Usefulness of gel immersion endoscopy to identify a colonic diverticulum with active bleeding

Management of colonic diverticular bleeding is clinically important because severe cases require transarterial embolization or surgical intervention; colonic diverticular bleeding can cause death in elderly patients with multiple comorbidities [1]. Colonoscopy enables the diagnosis and treatment of the bleeding site; however, identifying the diverticulum with active bleeding is challenging. Gel immersion endoscopy has been reported to be useful for securing the visual field during endoscopy for gastrointestinal bleeding [2] [3]. We report a case in which gel immersion endoscopy was effective in allowing the colonic diverticulum with active bleeding to be identified.

An 87-year-old man taking aspirin and apixaban for ischemic heart disease presented to our hospital with massive hematochezia from that morning. On admission, his hemoglobin level was 8.0 g/dL and he exhibited vital signs of shock. Contrast-enhanced computed tomography revealed extravasation in the ascending colon ([Fig. 1]). We performed emergency colonoscopy with blood transfusion. Fresh blood and clotting were observed in the ascending colon ([Fig. 2]). However, we were unable to identify the bleeding point because of active bleeding and poor visual field. After injecting Viscoclear gel (Otsuka Pharmaceutical Factory, Tokushima, Japan) [4], the visual field improved and a diverticulum with pulsatile bleeding was identified ([Fig. 3], [Video 1]). An endoclip was placed as a marker close to this diverticulum, and endoscopic band ligation was then carried out ([Fig. 4]). Bleeding did not recur after the treatment.

Fig. 1 Contrast-enhanced computed tomography revealed extravasation in the ascending colon (arrow).

Fig. 2 Fresh blood and clotting were observed in the ascending colon.

Fig. 3 Gel immersion endoscopy showed a diverticulum with pulsatile bleeding (arrow).

Video 1 Gel immersion endoscopy for colonic diverticular bleeding with active bleeding.

Fig. 4 A vessel was visualized on the ligated diverticulum.

In summary, we found gel immersion endoscopy to be useful for identifying a colonic diverticulum with active bleeding.

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• References

• 1 Kaise M, Nagata N, Ishii N. et al. Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding. Dig Endosc 2020; 32: 240-250
• 2 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 3 Yano T, Takezawa T, Hashimoto K. et al. Gel immersion endoscopy: innovation in securing the visual field – clinical experience with 265 consecutive procedures. Endosc Int Open 2021; 9: E1123-E1127
• 4 Yano T, Ohata A, Hiraki Y. et al. Development of a gel dedicated to gel immersion endoscopy. Endosc Int Open 2021; 9: E918-E924