Introduction

It has been reported that most patients with colonic diverticular bleeding achieve hemostasis spontaneously. Although endoscopic hemostasis is required in some cases, it remains controversial whether early colonoscopy would contribute to prevent rebleeding and shorten length of hospital stay. Previously reported, our retrospective study showed the effectiveness of conservative treatment for non-severe cases with colonic diverticular bleeding.¹ Therefore, we aimed to conduct a prospective, single center study to establish the efficacy of conservative treatment for non-severe cases and verify that early colonoscopy is necessary only for limited cases (trial registration: UMIN000028007).

Aims & Methods

It was conducted from January 2017 and December 2022, with the patients with colonic diverticulum on computed tomography (CT), who were hospitalized due to frequent hematochezia without any other sources of bleeding. Early colonoscopy was performed within 24 hours, only when both hemorrhagic shock and extravasation on contrast-enhanced CT were present at the time of hospital visit. However, in case of failure of recovery from hemorrhagic shock, either interventional radiology (IVR) or surgery was undergone without performing early colonoscopy. In other cases, patients received conservative treatment under fasting without performing early colonoscopy. Early colonoscopy was performed after bowel preparation with carbon dioxide insufflation, water jet system and a cap attachment, and if the stigma of recent hemorrhage (SRH) was identified, hemostasis was performed by clipping method or using an over-the-scope clip. Food intake was resumed, more than 24 hours after disappearance of hematochezia.

Results

One hundred eighty patients were enrolled in this study and 14 patients met the criteria for performing early colonoscopy. Ten of 14 patients achieved endoscopic successful hemostasis, whereas four patients underwent IVR due to difficulty in recovering from hemorrhagic shock or severe bleeding. Meanwhile, 166 patients received conservative treatment, resulting in spontaneous hemostasis in 157 patients (94.0%). However, other nine patients required endoscopic intervention due to repeated rebleeding. Eight of 9 patients achieved successful endoscopic hemostasis, whereas one patient underwent surgery due to repeated severe bleeding and difficulty in identification of SRH with endoscopy. No patients died from hemorrhagic shock. Rebleeding rate within 30 days after hospitalization (15.5% in all patients, 95% confidence interval [CI]:10.9-21.4) was significant lower in conservative treatment group than in early colonoscopy group (13.8 % vs. 35.7%, P=0.0453), hospitalization costs likewise ($227.88±79.50 vs. $362.17±339.70, P=0.0079). Median length of hospital stay did not significantly differ between two groups (8 days vs. 7.5 days, P=0.0740). Moreover, the overall 1-year cumulative late rebleeding rate after 30 days of hospitalization was 10.2% in all patients, with no significant difference between the two groups. In multivariate analyses, the presence or absence of dialysis was a significant factor associated with late rebleeding (Hazard ratio 3.6, P=0.0193, 95% CI 1.26-9.08), whereas a history of hemostatic intervention and an administration of antithrombotic drugs were not.

Conclusion

Conservative treatment without performing early colonoscopy would be an appropriate and efficient treatment for the patients with non-severe colonic diverticular bleeding, except the patients with both hemorrhagic shock and extravasation on contrast-enhanced CT.

References

1. Doi H, Sasajima K, Takahashi M, Sato T, Ootsu I, Chinzei R. Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage. Can J Gastroenterol Hepatol. 2020;2020.