Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Abstract

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

Keywords: colonic diverticular bleeding; colonic diverticular hemorrhage; endoscopic hemostasis; epidemiology; lower gastrointestinal bleeding.

FIGURE 1

National trends in hospitalizations for colonic diverticular bleeding and hemorrhagic gastric ulcers in Japan from 2012 to 2019^†. ^†Partially modified from Figure 1 in Reference 6.

FIGURE 2

Endoscopic images of stigmata of recent hemorrhage (SRH). (a) Colonic diverticulum with adherent clots. (b) Colonic diverticulum with a visible nonbleeding vessel (yellow arrow). (c) Active bleeding from the colonic diverticulum.

FIGURE 3

Endoscopic hemostasis for colonic diverticular bleeding (Clipping and ligation methods). (a) The diverticulum is closed in a zipper‐like manner via indirect clip placement (indirect clipping). (b) After direct clip placement of the vessel at the base of the diverticulum (direct clipping). (c) Diverticulum ligated by an elastic O‐ring (endoscopic band ligation). (d) Diverticulum ligated using a detachable snare (endoscopic detachable snare ligation).

FIGURE 4

Comparison of treatment outcomes among endoscopic hemostasis techniques in a large‐scale multicenter retrospective cohort study in Japan. (a): Comparison of treatment outcomes between direct clipping and indirect clipping. (b): Comparison of treatment outcomes between endoscopic band ligation and clipping. Note. This figure was based on references 56 and 57. Bold values indicate p < 0.05. * Adjusted odds ratios were obtained using multivariate logistic regression analysis. Adjustment for potential confounders included the eight factors of age ≥70 years, sex, heart rate ≥100 bpm, modified Charlson Comorbidity Index ≥2, extravasation on computed tomography, active bleeding, use of distal attachment, and use of water‐jet scope. Most of these were significant in the univariate analysis (p < 0.05). ** The multivariate analysis was adjusted for age, sex, and the following 15 factors that were potentially clinically important variables, most of which were found to have at least borderline significance (p < 0.10) on univariate analysis: current drinker, systolic blood pressure ≤100 mmHg, loss of consciousness, hemoglobin <12 g/dL, white blood cell >10,000 /µL, blood urea nitrogen >25 mg/dL, antiplatelet use, anticoagulant use, corticosteroid use, extravasation on computed tomography, location, early colonoscopy, bowel preparation, use of distal attachment, and use of water‐jet scope. In the analysis of the need for interventional radiology, multivariate analysis was adjusted for age, sex, and four factors found to be significant (p < 0.01) on the univariate analysis between the groups because at least 10 events per confounder were required. CI, confidence interval.

FIGURE 5

Differences in early rebleeding rates by bleeding findings and locations in a large‐scale multicenter retrospective cohort study of colonic diverticular bleeding in Japan. Note. This figure was created based on reference 88. Ligations included the snare and band ligation methods. Bold values indicate p < 0.05. ***Twelve variables that had the potential to be clinically important variables were integrated as covariates by calculating the propensity score, including performance status, systolic blood pressure ≤100 mmHg at admission, pulse rate ≥100 bpm at admission, loss of consciousness, antiplatelet use, anticoagulant use, corticosteroid use, history of colonic diverticular bleeding, early colonoscopy, bowel preparation, use of a distal attachment, and use of a waterjet scope. Thus, the multivariate analysis was adjusted for age, sex, and propensity score‐based covariates. Exact logistic regression analysis.

FIGURE 6

Endoscopic hemostatic methods for colonic diverticular bleeding considered based on the bleeding findings and location.