The ‘step-clipping’ method: a guide for identifying a previously bleeding colonic diverticulum

Abstract

Background and study aims Unsatisfactory detectability of a previously bleeding diverticulum by colonoscopy results from difficulty in precisely locating the target lesion, even with presence of an extravasation on contrast-enhanced computed tomography (CECT). This study aimed to evaluate the usefulness of the step-clipping method to overcome this limitation.

Patients and methods Step-clipping was indicated for patients with colonic diverticular bleeding and presence of extravasation on CECT, but with absence of active bleeding on subsequent colonoscopy. The target diverticulum was identified by comparing computed tomography images before and after step clipping, which provided a positional relationship between each clip and the target lesion.

Results Based on data from 21 consecutive cases meeting our inclusion criteria (14 men and 7 women; mean age, 73.2 years), the target diverticulum was endoscopically identified in 20 cases (95 %), in a median time of 5 minutes, and successfully treated. No adverse events were observed with the step-clipping method.

Conclusion Step-clipping provided easy guidance to the target site for treatment in a short time, despite spontaneous cessation of bleeding at the diverticulum.

• References

• 1 Nakatsu S, Yasuda H, Maehata T. et al. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med 2015; 54: 553-558
• 2 Obana T, Fujita N, Sugita R. et al. Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding. Dig Dis Sci 2013; 58: 1985-1990
• 3 Tamari H, Aoyama T, Nagata S. et al. “Step-clipping” method: a technique for detecting previously bleeding diverticula. Endoscopy 2018; 50: E10-E12
• 4 Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003; 163: 838-843
• 5 Aoki T, Nagata N, Shimbo T. et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570
• 6 Peery AF, Sandler RS, Ahnen DJ. et al. Constipation and a low-fiber diet are not associated with diverticulosis. Clin Gastroenterol Hepatol 2009; 11: 1622-1627
• 7 Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363: 631-639
• 8 Niikura R, Nagata N, Shimbo T. et al. Colonoscopy can miss diverticula of the left colon identified by barium enema. World J Gastroenterol 2013; 19: 2362-2367
• 9 Shimamura Y, Ishii N, Omata F. et al. Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization. Endosc Int Open 2016; 4: E233-E237
• 10 Yen EF, Ladabaum U, Muthusamy VR. et al. Colonoscopic treatment of acute diverticular hemorrhage using endoclips. Dig Dis Sci 2008; 53: 2480-2485
• 11 Farrell JJ, Graeme-Cook F, Kelsey PB. Treatment of bleeding colonic diverticula by endoscopic band ligation: an in-vivo and ex-vivo pilot study. Endoscopy 2003; 35: 823-829
• 12 Niikura R, Nagata N, Aoki T. et al. Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. J Clin Gastroenterol 2015; 49: e24-e30
• 13 Nagata N, Niikura R, Aoki T. et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy. J Gastroenterol 2015; 50: 1162-1172