Group has reported classifying patients with severe diverticular hemorrhage according to stigmata of hemorrhage, as with peptic ulcer hemorrhage. >3 Rates of further (ie, ongoing or recurrent) bleeding were defined from a previous prospective study of different stigmata of diverticular hemorrhage with medical treatment.

Active Bleeding Figure 3 shows an example of active bleeding from a divertic-

u[um. Bleeding varies from continued oozing bleeding (which does not clear with water jet target irrigation) to severe pulsatile arterial-type bleeding. Spurting bleeding is very uncommon from diverticula on urgent colonoscopy. In approximately 50% of cases active bleeding is found with another stigmata, such as an adherent clot or a visible vessel. The location of the bleeding point at the neck of the diverticulum is as common as bleeding from the base of the diverticulum. Figure 4 is a summary of the natural history data or outcomes of patients in an initial prospective study of urgent colonoscopy and medical therapy for patients with active diverticular hemorrhage. 3 Two thirds had further bleeding that required more transfusions of red cells after the resuscitation and the urgent colonoscopy. Half of the patients had more than 3 additional units of red cell transfusions for severe ongoing or recurrent bleeding, and they required emergency surgery for hemostasis. 1,3

TABLE 3. Hemostasis of Definitive Diverticular Hemorrhage (CURE Hemostasis Research Group)

Epi 1:20,000 Other Thermal Power setting (watts) Pulses (sec) Tamponade pressure Endpoint

Active Bleed

NBVV

Clot

Yes Wash GP* 10 to 12 1 to 2 Moderate Stop bleeding

No Wash GP 10 to 12 1 to 2 Moderate W flatten

Yes Guillotine off clot GP 10 to 12 1 to 2 Moderate W flatten

Abbreviations: GP, bipolar coagulation with a Gold Probe, probe size 7F or 10F diameter; NBW, nonbleeding visible vessel. 1 93

Fig 2. India Ink tatooing of a definitive diverticular hemorrhage, after coagulation.

Fig 3. Active bleeding from a colonic diverticulum; this was in the descending colon.

Fig 5. A nonbleeding visible vessel in a colon diverticulum.

Fig 7. Nonbleeding adherent clot was in a single sigmoid diverticulum and could be suctioned out only after epinephrine injection and forceful target irrigation.

Nonbleeding Visible Vessels (NBVVs)

For an example of an NBVV, refer to Figure 5. Most of the NBBVs were located at the m o u t h or neck of the diverticulum, rather than in the base3.9; these are raised lesions that are resistant to target irrigation. Most often the color of the visible vessel is a shade of red. The sizes are 2 m m to 4 m m in diameter, as measured by a probe of k n o w n size. These N B W s are not

In the same prospective study of the natural history of diverticular hemorrhage, patients who were found to have NBVVs and adherent clots were treated medically.l,3 For rebleeding, transfusions were given, and, if more than three additional units of red cells were transfused, emergency surgery was performed.

Fig 10. Sequence of treatment of active bleeding from a diverticulum. Combination epinephrine injection and Gold probe were used.

194

Fig 11. Sequence of treatment of a nonbleeding visible vessel in a diverticulum. Gold probe was used for target irrigation, moderate tamponade, and coagulation of the nonbleeding visible vessel at the neck of a hepatic flexure diverticulum. DENNIS M. JENSEN

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Fig 4. Outcomes of diverticular hemorrhage for medicalsurgically managed patients: active bleeding.

Fig 8. Outcomes of diverticular hemorrhage for medicalsurgically managed patients: adherent clots.

associated with an ulcer, erosion, or exudate; however, edema and erythema of the diverticulum are common. Cumulatively, approximately 31% of patients with definitive diverticular hemorrhage have had an NBVV. The rebleeding and emergency surgery rates for patients included in the CURE Hemostasis Group's prospective natural history study are presented in Figure 6.3 Half of the patients had further bleeding, and 25% required emergency surgery for severe rebleeding with transfusions of more than 3 umts of red cells in addition to those for initial resuscitation. ~,3

on urgent colonoscopy in patients with severe hematochezia. Approximately 60% of the stigmata were found in the right colon (eg, at or proximal to the hepatic flexure) even though the diverticula were usually more numerous in the left colon (eg, splenic flexure and distally).

Nonbleeding Adherent Clot The identification of an adherent clot on a single diverticulum (Fig 7) is greatly facilitated by adequate purging to cleanse the colon of nonadherent clots and blood. This stigma is defined as a single diverticulum with a clot that is adherent, cannot be suctioned off, obscures the underlying stigma, and is resistant to water jet irrigation. 3 Approximately 31% of patients with definitive diverticular hemorrhage had this stigma in recent studies by the CURE Hemostasis Research Group. Rebleeding and emergency surgery rates for patients who were included in the prospective natural history study of the CURE Hemostasis Research Group are shown in Figure 8. For patients with adherent clots who were treated medically, 43% had rebleeding that required additional transfusions of red blood cells, and 29% required emergency surgery. 1,3

Prevalence of Different Stigmata For patients with definitive diverticular hemorrhage, the most prevalent stigma was active bleeding (38%), followed by NBBV (31%), and adherent clot (31%) (Fig 9). These were diagnosed Percent

so 40

50%

For a summary of actively bleeding colonic diverticulosis, refer to Table 4. In our experience with active diverticular bleeding, 100% of patients have had initial endoscopic hemostasis. Rebleeding is probably more common with epinephrine injection alone as compared with combination therapy. Refer to Figure 10 for a sequence of treatment of active bleeding from a diverticulum. Note that initially an adherent clot was found, but once this was washed with gentle irrigation, active bleeding was found. Table 5 is a summary of findings and recommendations for patients with severe hematochezia and NBBVs on diverticulosis. After thermal (or combination therapy), no patient with severe diverticular hemorrhage and this stigma of hemorrhage has rebled. 3,9 Refer to Figure 11 for a treatment sequence for an NBVV in a diverticulum. Table 6 includes a summary of observations and recommendations about patients with severe lower gastrointestinal (GI) hemorrhage and an adherent clot on a diverticulum. With combination endoscopic therapy of this stigma of diverticular hemorrhage, no patient has had rebleeding or complications. 3 The epinephrine injection and shaving down the clot to a pedicle has not precipitated active bleeding in patients for whom the clot cannot be washed or suctioned off. This technique of guillotining off the clot has facilitated visualization and treatment of the underlying stigma, which is usually an NBVV. Results with this treat-

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Active Bleed 38%

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RebleedMore RBC'S

Severe Rebleeding

Emergency Surgery

Fig 6. Outcomes of diverticular hemorrhage for medicalsurgically managed patients: nonbleeding visible vessel. DIVERTICULAR BLEEDING

NBVV 31%

Fig 9. Stigmata of severe diverticular hemorrhage. 1 95

TABLE 6. Adherent Clot in a Diverticulum

TABLE 4. Active Bleeding From a Diverticulum Prevalence: 38% of definitive diverticular bleeds More bleeding in 67% on medical therapy alone Often from neck or base of diverticulum May be associated with visible vessel or adherent clot Consider combination therapy Source: CURE Hemostasis Research Group

ment technique are similar to those of similar treatment techniques of peptic ulcers with adherent clots. 1~

Comparative Outcomes of Definitive Diverticular Hemorrhage: Medical-Surgical Versus MedicalColonoscopic Treatment A total of 32 patients with definitive diverticular hemorrhage have been diagnosed and treated in 2 sequential prospective CURE Hemostasis trials. 1,3 The first 17 were treated medically and not colonoscopically. Patients with recurrent or continued bleeding were kept in an intensive care unit (ICU), were transfused further, and were not fed orally. Urgent surgery was performed for more bleeding and transfusion of at least 3 additional units of packed red blood cells (RBCs) in addition to those transfusions for initial resuscitation. The next 15 patients were all treated medically (with ICU care, transfusion, and, when applicable, correction of coagulopathies) and with colonoscopic hemostasis. When possible, combination therapy was used for active bleeding or adherent clots, and bipolar coagulation alone was used for NBBVs. Table 7 summarizes clinical and endoscopic findings in the 32 patients with definitive diverticular hemorrhage. All patients were in their mid 60s in age and had other comorbidity, and many were ingesting aspirin (ASA) or nonsteroidal anti-inflammatory agents (NSAIDs) prior to hospitalization for severe hematochezia. Multiple transfusions of RBCs were necessary for initial resuscitation. All patients had oral purges and urgent colonoscopy, The outcomes of treatments for diverticular hemorrhage are shown in Table 8. After urgent colonoscopy, 53% (9/17) of the patients with medical-surgical treatment had more transfusions. Hemorrhage stopped in 3 of these with transfusion of 2 or less units of RBC and with medical treatment. Severe bleeding that required 3 or more additional units of RBCs and emergency surgery was documented in the other 6 patients. Two patients who had had surgery developed complications postoperatively: one had pneumonia and another had a wound infection. The median time to discharge after colonoscopy was 5 days, in patients who were managed with medical-surgical therapy. For patients who had colonoscopic hemostasis, only one (7%) rebled and required hemicolectomy. The median time to discharge after colonoscopy was 2 days. No complications of the colonoscopic hemostasis were found during prospective follow-up. Although the numbers of patients treated with different en-

TABLE 5. Nonbleeding Visible Vessel in Diverticulum Prevalence: 31% of definitive diverticular bleeds More bleeding in 50% on medical therapy alone Often found on neck of the diverticulum Consider thermal therapy to coagulate at low power and moderate tamponade pressure to flatten the vessel Source: CURE Hemostasis Research Group

196

Prevalence: 31% of definitive diverticular bleeds More bleeding in 43% on medical therapy alone May be seen with active bleeding Consider epinephrine injection, cold guillotining off clot and thermal coagulation of pedicle or underlying stigma. Source: CURE Hemostasis Research Group

doscopic hemostasis techniques was small, there was a trend in outcomes. For the 3 patients who were treated with epinephrine alone, one rebled and required surgery. In comparison, for 6 patients with active bleeding or clots treated with combination therapy and 6 patients with NBBVs treated with Gold probe, none rebled. In general, definitive diverticular hemorrhage, once diagnosed, has been easier to treat endoscopically than severe ulcer hemorrhage. This probably relates to the smaller size of the underlying artery and the fact that spurting bleeding and inability to clear the endoscopic field are uncommon with diverticular hemorrhage but common with spurting peptic ulcers. Combination epinephrine and thermal therapy has been more effective than epinephrine injection alone. The short-term rebleeding rate from a diverticulum after epinephrine injection treatment alone bas been higher than thermal therapy with bipolar coagulation or combination injection plus thermal coagulation (0% rebleeding rate). In all likelihood, vasoconstriction with epinephrine alone does not thrombose or obliterate the underlying artery as effectively as thermal coaptive coagulation, and therefore further hemorrhage may result. 12,13At this time there are no prospective randomized studies that compare different treatment results or histopathologic effects of coagulation or epinephrine injection on the artery causing the diverticular hemorrhage, and only preliminary data are available. Also, there are no large prospective studies of different treatments. Only case reports with different therapies such as hemoclips, heater probe, or injection of fibrin glue or epinephrine have been published5 *-19

Secondary Prevention and Long-Term Follow-Up Before discharge from the hospital, all patients with presumptive or definitive diverticular hemorrhage are counseled about long-term management as secondary prevention of recurrent diverticular hemorrhage (Table 9). Patients are instructed to take high-fiber diets with supplemental psyllium (eg, Metamucil [Procter & Gamble, Cincinnati, OH] or Citrucel [Smith-

TABLE 7, Clinical and Endoscopic Findings in 32 Patients With Definitive Diverticular Hemorrhage

Variable

MedicalSurgery (N = 17)

Age (y) 66 + 3 Comorbidity (%) 100% Recent ASA/NSAID use (%) 18% Initial URBCs before colonoscopy 6.0 + 1.2 Endoscopic findings, number of patients (%) Active bleeding 6 (35%) Nonbleeding vessel 4 (24%) Adherent clot 7 (41%)

MedicalColonoscopic ( N - 15) 67 _+ 4 100% 27% 4.8 + 1.4 5 (33%) 6 (40%) 4 (27%)

Abbreviations: ASA, aspirin; NSAID, nonsteroidal anti-inflammatory drug; URBC, units of red blood cells transfused. DENNIS M. JENSEN

TABLE 8. Outcomes of Treatments for Diverticular Hemorrhage MedicalSurgical

MedicalCelonoscepic

Variable

(N = 17)

(N = 15)

Endoscopic hemostasis: number (%) Additional bleeding: number (%) Severe bleeding: number (%) Emergency surgery: number (%)

0 9 (53%) 6 (35%) 6 (35%)

Median time to discharge after colonoscopy (days) Complications: number (%)

5 2 (12)

15 (100%)* 1 (7%)* 1 (7%)* 1 (7%)* 2 0

TABLE 10. Recurrence of Severe Hemorrhage on Medical Therapy Long-Term Definitive diverticular hemorrhage Study 1 (11 pts without surgery) Study 2 (all 15 pts) Presumptive diverticular hemorrhage Study 2 (all 35 pts) Total recurrence

0/26

0 of 11 0 of 15

Incidental diverticulosis

2 of 35 (5.7%) 2 of 61 (3.3%)

about 33%

*Mean 36 months F/U.

Source: CURE Hemostasis Research Group

*p < 0.05

kline Beecham Consumer Healthcare, Pittsburgh, PA]) and control constipation with stool softeners or laxatives. They are cautioned to abstain from nonselective NSAIDs, aspirin, gingko, and anticoagulants. Iron-deficiency anemia is treated with iron supplements and foods with high iron content. In addition, patients are instructed to avoid small hard seeds, popcorn, and nuts with husks or shells. These recommendations are reinforced at regularly scheduled GI clinic visits. Table 10 details the recurrence rates of severe diverticular hemorrhage on medical therapy during long-term follow-up. For 11 patients with definitive diverticular hemorrhage from Study 1 (the medical-surgical therapy) who did not require surgery and 15 patients from Study 2 (the medical-colonoscopic study), there have been no recurrences of diverticular bleeding (0 of 26, 0%) during a mean of 36 months of followup. For the 35 patients with presumptive diverticular hemorrhage, 2 (5.7%) have rebled during long-term follow-up. One was related to warfarin anticoaguladon, and another to NSA1D ingestion. The cumulative recurrence rate of diverticular hemorrhage among patients with either definitive or presumptive diverticular hemorrhage has been 3.3% for 36 months of follow-up. Compared with other patients of similar age and comorbidities, the recurrence rate of severe hematochezia has been 33 % for 45 patients with incidental diverticulosis during 3 years of follow-up.

Discussion And Summary Lower GI bleeding is a common reason for hospital admission, particularly in elderly patients. Among the causes, diverticular hemorrhage is the most common in older, retrospective studies, where the diagnosis was based on indirect evidence such as radiologic studies or elective colonoscopy that showed diverticulosis. >3 In the past, surgical resection, often with subtotal colectomy for removal of all visible diverticula, was the treatment of choice. 5,6 Previously, gastroenterologists had been

TABLE 9. General Recommendations for Chronic Management of Patients With Severe Diverticular Bleeding Stop NSAIDs, ASA, gingko, anticoagulants Control constipation with fiber, laxatives, stool softeners Schedule regular gastrointestinal clinic follow-ups Treat residual iron deficiency anemia Abstain from eating small hard seeds, nuts with husks or shells, and

popcorn Abbreviations: ASA, aspirin; NSAID, nonsteroidal anti-inflammatory drug. DIVERTICULAR BLEEDING

taught that radiologic diagnosis and surgical therapy were the standard of care of patients with presumed diverticular hemorrhage. 4-6 However, the diagnosis of lower GI bleeding and, in particular, the treatment of patients with diverticular hemorrhage is beginning to change. This is based on reports of first purging the colon to thoroughly cleanse it of blood and stool, of performing urgent colonoscopy within 6 to 12 hours of presentation, 1-3 and of recognizing stigmata of diverticular hemorrhage. 2,3,9 Meanwhile, there are reports that about 50% of patients with colonic diverticulosis have a nondiverticular site of bleeding when urgent colonoscopy after purge is performed.13 Most of these patients will not benefit acutely or chronically from surgical resection of the diverticulosis unless the resection margin includes the nondiverticular source of hemorrhage. For definitive diverticular hemorrhage, thermal or combination epinephrine and thermal coagulation has been much more effective than medical management for definitive hemostasis (Table 3). There have been no complications of colonoscopic hemostasis with these techniques for treatment of consecutive patients with definitive diverticular hemorrhage by the CURE Hemostasis Research Group. Others have used other endoscopic methods in case reports to successfully treat different stigmata of diverticular hemorrhage.>-~9 For patients with a severe index hemorrhage that is presumed to be from diverticulosis and not treated with initial surgery, high recurrence rates of hemorrhage (38% to 50%) have been reported from retrospective surgical series. 3,5,6 High recurrence rates of diverticular hemorrhage are often cited as the rationale for early surgery in patients with diverticular hemorrhage to prevent recurrence as they become older. 5,6 Now another approach for acute and long-term management is now feasible and recommended. Patients with diverticulosis and severe GI hemorrhage can be triaged and managed based on their subgroup findings after thorough purge and during careful urgent colonoscopy: incidental diverticulosis, presumed diverticular hemorrhage, and definitive diverticular hemorrhage. Those with definitive diverticular hemorrhage are treated endoscopically. These patients and patients with presumed diverticular hemorrhage are then placed on chronic medical therapy to prevent recurrence (Table 9). For patients who were followed-up for a mean of 3 years after initial presumed or definitive diverticular hemorrhage, the cumulative recurrence rate of diverticular hemorrhage has been 3.3%. This is in contrast to surgical series, which report 38% to 50% recurrence, and to our patients with incidental diverticulosis who had a 33% rebleeding rate from nondiverticular sources in 36 months of follow-up. With the endoscopic approach presented,

197

surgical therapy for removal of diverticulosis should be reserved for patients with colonoscopically documented presumed or definitive diverticulosis hemorrhage who fail medical and colonoscopic management.

Acknowledgment The author thanks his colleagues, who are members of the CURE Hemostasis Research Team, for their collaboration and support: Gustavo Machicado, MD, Thomas O.G. Kovacs, MD, Rome Jutabha, MD, Ian Gralnek, MD, and Gareth Dulai, MD. The author also thanks Julie Pham for the word processing and administrative support of these efforts and Ken Hirabayashi for preparing the graphics.

References 1. Jensen DM, Machicado GA: Diagnosis and treatment of severe hematochezia: The role of urgent colonoscopy after purge. Gastroenterology 195: 1569-1574, 1988 2. Jensen DM, Machicado GA: Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding: Routine outcomes and cost analysis. Gastrointest Endosc Clin N Am 7: 477-498, 1997 3. Jensen DM, Machicado GA, Jutabha R, et al: Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 342:78-82, 2000 4. Baum S, Athanasoulis CA, Waltman AC: Angiographic diagnosis and control of large bowel bleeding. Dis Colon Rectum 17: 447-453, 1974 5. Knight CD: Massive hemorrhage from diverticular disease of the colon. Surgery 42:853-861, 1957 6. McGuire HH Jr, Haynes BW Jr: Massive hemorrhage for diverticulosis of the colon: guidelines for therapy based on bleeding patterns observed in fifty cases. Ann Surg 175:847-855, 1972 7. Jensen DM: Endoscopic diagnosis and treatment of severe hematochezia. Tech Gastrointest Endosc 3:178-184, 2001 8. Jensen DM: GI endoscopic hemostasis and tumor treatment--ex-

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19.

perimental results and techniques. In: Jensen DM, Brunetaud JM, eds. Medical Laser Endoscopy. Dordrecht, the Netherlands, Klower Academic Press, pp 45-70, 1990 Savides T, Jensen DM: Colonoscopic hemostasis of recurrent diverticular hemorrhage associated with a visible vessel: a report of three cases. Gastrointest Endosc 40:70-73, 1994 Hyman N, Waye JD: Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery. Gastrointest Endosc 37:56-58, 1991 Jensen DM: Endoscopic control of nonvariceal upper gastrointestinal hemorrhage. In: Yamada T, ed. Textbook of Gastroenterology, 3rd ed, Vol 2, pp 2857-2879. Philadelphia, Lippincott Williams & Wilkins, 1999 Johnston JH, Jensen DM, Auth D: Experimental comparison of endoscopic Yttrium-Aluminum-Garnet laser, electrosurgery and heater probe for canine gut arterial coagulation: The importance of vessel compression and avoidance of tissue erosion. Gastro 92: 1101-1108, 1987 Randall GA, Jensen DM, Hirabayashi K, et al: Controlled study of different sclerosing agents for coagulation of gut arteries. Gastro 96:1274-1281, 1989 Johnston J, Sones J: Endoscopic heater probe coagulation of the bleeding colonic diverticulum. Gastrointest Endosc 32:160, 1986 (abstr) Ramirez FC, Johnson DA, Zierer ST, et al: Successful endoscopic hemostasis of bleeding colonic diverticula with epinephrine injection. Gastrointest Endosc 43:167-170, 1996 Kim YI, Marcon NE: Injection therapy for colonic diverticular bleeding: A case study. J Clin Gastroenterol 17:46-48, 1993 Andress HJ, Mewes A, Lange V: Endoscopic hemostasis of bleeding diverticulum of the sigma with fibrin sealant. Endoscopy 25:193, 1993 Bertoni G, Conigliaro R, Ricci E, et al: Endoscopic injection hemostasis of colonic diverticular bleeding: A case report. Endoscopy 22:202, 1990 Hokama A, Uechara T, Nakayoshi T, et al: Utility of endoscopic hemoclipping for colonic diverticular bleeding. Am J Gastroenterol 92:543-546, 1997

DENNIS M. JENSEN