Clinical features and treatment outcomes of colonic diverticular bleeding with stigmata of recent hemorrhage

Aims Colonic diverticular bleeding (CDB) is increasing with the increase in patients taking antithrombotic agents. Stigmata of recent hemorrhage (SRH) is defined as (i) active bleeding, (ii) non-bleeding visible vessels, or (iii) adherent clots underlying (i) or (ii) [1]. Endoscopic hemostasis is recommended in cases of CDB with SRH [1]. However, endoscopic treatment methods for CDB with SRH have not yet been established. This study aimed to evaluate the treatment outcomes of CDB with SRH.

Methods We retrospectively included consecutive patients diagnosed as CDB and underwent colonoscopy between January 2018 and December 2022 at a university hospital. The diagnostic criteria for CDB were as follows: diverticulum with SRH on colonoscopy; extravasation from diverticulum on contrast-enhanced computed tomography (CT); or cases with colonic diverticulum and no bleeding cause other than CDB. We investigated the association between SRH identification and rebleeding, and examined the treatment outcomes of each endoscopic hemostatic method for CDB with SRH.

Results A total of 89 patients were included in this study. Twenty-nine (32.6%), 13 (14.6%), and 15 (16.9%) patients were taking antiplatelet agents, anticoagulants, and NSAIDs, respectively. Forty-six (51.7%) patients underwent contrast-enhanced CT scans before colonoscopy, of whom 13 (14.6%) had extravasation. SRH was identified in 30 patients (33.7%). The proportion of men and patients on antithrombotic medication was significantly higher in the SRH-identified group. (83.3% vs. 62.7%, P=0.045; 46.7% vs. 25.4%, P=0.043). The rate of extravasation on contrast-enhanced CT tended to be higher in the SRH-identified group (26.7% vs. 11.7%, P=0.09). The rate of rebleeding within 30 days tended to be lower in the SRH-identified group (11.7% vs. 26.7%, P=0.09). The SRH identification rate was not significantly different between early and elective colonoscopies. In the CDB with SRH cases, endoscopic hemostasis was achieved by endoscopic band ligation (EBL) in 3 cases and clipping in 27 cases (direct clipping in 7 cases and diverticular closure [indirect clipping] in 20 cases). Rebleeding within 30 days was observed in three cases in which indirect clipping was performed, whereas no rebleeding was observed in patients treated with EBL and direct clipping. Of the three rebleeding cases, one resulted in spontaneous hemostasis, while two cases were treated with interventional radiology.

Conclusions Identification and treatment of SRH on colonoscopy may reduce the risk of CDB rebleeding. SRH is more likely to be identified in men, in patients on antithrombotic treatment, and in those with extravasation on contrast-enhanced CT. Direct clipping or EBL for CDB with SRH may be more effective than indirect clipping in terms of lower rebleeding risk.

Publication History

Article published online:
27 March 2025

• References

• 1 Nagata N, Ishii N, Manabe N. et al. Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association. Digestion 2019; 99 (Suppl 1) 1-26