Management of diverticular bleeding

Diverticular bleeding is a common cause of large-volume lower gastrointestinal bleeding. All patients who present with lower gastrointestinal bleeding require a risk assessment to determine the extent of bleeding and the presence of haemodynamic instability. Patients with large-volume bleeding or haemodynamic instability should be admitted to hospital because there is a possibility of further, massive bleeding. Blood transfusion may also be required.

Detailed management of antithrombotic therapy in patients with diverticular bleeding is beyond the scope of these guidelines. The decision to stop an antithrombotic drug requires a detailed risk assessment, including consideration of the patient’s presentation and degree of bleeding, and the indication for antithrombotic therapy.

Diverticular bleeding stops spontaneously in 75% of cases. If it continues, the site of bleeding may be localised with colonoscopy, red blood cell scanning, or computerised tomography angiography. Haemostasis can be achieved by urgent colonoscopy and direct treatment of the bleeding vessel with endoscopic techniques, or by selective angiography with embolisation of the bleeding vessel.

Urgent surgery should be considered in patients who continue to bleedMurphy, 2007 and:

• remain haemodynamically unstable despite resuscitation
• have had a large blood transfusion
• have failed endoscopic or radiological attempts at haemostasis.

Approximately 30 to 40% of patients who have a significant diverticular bleed have a subsequent episodeAytac, 2014.

In some cases, a colonoscopy is not performed during the hospital admission because the bleeding stops with conservative management. In these patients, a colonoscopy is recommended soon after discharge to exclude other diagnoses such as colorectal cancer.