Therapeutic high-density barium enema in a case of presumed diverticular hemorrhage

Abstract

Many patients with lower gastrointestinal bleeding do not have an identifiable source of bleeding at colonoscopy. A significant percentage of these patients will have recurrent bleeding. In many patients, the presence of multiple diverticula leads to a diagnosis of presumed diverticular bleeding. Current treatment options include therapeutic endoscopy, angiography, or surgical resection, all of which depend on the identification of the diverticular source of bleeding. This report describes a case of recurrent bleeding in an elderly patient with diverticula but no identifiable source treated successfully with barium impaction therapy. This therapeutic modality does not depend on the identification of the bleeding diverticular lesion and was well tolerated by our 86-year-old patient.

Keywords: Anemia; Diverticula; Diverticular hemorrhage; Hematochezia; Lower gastrointestinal bleeding; Therapeutic barium enema.

Fig. 1

High-density barium enema with multiple diverticula. The high-density barium (800 ml of 171.5% w/v suspension in water) was instilled by gravity into the colon. Contrast filled the colon, and after repeated position changes by the patient, numerous diverticula were noted scattered from the sigmoid colon to the cecum.

Fig. 2

Remaining barium in the diverticula at 48 h post procedure. After 48 h of liberal oral fluids and ambulation to minimize any risk of colonic impaction, the patient was able to tolerate clear liquids without any nausea, vomiting, or abdominal pain. This abdominal X-ray done 48 h after treatment showed barium remaining in the diverticula throughout the colon but largely cleared from the lumen proper.

Fig. 3

Time course of bleeding and hemoglobin level. Three bleeding episodes occurred and were assessed endoscopically. Upper endoscopies (esophagogastroduodenoscopy for the first episode and small bowel enteroscopy for the second episode) are designated by the letter E, while colonoscopies are designated by the letter C. The tagged red blood cell scan is designated by the letter T, capsule endoscopy is designated by ‘Cap’, and the numbers indicate the number of units of packed red blood cells transfused. The barium impaction therapy on day 10 is designated by the letter B.