Treatment of Bleeding Colonic Diverticula by Endoscopic Band Ligation: an In-Vivo and Ex-Vivo Pilot Study

Background and Study Aims: Angiographic and surgical therapy are standards of care for persistent diverticular bleeding. Colonoscopic intervention using epinephrine injection, multipolar electrocautery, and placement of an Endoclip has not gained widespread acceptance due to concerns about complications, and the widespread management of severe lower gastrointestinal bleeding by surgeons and interventional radiologists. The utility of colonoscopic band ligation for control of diverticular bleeding was evaluated both in vivo and ex vivo.
Patients and Methods: Endoscopic band ligation of diverticula was performed on surgical resection specimens and in patients with actively bleeding colonic diverticula.
Results: In the in-vivo study, active diverticular bleeding was completely controlled in four patients by endoscopic band ligation. In two cases, a visible vessel was seen on the everted and banded diverticulum. Procedure time ranged from 45 to 140 min. The total lengths of hospital stays for the four patients were 2, 6, 14, and 35 days. The long hospital stays (> 7 days) were associated with non-gastrointestinal co-morbidity. There were no acute complications of band ligation. No rebleeding or need for surgery occurred during a follow-up period of 12 months in any of the patients. In the ex-vivo study, 11 diverticula were successfully everted and banded in five of nine surgical specimens (one right colon and four left colons). Mucosa was identified in all of the ”banded” segments. Ten of 11 ligated diverticula revealed evidence of blood vessels or submucosal tissue. The presence of subserosal fat was suggested in three of the 11 ”banded” segments, and none of the ex-vivo ligated diverticula contained muscularis propria or serosal involvement. There was no evidence of perforation.
Conclusions: Both in-vivo and ex-vivo data suggest that endoscopic band ligation may be a safe and effective therapy for actively bleeding colonic diverticula.

References

• 1 Meyers M A, Alonso D R, Gray G F, Baer J W. Pathogenesis of bleeding colonic diverticula.  Gastroenterology. 1976;  71 577-583
• 2 Zuckerman G R, Prakash C. Acute lower intestinal bleeding, 2: etiology, therapy, and outcomes.  Gastrointest Endosc. 1999;  49 228-238
• 3 Richter J M, Christensen M R, Kaplan L M, Nishioka N S. Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage.  Gastrointest Endosc. 1995;  41 93-98
• 4 McGuire H H. Bleeding colonic diverticula: a reappraisal of natural history and management.  Ann Surg. 1994;  220 653-656
• 5 Jensen D M, Machiado G A. Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding.  Gastrointest Endosc Clin N Am. 1997;  7 477-498
• 6 Farrell J J, Kelsey P B. Interventions and outcomes in significant diverticular bleeding [abstract].  Gastrointest Endosc. 1999;  49 A136
• 7 Pardoll P M, Neubrand S. Injection control of colonic hemorrhage with hypertonic saline-epinephrine solution [abstract].  Am J Gastroenterol. 1989;  84 A119
• 8 Bertoni G, Conigliaro R, Ricci E. et al . Endoscopic injection hemostasis of colonic diverticular bleeding: a case report.  Endoscopy. 1990;  22 154-155
• 9 Kim Y I, Marcon N E. Injection therapy for colonic diverticular bleeding: a case study.  J Clin Gastroenterol. 1993;  17 46-48
• 10 Ramirez F C, Johnson D A, Zierer S T. et al . Successful endoscopic hemostasis of bleeding colonic diverticula with epinephrine injection.  Gastrointest Endosc. 1996;  43 167-169
• 11 Johnston J, Sones J. Endoscopic heater probe coagulation of the bleeding colonic diverticulum [abstract].  Gastrointest Endosc. 1986;  32 A160
• 12 Savides T J, Jensen D M. Colonoscopic hemostasis for recurrent diverticular hemorrhage associated with a visible vessel: a report of three cases.  Gastrointest Endosc. 1994;  40 70-72
• 13 Jensen D M, Machicado G A, Jutabha R, Kovacs T O. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.  N Engl J Med. 2000;  342 78-82
• 14 Yoshikane H, Sakakibara A, Ayakawa T. et al . Hemostasis by capping bleeding diverticulum of the colon with clips.  Endoscopy. 1997;  29 S33-34
• 15 Steigmann G V. Endoscopic ligation of esophageal varices.  Am J Surg. 1988;  156 9B-12B
• 16 Rossini F P, Ferrari A, Spandre M. et al . Emergency colonoscopy.  World J Surg. 1989;  13 190-192
• 17 Jensen D M, Machicado G A. Diagnosis and treatment of severe hematochezia: the role of urgent colonoscopy after purge.  Gastroenterology. 1998;  95 1569-1574
• 18 Caos A, Benner K G, Manier J. et al . Colonoscopy after GoLytely preparation in acute rectal bleeding.  J Clin Gastroenterol. 1986;  8 46-49
• 19 Athanasoulis C A, Baum S, Rosch J. Mesenteric arterial infusions of vasopressin for hemorrhage from colonic diverticulosis.  Am J Surg. 1975;  129 212-216
• 20 Casarella W J, Galloway S J, Taxin R N. Lower gastrointestinal tract hemorrhage: new concepts based on arteriography.  AJR Am J Roentgenol. 1974;  121 357-368
• 21 Drapanas T, Pennington G, Kappelman M. Emergency subtotal colectomy: preferred approach to management of massively bleeding diverticular disease.  Ann Surg. 1973;  177 519-526
• 22 Eaton A C. Emergency surgery for acute colonic hemorrhage: a retrospective study.  Br J Surg. 1981;  68 109-112
• 23 Bloomsfeld R C, Rockey D C, Shetzline M A. Endoscopic therapy of acute diverticular hemorrhage.  Am J Gastroenterol. 2001;  96 2367-2372