Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage

Background and study aims: Endoscopic band ligation (EBL) has been used for hemostasis of colonic diverticular hemorrhage. However, early rebleeding (< 30 days after EBL) has been reported in some cases. The aim of this study was to elucidate risk factors for early rebleeding after EBL in treatment of colonic diverticular hemorrhage.

Patients and methods: A total of 101 patients with definite diverticular hemorrhage treated using EBL from June 2009 to October 2014 were included in the retrospective cohort study and divided into rebleeding and non-rebleeding groups, depending on the presence or absence of early rebleeding. Patients’ ages, comorbid diseases, stigmata of recent hemorrhage (SRH) [active bleeding (AB), non-bleeding visible vessel (NBVV), or adherent clot (AC)], locations of bleeding diverticula, and eversions of the diverticula after EBL were retrospectively evaluated in each group.

Results: Early rebleeding occurred in 15 cases. The median time (range) of early rebleeding occurrence was 5 days (range, 2 h to 26 days). Early rebleeding could be managed conservatively and/or endoscopically, except in one case in which surgery was done. Multivariate analysis revealed that age under 50 (adjusted OR, 8.7; 95 % CI 1.6 – 52.5; P = 0.014) and AB (adjusted OR, 4.21; 95 % CI 1.15 – 18.1; P = 0.03) were shown to be significant risk factors. The right side of the colon carried less risk than did the left side (adjusted OR, 0.21; 95 % CI 0.04 – 0.84; P = 0.028).

Conclusions: Younger age, AB of SRH, and leftsided lesions were identified as the risk factors for early rebleeding after EBL in the treatment of colonic diverticular hemorrhage.

• References

• 1 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419-424
• 2 Chaudhry V, Hyser MJ, Gracias VH et al. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998; 64: 723-728
• 3 Newman J, Fitzgerald JE, Gupta S et al. Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding. Colorectal Dis 2012; 14: 1020-1026
• 4 McGuire Jr HH. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220: 653-656
• 5 Poncet G, Heluwaert F, Voirin D et al. Natural history of acute colonic diverticular bleeding: a prospective study in 133 consecutive patients. Aliment Pharmacol Ther 2010; 32: 466-471
• 6 Jensen DM, Machicado GA, Jutabha R et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342: 78-82
• 7 Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol 2001; 96: 2367-2372
• 8 Hokama A, Uehara T, Nakayoshi T et al. Utility of endoscopic hemoclipping for colonic diverticular bleeding. Am J Gastroenterol 1997; 92: 543-546
• 9 Yen EF, Ladabaum U, Muthusamy VR et al. Colonoscopic treatment of acute diverticular hemorrhage using endoclips. Dig Dis Sci 2008; 53: 2480-2485
• 10 Kaltenbach T, Watson R, Shah J et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol 2012; 10: 131-137
• 11 Ishii N, Hirata N, Omata F et al. Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping. Gastrointest Endosc 2012; 76: 1175-1181
• 12 Witte JT. Band ligation for colonic bleeding: modification of multiband ligating devices for use with a colonoscope. Gastrointest Endosc 2000; 52: 762-765
• 13 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
• 14 Ishii N, Itoh T, Uemura M et al. Endoscopic band ligation with a water-jet scope for the treatment of colonic diverticular hemorrhage. Dig Endosc 2010; 22: 232-235
• 15 Ishii N, Uemura M, Itoh T et al. Endoscopic band ligation for the treatment of bleeding colonic and ileal diverticula. Endoscopy 2010; 42: 82-83
• 16 Setoyama T, Ishii N, Fujita Y. Endoscopic band ligation (EBL) is superior to endoscopic clipping for the treatment of colonic diverticular hemorrhage. Surg Endosc 2011; 25: 3574-3578
• 17 Ishii N, Setoyama T, Deshpande GA et al. Endoscopic band ligation (EBL) for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382-387
• 18 Shibata S, Shigeno T, Fujimori K et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis. Endoscopy 2014; 46: 66-69
• 19 Meyers MA, Alonso DR, Gray GF et al. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976; 71: 577-583
• 20 Barker KB, Amold HL, Fillman EP et al. Safety of band ligator use in the small bowel and the colon. Gastrointest Endosc 2005; 62: 224-227
• 21 Yamada A, Sugimoto T, Kondo S et al. Assessment of the risk factors for colonic diverticular hemorrhage. Dis Colon Rectum 2008; 51: 116-120
• 22 Strate LL, Liu YL, Huang ES et al. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011; 140: 1427-1433
• 23 Niikura R, Nagata N, Akiyama J et al. Hypertension and concomitant arteriosclerotic diseases are risk factors for colonic diverticular bleeding: a case-control study. Int J Colorectal Dis 2012; 27: 1137-1143
• 24 Okamoto T, Watabe H, Yamada A et al. The association between arteriosclerosis related diseases and diverticular bleeding. Int J Colorectal Dis 2012; 27: 1161-1166