North Shore-LIJ Health System Manhasset, NY, United States
Jacob Levenson, MD1, Anam Rizvi, MD2, Chun Kit Hung, MD2 1North Shore-LIJ Health System, Manhasset, NY; 2Hofstra North Shore-LIJ School of Medicine, Manhasset, NY
Introduction: While the first line modality for diagnosis and treatment of diverticular bleeding is colonoscopy, guidelines recommend against endoscopic evaluation in the setting of acute diverticulitis. We present a case of concurrent acute diverticulitis with diverticular hemorrhage, successfully treated endoscopically without complications.
Case Description/Methods: A 64 year old man presented with nausea, lower abdominal pain and hematochezia for 1 day. He had co-morbidities including atrial fibrillation on warfarin, coronary stents on aspirin and clopidogrel, chronic systolic heart failure, and previous deceased donor renal transplantation for IgA nephropathy. A non-contrast CT of the abdomen and pelvis showed uncomplicated mid-descending colon diverticulitis (Image 1). Hemoglobin was initially 9.8g/dL and stable. Antiplatelet and anticoagulation agents were held, and he was treated with IV antibiotics which quickly resolved his pain and bleeding.
On day 6 of admission, multiple profuse episodes of hematochezia recurred, progressing to hemorrhagic shock requiring vasopressor support. Massive transfusion protocol was initiated. Due to his chronic kidney disease and transplant status, he declined angiography and embolization given the risks of contrast injury to his renal allograft. After a thorough discussion of risks of colonoscopy including perforation in the setting of diverticulitis, an unsedated colonoscopy was performed. At 38 cm from the anal verge, active oozing amongst multiple diverticula was seen corresponding to the area of diverticulitis seen on imaging. Hemostasis was attempted with 10 mL of 1:10,000 of epinephrine injections failed. A total of 6 endoclips were then successfully deployed through the colonoscope and achieved hemostasis (Image 2). Other than mild abdominal discomfort during clip positioning, the patient tolerated the procedure well. He was discharged 6 days later without any further bleeding at 2 months follow-up.
Discussion: This case report represents a rare presentation of concurrent diverticulitis and hemorrhage. It also is the first report in the literature where endoscopic clips are used to stop bleeding with concurrent active diverticulitis inflammation without any complications. Despite theoretical risks of perforation, when there is no clear contraindication such as free air on imaging, endoscopic therapy for bleeding with acute diverticulitis appears safe and should be considered.
Figure: Image 1. Active diverticulitis seen on sagittal CT. Image 2a. Active oozing in area of diverticula. 2b. Hemostasis achieved after clips were deployed.
Jacob Levenson indicated no relevant financial relationships.
Anam Rizvi indicated no relevant financial relationships.
Chun Kit Hung indicated no relevant financial relationships.
Jacob Levenson, MD1, Anam Rizvi, MD2, Chun Kit Hung, MD2. P2313 - Successful Endoscopic Treatment for Diverticular Bleeding With Concurrent Acute Diverticulitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.