Innovations and brief communications
Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis
Authors
Soichiro Shibata1, 2, Takashi Shigeno1, Kazuya Fujimori1, Keita Kanai1, 2, Kaname Yoshizawa1
Institutions
1 2
submitted 18. November 2012 accepted after revision 20. August 2013
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1344890 Published online: 11.11.2013 Endoscopy 2014; 46: 66–69 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Soichiro Shibata, MD Second Department of Internal Medicine Shinshu University School of Medicine 3-1-1 Asahi Matsumoto Nagano Japan Fax: +81-263-373024 [email protected]
Department of Gastroenterology, Shinshu Ueda Medical Center, Ueda, Nagano, Japan Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
Background and study aims: Although colonic diverticular hemorrhage is a common cause of lower gastrointestinal bleeding, the low rate of detection of the diverticula responsible for bleeding, together with inadequate evaluation of endoscopic hemostasis, remain unsatisfactory. Patients and methods: Over 3 years, we employed the hood method to diagnose diverticular hemorrhage in 53 patients and applied endoscopic band ligation (EBL) for hemostasis in 27 patients with responsible diverticula. Results: The hood method revealed active bleeding in 13 patients (24.5 %), nonbleeding visible vessels in 14 patients (26.4 %), and presumptive
diverticular hemorrhage in 26 patients (49.1 %). The nonbleeding visible vessels were located in the diverticular dome in 13 patients and at the diverticular orifice in one patient. EBL was performed in 27 patients, and a hemostasis rate of 96.3 % was achieved. In 9 of 12 patients treated with EBL, follow-up colonoscopy revealed resolution of the responsible diverticula. Conclusions: The hood method improves the detection rate of diverticula responsible for bleeding by revealing potential nonbleeding visible vessels in the diverticular dome. EBL may become an effective procedure for hemostasis of colonic diverticular hemorrhage.
Introduction
hibiting either definitive sign was considered to be a responsible diverticulum. Presumptive diverticular hemorrhage meant that, although neither definitive sign was detected, colonoscopy did not reveal other lesions apart from colonic diverticula; thus, any of the diverticula could have been the bleeding source.
!
Although colonic diverticular hemorrhage is a common cause of lower gastrointestinal bleeding [1], clinical outcomes have been unsatisfactory. In particular, the diverticulum responsible for the bleeding is revealed in only 15 % – 25 % of cases [1, 2], and the clinical evaluation of endoscopic hemostasis is often inadequate [2]. In order to improve these mediocre results, we have adopted a “hood method” for detecting diverticula responsible for colonic diverticular hemorrhage, and endoscopic band ligation (EBL) for their hemostasis, as we describe in this report.
Patients and methods !
Definition of colonic diverticular hemorrhage We defined colonic diverticular hemorrhage as the presence of one of the following colonoscopic findings [1, 3]: active bleeding, a nonbleeding visible vessel, or presumptive diverticular hemorrhage. Active bleeding and a nonbleeding visible vessel were both regarded as definitive signs of diverticular hemorrhage, and a diverticulum ex-
The hood method The hood method employed a transparent soft hood (disposable distal attachment D-201 – 11804; Olympus Medical Systems, Tokyo, Japan) attached to the tip of a PCF-Q260JI colonoscope (Olympus) with a water-jet function. While inspecting each colonic diverticulum, we let the hood adhere closely to the exterior of the diverticular mouth and then manipulated it up/down, right/left, or in a circle to widen the diverticular mouth and better visualize the entire diverticular " Fig. 1). For some diverticula in which the dome (● dome could not be inspected sufficiently by the above technique, we inverted the diverticulum into the hood by suction such that the inside of the diverticular dome could be visualized [4].
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
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66
Fig. 1a – c Potential nonbleeding visible vessel in a narrowmouthed diverticulum visualized using the hood method.
Fig. 2 Endoscopic band ligation (EBL). a, b A responsible diverticulum that exhibited a nonbleeding visible vessel (arrow) was inverted into the hood by suction. The O-ring was then released so as to tighten it firmly around the base of the inverted diverticulum. c Colonoscopy revealed resolution of the responsible diverticulum and scar formation at the original site 6 weeks after EBL (indigo carmine spray).
Endoscopic band ligation
Patients
For EBL, we diverted a pneumoactivated endoscopic esophageal varix ligation (EVL) device (Sumitomo Bakelite Co. Ltd., Tokyo, Japan) that used an exclusive hood and a rubber band (i. e., an Oring) for hemostasis; as the name implies, it was originally used for hemostasis of esophageal varices. When we detected a responsible diverticulum, two marker clips (standard HX-610 – 135 clip; Olympus) were placed on the oral and anal sides of the mucosa near the diverticulum. The colonoscope was pulled out, fitted with the EVL device, and then reinserted and returned to the responsible diverticulum, identified by the two clips. We then inverted the diverticulum into the hood by suction and released the O-ring to tighten it firmly around the base of the inver" Fig. 2 a, b; ● " Video 1). Carbon dioxide was ted diverticulum (● used for insufflation during colonoscopic observation and hemostasis.
From January 2010 to December 2012, we employed the hood method in 70 patients who presented with painless hematochezia. Fifty-three of these patients were diagnosed as having colonic diverticular hemorrhage (34 men and 19 women; average age 74 years, range 43 – 88 years, 95 %CI 0.657 – 0.858). The remaining 17 patients were diagnosed as having other diseases, such as colorectal cancer, rectal ulcer, or colitis. The 53 patients underwent total colonoscopy using the hood method along with EBL for hemostasis when a responsible diverticulum was detected. All patients were admitted as inpatients and gave their written informed consent to colonoscopic examination and hemostasis. Prior to colonoscopy, all patients underwent bowel preparation: 37 patients were prepared by oral purge with polyethylene glycol and 16 by water enema. All colonoscopies were performed with the patient under conscious sedation with diazepam or midazolam and standard hemodynamic monitoring. If the patient’s vital signs were unstable, we postponed the colonoscopic procedure until they improved following treatment with fluid resuscitation, blood transfusion, and/or vasopressor drugs. Colonoscopic observation and hemostasis procedures were performed by one of four colonoscopists; the colonoscopists had 5, 7, 20, and 28 years of experience, respectively.
Video 1 Practical endoscopic band ligation for hemostasis of a diverticulum exhibiting a nonbleeding visible vessel. online content including video sequences viewable at: www.thieme-connect.de
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
67
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Innovations and brief communications
Innovations and brief communications
Detection of responsible diverticula and endoscopic hemostasis results We assessed the rate of detection and the locations of responsible diverticula in addition to results of hemostasis. Early rebleeding and late bleeding were recorded when recurrent hemorrhage was noted within 30 days and later than 30 days after EBL, respectively [1, 5]. The hemostasis achievement rate was defined as the percentage of treated patients who did not experience early rebleeding. Twelve of the 27 patients who underwent EBL therapy were followed up with colonoscopy to evaluate the state of the ligated diverticulum.
Results !
Table 1 Results for detection of responsible diverticula using the hood method and for endoscopic band ligation for hemostasis. Hood method for diagnosis (n = 53) Responsible diverticulum, n (%) Active bleeding Nonbleeding visible vessel Presumed diverticular hemorrhage, n (%)
27/53 (50.9) 13/53 (24.5) 1 14/53 (26.4)2 26/53 (49.1)
EBL for hemostasis (n = 27) Achieved hemostasis rate, n (%) Late bleeding, n (%) Procedure time, min, mean (range)
26/27 (96.3) 1/27 (3.7) 44 (27 – 122)
EBL, endoscopic band ligation. 1 Cecum, 2; ascending colon, 6; transverse colon, 1; descending colon, 0; sigmoid colon, 4 2 Cecum, 1; ascending colon, 8; transverse colon, 1; descending colon, 1; sigmoid colon, 3 (dome, 13, orifice: 1)
Detection of responsible diverticula The hood method demonstrated active bleeding in 13 of 53 patients (24.5 %), nonbleeding visible vessels in 14 patients (26.4 %), and presumptive diverticular hemorrhage in 26 patients (49.1 %). Thus, the rate of detection of responsible diverticula was 50.9 %. Regarding the location of responsible diverticula, 3 diverticula were found in the cecum, 14 in the ascending colon, 2 in the transverse colon, 1 in the descending colon, and 7 in the sigmoid colon, " Table 1). Nonbleeding visible vessels were located respectively (● at the diverticular dome in 13 cases and at the diverticular orifice in one case. No complications occurred during colonoscopic inspection.
Endoscopic hemostasis Complete inversion of the diverticulum and immediate hemostasis was achieved in all patients treated with EBL. The mean procedure time for EBL was 44 minutes (range 27 – 122 minutes). Early rebleeding developed in 1 of 27 cases, resulting in a hemo" Table 1). The patient with a stasis achievement rate of 96.3 % (● rebleed exhibited mild hematochezia at 5 days after EBL. Colonoscopy revealed that a shallow ulceration had formed around the ligated diverticulum and bled at its edges, which we treated by clipping. During a mean follow-up period of 18 months (range 3 – 27 months), one patient developed late bleeding from a different diverticulum 12 months after EBL that was confirmed by colonoscopy. Neither perforation nor peritonitis developed in any patient.
Outcomes of responsible diverticula treated with EBL Among the 27 patients who received EBL, 12 underwent followup colonoscopy 1 – 3 months afterwards. In 9 of these patients, the responsible diverticulum had disappeared and a scar had " Fig. 2 c). No trace of EBL treatment formed at the original site (● was noted in the remaining 3 patients.
preferentially located at the diverticular orifice in endoscopic studies, pathological studies demonstrated them more frequently in the dome of the diverticulum, as Simpson et al. pointed out [7]. The detection of nonbleeding visible vessels in the dome is difficult with conventional colonoscopy because the entrance of a diverticulum is often narrower than the sac inside, thus preventing full observation of the inner diverticulum. That is, conventional colonoscopy is likely often to fail to reveal the existence of nonbleeding visible vessels in the diverticular dome. Our results indicate that the hood method improves the rate of detection of responsible diverticula by permitting detection of potential nonbleeding visible vessels in the dome. In 2003, Farrell et al. reported four cases of bleeding diverticula treated by EBL with excellent outcomes [8]. They also confirmed the safety of EBL both in vivo and ex vivo [8]. It is surprising that EBL has not become more widespread. Several series of EBL for hemostasis of bleeding diverticula with favorable results have recently been reported: rates of early rebleeding ranged from 6 % to 11 % [5, 9]. In these reports, early rebleeding was caused by incomplete banding due to insufficient inversion of the responsible diverticulum [5, 9]. Susceptibility to complications including perforation and peritonitis has not been reported for any case treated by EBL. In the present series, follow-up colonoscopy in 9 of 12 patients after EBL revealed disappearance of the responsible diverticulum and scar formation at the original site, which accords with a previous description [9]. Thus, EBL can be used to perform a kind of “endoscopic diverticulectomy.” In conclusion, the hood method appears to improve the detection of nonbleeding visible vessels, especially in the diverticular dome. EBL may become an effective procedure for the endoscopic hemostasis of colonic diverticular hemorrhage. Further evaluation is needed to assess both procedures. Competing interests: None
Discussion !
Although detection of active bleeding or nonbleeding visible vessels confirms the accuracy of a diagnosis of diverticular hemorrhage [1], cases with either definitive sign are detected far less commonly than cases with presumptive diverticular hemorrhage [1, 2]. In previous studies, active bleeding and nonbleeding visible vessels were observed in fewer than 25 % and 10 % of patients, respectively [1, 2]. Active bleeding may be overlooked since colonic diverticular hemorrhage is often intermittent [6]. Regarding the location of nonbleeding visible vessels, although they were
References 1 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 2 Smoot RL, Gostout CJ, Rajan E et al. Is early colonoscopy after admission for acute diverticular bleeding needed? Am J Gastroenterol 2003; 98: 1996 – 1999 3 Yen EF, Ladabaum U, Muthusamy VR et al. Colonoscopic treatment of acute diverticular hemorrhage using endoclip. Dig Dis Sci 2008; 53: 2480 – 2485 4 Sugiyama H. Endoscopic diagnosis and treatment for diverticular bleeding of the colon [in Japanese with English abstract]. Nihon Fuku-
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
68
Innovations and brief communications 7 Simpson PW, Nguyen MH, Lim JK et al. Use of endoclips in the treatment of massive colonic diverticular bleeding. Gastrointest Endosc 2004; 59: 433 – 437 8 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 9 Ishii N, Sotoyama T, Deshpande GA et al. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382 – 387
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
bu Kyukyu Igakkai Zasshi (Japanese Journal of Abdominal Emergency Medicine) 2000; 20: 667 – 673 5 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 6 Sos TA, Lee JG, Wixson D et al. Intermittent bleeding from minute to minute gastrointestinal hemorrhage: arteriographic demonstration. Am J Roentgenol 1978; 131: 1015 – 1017
69
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula and endoscopic band ligation for hemostasis
Authors
Soichiro Shibata1, 2, Takashi Shigeno1, Kazuya Fujimori1, Keita Kanai1, 2, Kaname Yoshizawa1
Institutions
1 2
submitted 18. November 2012 accepted after revision 20. August 2013
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1344890 Published online: 11.11.2013 Endoscopy 2014; 46: 66–69 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Soichiro Shibata, MD Second Department of Internal Medicine Shinshu University School of Medicine 3-1-1 Asahi Matsumoto Nagano Japan Fax: +81-263-373024 [email protected]
Department of Gastroenterology, Shinshu Ueda Medical Center, Ueda, Nagano, Japan Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
Background and study aims: Although colonic diverticular hemorrhage is a common cause of lower gastrointestinal bleeding, the low rate of detection of the diverticula responsible for bleeding, together with inadequate evaluation of endoscopic hemostasis, remain unsatisfactory. Patients and methods: Over 3 years, we employed the hood method to diagnose diverticular hemorrhage in 53 patients and applied endoscopic band ligation (EBL) for hemostasis in 27 patients with responsible diverticula. Results: The hood method revealed active bleeding in 13 patients (24.5 %), nonbleeding visible vessels in 14 patients (26.4 %), and presumptive
diverticular hemorrhage in 26 patients (49.1 %). The nonbleeding visible vessels were located in the diverticular dome in 13 patients and at the diverticular orifice in one patient. EBL was performed in 27 patients, and a hemostasis rate of 96.3 % was achieved. In 9 of 12 patients treated with EBL, follow-up colonoscopy revealed resolution of the responsible diverticula. Conclusions: The hood method improves the detection rate of diverticula responsible for bleeding by revealing potential nonbleeding visible vessels in the diverticular dome. EBL may become an effective procedure for hemostasis of colonic diverticular hemorrhage.
Introduction
hibiting either definitive sign was considered to be a responsible diverticulum. Presumptive diverticular hemorrhage meant that, although neither definitive sign was detected, colonoscopy did not reveal other lesions apart from colonic diverticula; thus, any of the diverticula could have been the bleeding source.
!
Although colonic diverticular hemorrhage is a common cause of lower gastrointestinal bleeding [1], clinical outcomes have been unsatisfactory. In particular, the diverticulum responsible for the bleeding is revealed in only 15 % – 25 % of cases [1, 2], and the clinical evaluation of endoscopic hemostasis is often inadequate [2]. In order to improve these mediocre results, we have adopted a “hood method” for detecting diverticula responsible for colonic diverticular hemorrhage, and endoscopic band ligation (EBL) for their hemostasis, as we describe in this report.
Patients and methods !
Definition of colonic diverticular hemorrhage We defined colonic diverticular hemorrhage as the presence of one of the following colonoscopic findings [1, 3]: active bleeding, a nonbleeding visible vessel, or presumptive diverticular hemorrhage. Active bleeding and a nonbleeding visible vessel were both regarded as definitive signs of diverticular hemorrhage, and a diverticulum ex-
The hood method The hood method employed a transparent soft hood (disposable distal attachment D-201 – 11804; Olympus Medical Systems, Tokyo, Japan) attached to the tip of a PCF-Q260JI colonoscope (Olympus) with a water-jet function. While inspecting each colonic diverticulum, we let the hood adhere closely to the exterior of the diverticular mouth and then manipulated it up/down, right/left, or in a circle to widen the diverticular mouth and better visualize the entire diverticular " Fig. 1). For some diverticula in which the dome (● dome could not be inspected sufficiently by the above technique, we inverted the diverticulum into the hood by suction such that the inside of the diverticular dome could be visualized [4].
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
66
Fig. 1a – c Potential nonbleeding visible vessel in a narrowmouthed diverticulum visualized using the hood method.
Fig. 2 Endoscopic band ligation (EBL). a, b A responsible diverticulum that exhibited a nonbleeding visible vessel (arrow) was inverted into the hood by suction. The O-ring was then released so as to tighten it firmly around the base of the inverted diverticulum. c Colonoscopy revealed resolution of the responsible diverticulum and scar formation at the original site 6 weeks after EBL (indigo carmine spray).
Endoscopic band ligation
Patients
For EBL, we diverted a pneumoactivated endoscopic esophageal varix ligation (EVL) device (Sumitomo Bakelite Co. Ltd., Tokyo, Japan) that used an exclusive hood and a rubber band (i. e., an Oring) for hemostasis; as the name implies, it was originally used for hemostasis of esophageal varices. When we detected a responsible diverticulum, two marker clips (standard HX-610 – 135 clip; Olympus) were placed on the oral and anal sides of the mucosa near the diverticulum. The colonoscope was pulled out, fitted with the EVL device, and then reinserted and returned to the responsible diverticulum, identified by the two clips. We then inverted the diverticulum into the hood by suction and released the O-ring to tighten it firmly around the base of the inver" Fig. 2 a, b; ● " Video 1). Carbon dioxide was ted diverticulum (● used for insufflation during colonoscopic observation and hemostasis.
From January 2010 to December 2012, we employed the hood method in 70 patients who presented with painless hematochezia. Fifty-three of these patients were diagnosed as having colonic diverticular hemorrhage (34 men and 19 women; average age 74 years, range 43 – 88 years, 95 %CI 0.657 – 0.858). The remaining 17 patients were diagnosed as having other diseases, such as colorectal cancer, rectal ulcer, or colitis. The 53 patients underwent total colonoscopy using the hood method along with EBL for hemostasis when a responsible diverticulum was detected. All patients were admitted as inpatients and gave their written informed consent to colonoscopic examination and hemostasis. Prior to colonoscopy, all patients underwent bowel preparation: 37 patients were prepared by oral purge with polyethylene glycol and 16 by water enema. All colonoscopies were performed with the patient under conscious sedation with diazepam or midazolam and standard hemodynamic monitoring. If the patient’s vital signs were unstable, we postponed the colonoscopic procedure until they improved following treatment with fluid resuscitation, blood transfusion, and/or vasopressor drugs. Colonoscopic observation and hemostasis procedures were performed by one of four colonoscopists; the colonoscopists had 5, 7, 20, and 28 years of experience, respectively.
Video 1 Practical endoscopic band ligation for hemostasis of a diverticulum exhibiting a nonbleeding visible vessel. online content including video sequences viewable at: www.thieme-connect.de
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
67
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Innovations and brief communications
Innovations and brief communications
Detection of responsible diverticula and endoscopic hemostasis results We assessed the rate of detection and the locations of responsible diverticula in addition to results of hemostasis. Early rebleeding and late bleeding were recorded when recurrent hemorrhage was noted within 30 days and later than 30 days after EBL, respectively [1, 5]. The hemostasis achievement rate was defined as the percentage of treated patients who did not experience early rebleeding. Twelve of the 27 patients who underwent EBL therapy were followed up with colonoscopy to evaluate the state of the ligated diverticulum.
Results !
Table 1 Results for detection of responsible diverticula using the hood method and for endoscopic band ligation for hemostasis. Hood method for diagnosis (n = 53) Responsible diverticulum, n (%) Active bleeding Nonbleeding visible vessel Presumed diverticular hemorrhage, n (%)
27/53 (50.9) 13/53 (24.5) 1 14/53 (26.4)2 26/53 (49.1)
EBL for hemostasis (n = 27) Achieved hemostasis rate, n (%) Late bleeding, n (%) Procedure time, min, mean (range)
26/27 (96.3) 1/27 (3.7) 44 (27 – 122)
EBL, endoscopic band ligation. 1 Cecum, 2; ascending colon, 6; transverse colon, 1; descending colon, 0; sigmoid colon, 4 2 Cecum, 1; ascending colon, 8; transverse colon, 1; descending colon, 1; sigmoid colon, 3 (dome, 13, orifice: 1)
Detection of responsible diverticula The hood method demonstrated active bleeding in 13 of 53 patients (24.5 %), nonbleeding visible vessels in 14 patients (26.4 %), and presumptive diverticular hemorrhage in 26 patients (49.1 %). Thus, the rate of detection of responsible diverticula was 50.9 %. Regarding the location of responsible diverticula, 3 diverticula were found in the cecum, 14 in the ascending colon, 2 in the transverse colon, 1 in the descending colon, and 7 in the sigmoid colon, " Table 1). Nonbleeding visible vessels were located respectively (● at the diverticular dome in 13 cases and at the diverticular orifice in one case. No complications occurred during colonoscopic inspection.
Endoscopic hemostasis Complete inversion of the diverticulum and immediate hemostasis was achieved in all patients treated with EBL. The mean procedure time for EBL was 44 minutes (range 27 – 122 minutes). Early rebleeding developed in 1 of 27 cases, resulting in a hemo" Table 1). The patient with a stasis achievement rate of 96.3 % (● rebleed exhibited mild hematochezia at 5 days after EBL. Colonoscopy revealed that a shallow ulceration had formed around the ligated diverticulum and bled at its edges, which we treated by clipping. During a mean follow-up period of 18 months (range 3 – 27 months), one patient developed late bleeding from a different diverticulum 12 months after EBL that was confirmed by colonoscopy. Neither perforation nor peritonitis developed in any patient.
Outcomes of responsible diverticula treated with EBL Among the 27 patients who received EBL, 12 underwent followup colonoscopy 1 – 3 months afterwards. In 9 of these patients, the responsible diverticulum had disappeared and a scar had " Fig. 2 c). No trace of EBL treatment formed at the original site (● was noted in the remaining 3 patients.
preferentially located at the diverticular orifice in endoscopic studies, pathological studies demonstrated them more frequently in the dome of the diverticulum, as Simpson et al. pointed out [7]. The detection of nonbleeding visible vessels in the dome is difficult with conventional colonoscopy because the entrance of a diverticulum is often narrower than the sac inside, thus preventing full observation of the inner diverticulum. That is, conventional colonoscopy is likely often to fail to reveal the existence of nonbleeding visible vessels in the diverticular dome. Our results indicate that the hood method improves the rate of detection of responsible diverticula by permitting detection of potential nonbleeding visible vessels in the dome. In 2003, Farrell et al. reported four cases of bleeding diverticula treated by EBL with excellent outcomes [8]. They also confirmed the safety of EBL both in vivo and ex vivo [8]. It is surprising that EBL has not become more widespread. Several series of EBL for hemostasis of bleeding diverticula with favorable results have recently been reported: rates of early rebleeding ranged from 6 % to 11 % [5, 9]. In these reports, early rebleeding was caused by incomplete banding due to insufficient inversion of the responsible diverticulum [5, 9]. Susceptibility to complications including perforation and peritonitis has not been reported for any case treated by EBL. In the present series, follow-up colonoscopy in 9 of 12 patients after EBL revealed disappearance of the responsible diverticulum and scar formation at the original site, which accords with a previous description [9]. Thus, EBL can be used to perform a kind of “endoscopic diverticulectomy.” In conclusion, the hood method appears to improve the detection of nonbleeding visible vessels, especially in the diverticular dome. EBL may become an effective procedure for the endoscopic hemostasis of colonic diverticular hemorrhage. Further evaluation is needed to assess both procedures. Competing interests: None
Discussion !
Although detection of active bleeding or nonbleeding visible vessels confirms the accuracy of a diagnosis of diverticular hemorrhage [1], cases with either definitive sign are detected far less commonly than cases with presumptive diverticular hemorrhage [1, 2]. In previous studies, active bleeding and nonbleeding visible vessels were observed in fewer than 25 % and 10 % of patients, respectively [1, 2]. Active bleeding may be overlooked since colonic diverticular hemorrhage is often intermittent [6]. Regarding the location of nonbleeding visible vessels, although they were
References 1 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 2 Smoot RL, Gostout CJ, Rajan E et al. Is early colonoscopy after admission for acute diverticular bleeding needed? Am J Gastroenterol 2003; 98: 1996 – 1999 3 Yen EF, Ladabaum U, Muthusamy VR et al. Colonoscopic treatment of acute diverticular hemorrhage using endoclip. Dig Dis Sci 2008; 53: 2480 – 2485 4 Sugiyama H. Endoscopic diagnosis and treatment for diverticular bleeding of the colon [in Japanese with English abstract]. Nihon Fuku-
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
68
Innovations and brief communications 7 Simpson PW, Nguyen MH, Lim JK et al. Use of endoclips in the treatment of massive colonic diverticular bleeding. Gastrointest Endosc 2004; 59: 433 – 437 8 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 9 Ishii N, Sotoyama T, Deshpande GA et al. Endoscopic band ligation for colonic diverticular hemorrhage. Gastrointest Endosc 2012; 75: 382 – 387
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
bu Kyukyu Igakkai Zasshi (Japanese Journal of Abdominal Emergency Medicine) 2000; 20: 667 – 673 5 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 6 Sos TA, Lee JG, Wixson D et al. Intermittent bleeding from minute to minute gastrointestinal hemorrhage: arteriographic demonstration. Am J Roentgenol 1978; 131: 1015 – 1017
69
Shibata Soichiro et al. Colonic diverticular hemorrhage: the hood method for detecting responsible diverticula … Endoscopy 2014; 46: 66–69
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
