Introduction
Diverticular hemorrhage accounts for approximately 20 % to 48 % of lower gastrointestinal
bleeding (LGIB) and is the most commonly identifiable cause of LGIB [1]
[2]
[3]. Incidence of diverticular hemorrhage has been increasing with growing use of antithrombotic
drugs in elderly patients [4]
[5]
[6]
[7].
Diverticular hemorrhage has a less severe course than upper gastrointestinal bleeding
and stops spontaneously in 70 % to 80 % of cases [3]
[8]. However, rebleeding occurs in approximately 25 % of these patients, with some requiring
medical intervention [3]
[8]
[9]
[10]. Moreover, the recurrent bleeding rate in patients with stigmata of recent hemorrhage
(SRH) is reported to be relatively high (more than 60 %) with medication alone [11].
After identification of SRH, the current standard treatment for diverticular bleeding
is endoscopic hemostasis [11]
[12] achieved by clipping, endoscopic band ligation (EBL), endoscopic detachable snare
ligation therapy (EDSL), injection therapy, or thermal contact. EBL has been used
more frequently than clipping because the early recurrent bleeding rate after EBL
is lower than that with clipping [13]. However, adverse events (AEs) after EBL, such as diverticulitis and perforation,
have been reported, albeit rarely [14]
[15].
The endoclip approach offers the theoretical advantage of causing less damage to adjacent
tissues [16]
[17]
[18]. However, the efficacy of endoclips for diverticular bleeding remains unclear. In
the current study, we retrospectively evaluated the safety and efficacy of endoclips
versus EBL for treatment of colonic diverticular hemorrhage.
Patients and methods
Study population
This was a retrospective study of patients who underwent colonoscopy with a diagnosis
of LGIB between January 2013 and December 2018 at Nara City Hospital. Definite colonic
diverticular hemorrhage was evident in 96 of 493 patients, with SRH being observed.
SRH was defined as a densely adherent clot despite vigorous irrigation, a non-bleeding
visible vessel, or active bleeding visualized on colonoscopy, SRH allowed for unequivocal
identification of a specific diverticulum as the source of bleeding [19]
[20]. In the first session, three of these patients were treated with transcatheter arterial
embolization (TAE) instead of endoscopic therapy and 93 with endoscopic clipping or
EBL. We classified the endoscopic clipping group into a direct clipping group and
indirect clipping group. The current study was approved by the Institutional Review
Board of Nara City Hospital and all patients provided informed consent before undergoing
the procedure.
Colonoscopic examinations
All patients received standard supportive medical care for LGIB, including hemodynamic
monitoring and fluid resuscitation. Packed red blood cells (RBCs) were transfused
to correct severe anemia if necessary. Bowel preparation with polyethylene glycol
or glycerin enema was performed before colonoscopic examinations. All patients underwent
colonoscopy using water-jet scopes with a tip hood (PCF-Q260AZI or GIF-Q260 J: Olympus
Optical Company Ltd., Tokyo, Japan), and a water-jet system was used for vigorous
irrigation. To improve endoscopic visualization of colonic diverticula, we observed
the colonic diverticulum under full water immersion [21] since 2016.
Endoscopic hemostasis with endoclips (video)
We classified clipping methods into direct and indirect clipping. In the direct clipping
method,
endoclips (HX-610-090S EZ CLIP; Olympus Optical Company Ltd.) were placed directly
onto the
vessel ([Fig. 1a], [Video 1]). When direct placement of endoclips onto the vessel was not possible, the diverticulum
was closed in a zipper manner ([Fig. 1b]). In the indirect clipping method, endoscopists selected the type of endoclips (HX-610-090S,
HX-610-135, or HX-610-090 L, EZ CLIP; Olympus Optical Company Ltd.) based on the shape
of the diverticulum ([Fig. 2]). In the current study, we distinguished between direct and indirect clip placement
using endoscopic reports and colonoscopic images.
Fig. 1 Endoscopic hemostasis with endoclips. a1 Colonic diverticulum with a non-bleeding visible vessel. a2 Endoclips were placed directly onto the vessel (direct clipping). b1 Active bleeding from the colonic diverticulum. b2 The diverticulum was closed in a zipper manner (indirect clipping).
Fig. 2 Types of endoclips. a HX-610-090S (short clip). b HX-610-135 (middle clip). c HX-610-090 L (long clip); EZ CLIP, Olympus Optical Company Ltd.
Video 1 Direct clip placement.
Endoscopic hemostasis with EBL
At our institution, we introduced EBL for colonic diverticular hemorrhage in February
2016. The method of EBL used for colonic diverticular hemorrhage was the same as that
reported previously [13]
[22]
[23]
[24]. After the site of bleeding had been marked with endoclips, the colonoscope was
removed and subsequently reinserted after attachment of a band-ligator device (MD-48912S
EHL Devices; Sumitomo Bakelite Company Ltd., Tokyo, Japan). The diverticulum was pulled
via suction into the cup of the endoscopic ligator, and the elastic O-ring was released.
Further treatment for rebleeding after initial endoscopic treatment
Early rebleeding was defined as clinical evidence of recurrent LGIB within 30 days
of initial treatment [19]. If rebleeding after initial endoscopic treatment occurred, a repeat endoscopic
intervention was attempted. If diverticular rebleeding was not controlled by endoscopic
retreatment, as in the case of massive rebleeding from previously treated diverticula,
a poor endoscopic view, or hemodynamic instability, TAE or colectomy was performed
based on the clinical judgment of the attending gastroenterologist.
Statistical analysis
Ddemographics of patients, location of bleeding diverticula (cecum, ascending colon,
transverse colon, descending colon, or sigmoid colon), bleeding point in the diverticulum
(dome, neck, or unconfirmed), total procedural time, time to hemostasis after identification
of the bleeding site, rate of early rebleeding, time to discharge after initial hemostasis,
units of packed RBCs, and complications were retrospectively evaluated. Results obtained
were expressed as medians (IQR, interquartile range) for continuous variables and
proportions for categorical variables. A multilevel logistic regression analysis was
performed to identify independent risk factors associated with early rebleeding, and
odds ratios (ORs and 95 % confidence intervals (Cis) were calculated. The significance
of differences was defined as P < 0.05. All statistical analyses were performed with EZR (Saitama Medical Center,
Jichi Medical University, Saitama, Japan), which is a graphical user interface for
R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it
is a modified version of R commander designed to add statistical functions frequently
used in biostatistics.
Results
Patient characteristics
Patient characteristics in the direct clipping, indirect clipping, and EBL groups
are shown in [Table 1]. Among 93 patients, 34, 28, and 31 were in the direct clipping group, indirect clipping
group, and EBL group, respectively. In the indirect clipping group, an initial injection
of hypertonic saline epinephrine solution (HSE) for diverticula with active bleeding
was used for four patients. No significant differences were observed in age of patients,
percentage of males, rate of hypertension, hyperlipidemia, chronic kidney disease,
or heart disease, usage of nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids,
a previous history of colonic diverticular hemorrhage, hematocrit on admission, or
the shock index between the three groups. The rate of diabetes mellitus was higher
in the EBL group (P = 0.043 for the direct clipping group vs the EBL group, P values were calculated with Bonferroni corrections). The rate of cerebrovascular
disease was not significantly different by Bonferroni corrections (P = 0.058 for the direct clipping group vs the EBL group). Furthermore, the rate of
usage of antithrombotic agents was not significantly different by Bonferroni corrections
(P = 0.099 for the indirect clipping group vs the EBL group). In the direct clipping
group, nine patients were taking a single antithrombotic agent (aspirin 5, clopidogrel
2, edoxaban 1, and dipyridamole 1), while one received combination therapy (aspirin
with clopidogrel). In the indirect clipping group, five patients were taking a single
antithrombotic agent (aspirin 3, clopidogrel 1, and rivaroxaban 1), while two received
combination therapy (aspirin with clopidogrel 1, and aspirin with warfarin 1). In
the EBL group, 15 patients were taking a single antithrombotic agent (aspirin 4, clopidogrel
4, rivaroxaban 4, warfarin 2, and apixaban 1), while 2 received combination therapy
(aspirin with cilostazol 1, and aspirin with clopidogrel 1).
Table 1
Characteristics of patients who underwent endoscopic hemostasis for colonic diverticular
hemorrhage with SRH
|
Direct clipping (n = 34)
|
Indirect clipping (n = 28)
|
EBL (n = 31)
|
P value
|
|
Age, years, median (IQR)
|
75.5 (68–82.8)
|
76 (65.8–82)
|
72 (67–86.5)
|
0.757[1]
|
|
Sex, male, n (%)
|
21 (61.8)
|
15 (53.6)
|
15 (48.4)
|
0.567[2]
|
|
Comorbidity, n (%)
|
|
|
20 (58.8)
|
14 (50.0)
|
20 (64.5)
|
0.541[2]
|
|
|
5 (14.7)
|
1 (3.6)
|
4 (12.9)
|
0.342[2]
|
|
|
3 (8.8)
|
3 (10.7)
|
11 (39.3)
|
0.014[2]
|
|
|
4 (11.8)
|
2 (7.1)
|
1 (3.2)
|
0.491[2]
|
|
|
3 (8.8)
|
5 (17.9)
|
8 (25.8)
|
0.19[2]
|
|
|
2 (5.9)
|
4 (14.3)
|
9 (29.0)
|
0.045[2]
|
|
Usage of antithrombotic agents, n (%)
|
10 (29.4)
|
7 (25.0)
|
17 (54.8)
|
0.039[2]
|
|
|
9
|
5
|
15
|
|
|
|
1
|
2
|
2
|
|
|
Usage of NSAIDs, n (%)
|
8 (23.5)
|
8 (28.6)
|
14 (45.2)
|
0.185[2]
|
|
Usage of steroids, n (%)
|
1 (2.9)
|
1 (3.6)
|
0 (0)
|
0.754[2]
|
|
Previous history of colonic diverticular hemorrhage, n (%)
|
19 (55.9)
|
10 (35.7)
|
18 (58.1)
|
0.178[2]
|
|
Hb on admission, g/dL, median (IQR)
|
11 (9.2–12.8)
|
11.8 (9.1–12.6)
|
12.1 (10.2–13.7)
|
0.1[1]
|
|
Shock index on admission, median (IQR)
|
0.64 (0.51–0.75)
|
0.63 (0.57–0.78)
|
0.64 (0.54–0.82)
|
0.952[1]
|
SRH, stigmata of recent hemorrhage; IQR, interquartile range; NSAIDs, nonsteroidal
anti-inflammatory drugs; Hb, hemoglobin; EBL, endoscopic band ligation
1 One-way analysis of variance
2 Fisher’s exact test
Clinical outcomes of patients who underwent endoscopic hemostasis for colonic diverticular
hemorrhage with SRH
Clinical outcomes of direct clipping, indirect clipping, and EBL for treatment of
colonic diverticular hemorrhage are shown in [Table 2]. A flowchart of treatment results is shown in [Fig. 3]. Initial therapy successfully achieved immediate hemostasis without any procedural
complications in all groups. After initial therapy, no complications occurred in any
group. Location of hemorrhage, time to discharge after initial hemostasis, and units
of packed RBCs were not significantly different between the three groups. The rate
of active bleeding was significantly lower in the direct clipping group (P = 0.006 for the direct clipping group vs the indirect clipping group, P values were calculated with Bonferroni corrections). Total procedure time was longer
in the EBL group (P = 0.019 for the direct clipping group vs the EBL group, P values were calculated with Bonferroni corrections). Time to hemostasis after identification
of bleeding site was longer in the EBL group (P < 0.001 for the direct clipping group vs the EBL group, P values were calculated with Bonferroni corrections). Rates of early rebleeding in
the direct clipping, indirect clipping, and EBL groups were 5.9 % (2/34: 95 % CI,
0.7 %–19.7 %), 35.7 % (10/28: 95 % CI, 18.6 %–55.9 %), and 6.5 % (2/31: 95 % CI, 0.8 %–21.4 %),
respectively (P = 0.006 for the direct clipping group vs the indirect clipping group, P = 1 for the direct clipping group vs the EBL group, P values were calculated with Bonferroni corrections). Four patients in the indirect
clipping group received an initial injection for diverticula with active bleeding,
and one had early rebleeding.
Table 2
Clinical outcomes of patients who underwent endoscopic hemostasis for colonic diverticular
hemorrhage with SRH.
|
Direct clipping (n = 34)
|
Indirect clipping (n = 28)
|
EBL (n = 31)
|
P value
|
|
SRH (AB/ NBVV or AC), n
|
13/21
|
22/6
|
21/10
|
0.004[1]
|
|
Location (proximal: C, A, T/ distal: D, S), n
|
29/5
|
19/9
|
21/10
|
0.181[1]
|
|
Bleeding point in the diverticulum (dome/neck/unconfirmed), n
|
30/3/1
|
6/0/22
|
14/2/15
|
|
|
Total procedure time[2], min, median (IQR)
|
34 (26.3–52)
|
31.5 (20.8–55.3)
|
51 (38–72.5)
|
0.012[3]
|
|
Time to hemostasis after identification of the bleeding site, min, median (IQR)
|
9 (5.5–13)
|
6 (3.8–11.3)
|
24 (14–31.5)
|
< 0.001[3]
|
|
Early rebleeding[4], n (%)
|
2 (5.9)
|
10 (35.7)
|
2 (6.5)
|
0.003[1]
|
|
Time to discharge after initial hemostasis, day, median (IQR)
|
7 (5–8)
|
6.5 (6–9)
|
5 (4–7)
|
0.1[5]
|
|
Units of PRBCs, median (IQR)
|
0 (0–2)
|
0 (0–4)
|
0 (0–0)
|
0.195[5]
|
|
Complications, n
|
0
|
0
|
0
|
1[1]
|
SRH, stigmata of recent hemorrhage; AB, active bleeding; NBVV, non-bleeding visible
vessel; AC, adherent clot; C, cecum; A, ascending colon; T, transverse colon; D, descending
colon; S, sigmoid colon; IQR, interquartile range; PRBCs, packed red blood cells;
EBL, endoscopic band ligation.
1 Fisher’s exact test
2 The total procedure time is defined as the total time from the start to end of colonoscopy
3 One-way analysis of variance
4 Early rebleeding is defined as rebleeding within 30 days of initial hemostasis
5 Welch’s test
Fig. 3 Flowchart of treatment results. SRH, stigmata of recent hemorrhage; EBL, endoscopic
band ligation; TAE, transcatheter arterial embolization; Early rebleeding, recurrent
bleeding within 30 days of treatment. *P = 0.006 for the direct clipping group vs the indirect clipping group; **P = 1 for the direct clipping group vs the EBL group. P values were calculated with Bonferroni corrections.
Annual changes in endoscopic hemostasis and rebleeding cases
Annual changes in endoscopic hemostasis and rebleeding cases are shown in [Table 3]. Direct clipping slightly increased from 2015, while indirect clipping slightly
decreased from 2016. Our institution introduced EBL in 2016. EBL has been increasing
every year.
Table 3
Annual changes in endoscopic hemostasis and rebleeding.
|
Endoscopic hemostasis
|
|
Year
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
|
Direct clipping, n
|
0
|
3
|
5
|
11
|
5
|
10
|
|
Indirect clipping, n
|
5
|
9
|
7
|
4
|
2
|
1
|
|
EBL, n
|
0
|
0
|
0
|
5
|
10
|
16
|
|
Rebleeding cases according to endoscopic hemostasis
|
|
Year
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018
|
|
Direct clipping, n
|
0
|
0
|
0
|
0
|
1
|
1
|
|
Indirect clipping, n
|
2
|
2
|
3
|
2
|
0
|
1
|
|
EBL, n
|
0
|
0
|
0
|
0
|
2
|
0
|
EBL, endoscopic band ligation.
Characteristics of early rebleeding cases after hemostasis
Characteristics of early rebleeding cases after hemostasis are shown in [Table 4].
Table 4
Characteristics of recurrent bleeding and non-recurrent bleeding groups after endoscopic
hemostasis.
|
Non-recurrent bleeding (n = 79)
|
Recurrent bleeding (n = 14)
|
P value
|
|
Age, years, median (IQR)
|
75 (66.5–82.5)
|
78 (69.3–85.3)
|
0.572
|
|
Sex, male, n (%)
|
45 (57.0)
|
6 (42.9)
|
0.39
|
|
Comorbidity, n (%)
|
|
|
48 (60.8)
|
6 (42.9)
|
0.248
|
|
|
9 (11.4)
|
1 (7.1)
|
1
|
|
|
17 (21.5)
|
0 (0)
|
0.065
|
|
|
7 (8.9)
|
0 (0)
|
0.589
|
|
|
15 (19.0)
|
1 (7.1)
|
0.45
|
|
|
12 (15.2)
|
3 (21.4)
|
0.693
|
|
Usage of antithrombotic agents, n (%)
|
28 (35.4)
|
6 (42.9)
|
0.764
|
|
Usage of NSAIDs, n (%)
|
25 (31.6)
|
5 (35.7)
|
0.764
|
|
Usage of steroids, n (%)
|
2 (2.5)
|
0 (0)
|
1
|
|
Previous history of colonic diverticular hemorrhage, n (%)
|
40 (50.6)
|
7 (50.0)
|
1
|
|
Endoscopic hemostasis, n (%)
|
0.003
|
|
|
32 (40.5)
|
2 (14.3)
|
|
|
18 (22.8)
|
10 (71.4)
|
|
|
29 (36.7)
|
2 (14.3)
|
|
SRH (AB/ NBVV or AC), n
|
44/35
|
12/2
|
0.041
|
|
Location (proximal: C, A, T/ distal: D, S), n
|
60/19
|
9/5
|
0.343
|
|
Bleeding point in the diverticulum (dome/neck/unconfirmed), n
|
44/5/30
|
6/0/9
|
0.417
|
|
Total procedure time[1], min, median (IQR)
|
40 (29–57)
|
28 (17.3–63)
|
0.429
|
|
Time to hemostasis after identification of the bleeding site, min, median (IQR)
|
12 (7–19)
|
9.5 (3.5–13)
|
0.247
|
IQR, interquartile range; NSAIDs, nonsteroidal anti-inflammatory drugs; EBL, endoscopic
band ligation; SRH, stigmata of recent hemorrhage; AB, active bleeding; NBVV, non-bleeding
visible vessel; AC, adherent clot; C, cecum; A, ascending colon; T, transverse colon;
D, descending colon; S, sigmoid colon.
1 The total procedure time is defined as the total time from the start to end of colonoscopy
Two patients (5.9 %) in the direct clipping group had early rebleeding and underwent
EBL ([Fig. 3]). No further bleeding occurred after repeat therapy, and neither surgical nor angiographic
therapy was required. Ten patients (35.7 %) in the indirect clipping group had early
rebleeding. Although seven patients were managed conservatively or endoscopically,
TAE or colectomy was performed on three patients because of uncontrollable hemorrhage
([Fig. 3]). Two patients (6.5 %) in the EBL group had early rebleeding. TAE was performed
on one patient. In the EBL group, no further bleeding occurred after repeat therapy
([Fig. 3]).
Risk factors associated with early rebleeding after endoscopic hemostasis
Multilevel logistic regression analysis was performed to verify the influence of endoscopic
hemostasis on early rebleeding ([Table 5]). We adjusted for age, sex, use of antithrombotic agents and NSAIDs, and SRH (active
bleeding). Only indirect clipping was identified as an independent risk factor for
early rebleeding after endoscopic hemostasis (OR, 12.7; 95 % CI 2.02–79.4; P = 0.0067).
Table 5
Multilevel logistic regression analysis to identify independent risk factors associated
with early rebleeding.
|
Odds ratio
|
95 % CI
|
P value
|
|
Age
|
0.998
|
0.93–1.07
|
0.948
|
|
Sex (Male)
|
0.457
|
0.11–1.96
|
0.291
|
|
Usage of antithrombotic agents
|
2.67
|
0.587–12.2
|
0.204
|
|
Usage of NSAIDs
|
1.22
|
0.287–5.18
|
0.789
|
|
SRH (active bleeding)
|
3.83
|
0.644–22.8
|
0.14
|
|
Endoscopic hemostasis
|
|
EBL
|
1
|
|
|
|
Direct clipping
|
1.91
|
0.216–16.8
|
0.561
|
|
Indirect clipping
|
12.7
|
2.02–79.4
|
0.0067
|
NSAIDs, nonsteroidal anti-inflammatory drugs; SRH, stigmata of recent hemorrhage;
EBL, endoscopic band ligation; CI, confidence interval.
Discussion
The current study showed two important clinical issues: the early rebleeding rate
was as low in the direct clipping group as that in the EBL group, but was higher in
the indirect clipping group than in the other groups.
In the current study, the early rebleeding rate with direct placement was 5.9 %. This
is lower
than the rates reported in a previous systematic review and meta-analysis [25], with rates of 19 % for clipping and 21 % for thermal contact,
which were similar to that for EBL (9 %). The early rebleeding rates of patients treated
with
endoclips were previously reported to be between 0 % and 50 %, which is a wide range
[13, 17, 18, 26–32]. We speculate that these differences in early
rebleeding rates following endoclips depend on whether endoclips are placed directly
on vessels.
Hemostasis with direct clip placement is sometimes considered to be difficult [22–26]. The following factors complicate direct clip placement: 1)
endoscopic observations in colonic diverticula; 2) insertion of endoclips into colonic
diverticula; and 3) stability of the endoscope. We attempted to overcome these issues
using the following strategies. To improve endoscopic visualization of colonic diverticula
and endoscope stability, we observed a colonic diverticulum under full water immersion
using a water-jet scope with a tip hood [21]. Water immersion observations are advantageous because water immersion significantly
improves endoscopic visualization and water pressure dilates a colonic diverticulum
without insufflation. To facilitate insertion of endoclips into the diverticulum,
we placed an open endoclip into the forceps hole of the endoscope, which reduced the
width of the endoclip ([Fig. 4]). This step facilitated insertion of the endoclip into the colonic diverticulum.
We also used a longer tip hood (approximately 7 mm), which enables rotation of an
endoclip in the tip hood and more accurate placement. These devices make it easier
to place endoclips directly ([Video 2]). We introduced these devices in 2016. The proportion of direct clip placement increased
to 40.6 % (26/64: between 2016 and 2018) from 24.1 % (7/29: between 2013 and 2015)
([Table 3]).
Fig. 4 a An open endoclip (HX-610-090S; EZ CLIP, Olympus Optical Company Ltd.). b After the open endoclip is placed into the forceps hole of the endoscope, the width
of the endoclip becomes narrower.
Video 2 Devices for direct clip placement.
In the current study, two patients in the direct clipping group had early rebleeding.
In one of these patients, direct clip placement was performed for massive active bleeding
([Fig. 5a]). Although bleeding was stopped by clipping ([Fig. 5b]), rebleeding occurred 16 hours later. Colonoscopy was performed, and an exposed
vessel with a clot was observed beside the endoclips ([Fig. 5c]). The diverticulum with endoclips was pulled via suction into the cup of the endoscopic
ligator, and the elastic O-ring was released ([Fig. 5d]). This case suggested that the endoclips did not capture the bleeding source, and
also that direct clip placement is not recommended for massive active bleeding because
of the poor visual field.
Fig. 5 a Active bleeding from the colonic diverticulum. b Bleeding was stopped after direct clip placement. c An exposed vessel with a clot beside the endoclips (yellow arrow). d The diverticulum was pulled via suction into the cup of the endoscopic ligator, and
the elastic O-ring was released. The yellow arrow indicates the diverticulum with
endoclips after EBL.
In the current study, the rate of active bleeding was significantly lower in the direct
clipping group, which may have contributed to the low rate of early rebleeding in
the direct clipping. However, the multilevel logistic regression analysis to identify
independent risk factors associated with early rebleeding showed that active bleeding
was not a risk factor for early bleeding ([Table 5]: P = 0.14).
On the other hand, the early rebleeding rate in the indirect clipping group was high
(35.7 %: 10/28). The reason for this was that the bleeding source was not captured
by indirect clip placement. Ishi et al. reported that the early rebleeding rate of
patients treated with endoclips was 34 % (30 out of 87 cases); indirect placement
in a zipper manner was performed on 85 % of patients. Indirect clip placement does
not always achieve complete hemostasis because of the arcades of arteries from the
neck that join and form the artery in the base of the diverticulum [13]
[24]
[33]. These findings suggest that indirect placement of hemoclips for bleeding diverticula
is ineffective for hemostasis. Moreover, Kume et al. reported a case of sepsis caused
by indirect placement of endoclips for colon diverticular bleeding [34]; a diverticulum with continuous arterial spurting was closed with endoclips in a
zipper manner, and the patient developed sepsis on the next day. This case report
suggests that a seamed diverticulum with active bleeding permits bacteria to invade
blood vessels. Therefore, indirect clip placement is not recommended from the viewpoint
of effectiveness and complications.
Incidence of diverticular hemorrhage has been increasing with growing use of antithrombotic
drugs in elderly patients [4]
[5]
[6]
[7]. In the current study, 37.6 % (35/93) of subjects were older than 80 years. If complications
occur in these patients, they may become severe. AEs such as colonic diverticulitis
and perforation after EBL have been reported, albeit rarely [14]
[15]. Akutsu et al. evaluated efficacy and safety of EDSL in patients with colonic diverticular
bleeding without severe comorbidities. In that study [35], one of 101 patients treated with EDSL developed diverticulitis. These findings
suggest that the safety of ligation methods, such as EBL and EDSL, for patients with
severe comorbidities remains unclear. Therefore, treatment of these patients needs
to be minimally invasive.
The endoclip approach offers the theoretical advantage of causing less damage to adjacent
tissues [17]
[18]
[36]. Moreover, endoclips are cheaper than EBL and EDSL. When rebleeding occurs after
direct clip placement, the bleeding point can be treated with EBL ([Fig. 5]). Therefore, direct clip placement is acceptable as the first choice for colonic
diverticulum hemorrhage. At our institution, direct clip placement has been the first
choice for colonic diverticulum bleeding in recent years. The overall rebleeding rate
in our institution was lower between 2016 and 2018 (10.9 %: 7/64) than between 2013
and 2015 (24.1 %: 7/29) ([Table 3]). These results indicate that the correct strategy to achieve hemostasis was selected.
A safe and cost-effective treatment may be selected by evaluating the form of the
diverticulum, maneuverability of the colonoscope, and condition of the bleeding site.
The current study has several limitations. One of the main limitations that need to
be addressed is that we treated bleeding without standardization. Furthermore, this
was a non-randomized retrospective study that involved some selection bias. We distinguished
between direct and indirect clip placement using endoscopic reports and images from
colonoscopy. Selection bias for judgements is also a major issue. Decision-making
and procedure skills must have differed to some extent among endoscopists. In the
future, we intend to conduct a retrospective multicenter study with a larger number
of patients.
Conclusion
In summary, direct clip placement is acceptable as the first treatment choice for
colonic diverticular hemorrhage. When direct placement of endoclips is not possible,
a ligation method such as EBL and EDSL needs to be performed instead of indirect clipping.
