Despite accumulating evidence and recommendations for management of colonic diverticular bleeding (CDB), the changes in its clinical management and outcomes remain unknown.

We performed a retrospective tendency analysis on a biennial basis, a propensity score-matched cohort study between the first and latter half groups, and mediation analyses to compare the diagnostic and treatment methods between January 2010 and December 2019 (CODE BLUE-J Study).

A total of 6575 patients with CDB were included. While the use of colonoscopy as the initial diagnostic procedure declined, the use of computed tomography (CT) increased in both the trend test and before-and-after comparisons. In hemostasis therapy, the use of endoscopic clips declined and band ligation increased. Interventional radiology remained unchanged; however, the number of surgeries decreased over time. The stigmata of recent hemorrhage (SRH) detection rate and length of hospital stay (LOS) improved significantly. Mediation analyses showed that use of a distal attachment and water-jet scope contributed to an improved SRH detection rate, and use of band ligation contributed to preventing rebleeding within 30 days.

Management strategies for CDB have changed in the past decade, particularly regarding the increased use of CT and decreased need for surgery. However, the main outcomes, except for the SRH detection rate and LOS, did not improve. The widespread use of distal attachment, water-jet scope, and band ligation could improve outcomes in CDB management.

The hemostatic mechanism of endoscopic detachable snare ligation (EDSL) for colonic diverticular hemorrhage (CDH) is similar to that of endoscopic band ligation, which is effective and safe. However, because reports on EDSL are scarce, we conducted a two-center cohort study to evaluate its effectiveness.

This study analyzed 283 patients with CDH treated with EDSL at two Japanese hospitals between July 2015 and November 2021. Patient characteristics and clinical outcomes were retrospectively evaluated. A Kaplan-Meier analysis was performed to evaluate the cumulative probability of rebleeding after EDSL. A Cox proportional hazards regression analysis was performed to compare the effects of complete and incomplete ligation on rebleeding.

The initial hemostasis success and early rebleeding rates were 97.9% and 11.0%, respectively. The time to hemostasis after identification of the bleeding site and total procedure time were 9 min and 44 min, respectively. Red blood cell transfusion was required for 32.9% of patients. The median hospital length of stay after EDSL was 5 days. The complete ligation rate of the early rebleeding group was significantly lower than that of the group without early rebleeding (P < 0.01). The 1-year cumulative rebleeding rate with EDSL was 28.2%. Complete ligation was associated with decreased cumulative rebleeding after EDSL (P < 0.01). One patient experienced colonic diverticulitis; however, colonic perforation was not observed.

Complete ligation is associated with reduced short-term and long-term rebleeding. EDSL could be valuable for CDH because of its low rebleeding rate and the absence of serious adverse events.

Acute lower gastrointestinal bleeding (ALGIB) increase with age and the administration of antiplatelet drugs. Colonic diverticular bleeding (CDB) is the most common cause of ALGIB, and endoscopic hemostasis is an effective treatment for massive CDB. But in patients without extravasation on contrast-enhanced computed tomography (CECT), the efficacy of urgent colonoscopy (UCS) is controversial from the point of the clinical course, including rebleeding rate. We aimed to establish a potential strategy including UCS for CDB patients without extravasation on CECT.

Patients from two centers treated for CDB without extravasation on CECT between July 2014 and July 2019 were retrospectively identified (n = 282). Seventy-four underwent UCS, and 208 received conservative management. We conducted two analyses. The first analysis investigates the risk factors of rebleeding rate within 5 days after administration (very early rebleeding), and no UCS (NUCS) was not the independent factor of the very early rebleeding. The second analysis is whether UCS positively influenced the clinical course after hospitalization.

The prevalence of very early rebleeding and early rebleeding (6-30 days from admission), patients requiring blood transfusion within 0-5 days and 6-30 days post-admission, and duration of hospitalization were examined as clinical course factors between UCS and NUCS group. There was no significant difference between the UCS and non-UCS groups in the clinical course factors. UCS for the CDB patients without extravasation was not improved rebleeding rate and clinical course.

UCS is not necessary in case ofCDB patient without extravasation on CECT.

Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.

Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system.

We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes.

The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay.

We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Factors associated with serious colonic diverticular bleeding (CDB) are unclear, although the incidence of CDB has increased. We carried out this study to clarify factors associated with serious CDB and rebleeding. Subjects included 329 consecutive patients hospitalized for confirmed or suspected CDB between 2004 and 2021. Patients were surveyed regarding backgrounds, treatment, and clinical course. Of 152 with confirmed CDB, 112 showed bleeding from the right colon, and 40 did from the left colon. Patients received red blood cell transfusions in 157 (47.7%), interventional radiology in 13 (4.0%), and surgery in 6 (1.8%) cases. Early rebleeding within one month occurred in 75 (22.8%) patients, and late rebleeding within one year occurred in 62 (18.8%). Factors associated with red blood cell transfusion included confirmed CDB, anticoagulants, and high shock index. The only factor related to interventional radiology or surgery was confirmed CDB, which was also associated with early rebleeding. Late rebleeding was associated with hypertension, chronic kidney disease and past CDB. Right CDB showed higher rates of transfusion and invasive treatment than left CDB. Confirmed CDB had high frequencies of transfusion, invasive treatment, and early rebleeding. Right CDB seemed to be a risk for serious disease. Factors related to late rebleeding were different from those related to early rebleeding of CDB.

Endoscopic band ligation (EBL) is used to treat colonic diverticular bleeding (CDB). An endoscopic variceal ligation device for esophageal varices is used as a conventional EBL device (C-EBL). A new EBL device (N-EBL) was developed by Sumitomo Bakelite in August 2018. We aimed to evaluate the clinical outcomes of N-EBL compared with those of C-EBL.

Seventy-nine patients who underwent EBL for CDB at St. Luke's International Hospital, Japan, between 2017 and 2020 were included in this retrospective study. Patients were divided into the C-EBL and N-EBL groups. Their clinical outcomes, including achieving initial hemostasis, early rebleeding, procedure time, and EBL-associated adverse events, were evaluated.

Of the 79 patients, 36 (45.6%) were in the C-EBL group and 43 (54.4%) were in the N-EBL group. The rate of achieving initial hemostasis was 100% in the C-EBL group and 93.0% in the N-EBL group. No significant difference was noted in the early rebleeding rate between the groups (P=0.24). The N-EBL group achieved a shorter median EBL procedure time than the C-EBL group (18.2 min vs. 14.2 min, P=0.02). No adverse events were observed in either group.

The N-EBL device is safe and useful and may reduce EBL procedure time.

BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay.

1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Either clipping or band ligation will become the most common endoscopic treatment for colonic diverticular bleeding (CDB). Rebleeding is a significant clinical outcome of CDB, but there is no cumulative evidence comparing reduction of short-term and long-term rebleeding between them. Thus, we conducted a systematic review and meta-analysis to determine which endoscopic treatment is more effective to reduce recurrence of CDB.

A comprehensive search of the databases PubMed/MEDLINE and Embase was performed through December 2019. Main outcomes were early and late rebleeding rates, defined as bleeding within 30 days and 1 year of endoscopic therapy for CDB. Initial hemostasis, need for transcatheter arterial embolization, or surgery were also assessed. Overall pooled estimates were calculated.

Sixteen studies fulfilled the eligibility criteria, and a total of 790 participants were included. The pooled prevalence of early rebleeding was significantly lower for band ligation than clipping (0.08 vs 0.19; heterogeneity test, P = 0.012). The pooled prevalence of late rebleeding was significantly lower for band ligation than clipping (0.09 vs 0.29; heterogeneity test, P = 0.024). No significant difference of initial hemostasis rate was noted between the two groups. Pooled prevalence of need for transcatheter arterial embolization or surgery was significantly lower for band ligation than clipping (0.01 vs 0.02; heterogeneity test, P = 0.031). There were two cases with colonic diverticulitis due to band ligation but none in clipping.

Band ligation therapy was more effective compared with clipping to reduce recurrence of colonic diverticular hemorrhage over short-term and long-term durations.

Colonic diverticular bleeding is a common cause of acute lower gastrointestinal bleeding. Endoscopic hemostasis is generally selected as the first-line treatment; however, a considerable number of patients experience early rebleeding after endoscopic treatment. We investigated the risk factors for early rebleeding after endoscopic treatment.

We retrospectively evaluated the data of 142 consecutive patients who underwent endoscopic treatment (endoscopic clipping or endoscopic band ligation) for colonic diverticular bleeding with stigmata of recent hemorrhage between April 2012 and April 2020. Multivariate logistic regression analysis was conducted to evaluate the statistical relationship between patient characteristics and the incidence of early rebleeding occurring within 30 days after endoscopic treatment.

Of 142 patients, early rebleeding was detected in 34 (23.9%) patients. According to univariate analysis, platelet count of <10 × 10⁴/μL, bleeding from the left-sided colon, and endoscopic clipping usage were associated with early rebleeding (P < 0.05). The subsequent multivariate logistic regression analysis identified bleeding from the left-sided colon (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.73-10.0; P = 0.001) and endoscopic clipping usage (OR, 2.92; 95% CI, 1.21-7.00; P = 0.017) as the independent risk factors for early rebleeding.

Bleeding from the left-sided colon and endoscopic clipping usage were the risk factors for early rebleeding after endoscopic treatment. Using endoscopic band ligation was associated with a decreased risk for early rebleeding compared with the use of endoscopic clipping, indicating that endoscopic band ligation was a preferable endoscopic modality to prevent early recurrent bleeding.

Background and study aims  Despite the information regarding extravasation from contrast-enhanced computed tomography (CECT), the detectability of the target diverticulum by colonoscopy remains unsatisfactory in colonic diverticular bleeding (CDB). The lack of common signs recognizable on CT and endoscopic images makes it difficult to set a region of interest; however, this can be overcome with the "step-clipping" method, a strategic marking technique for revealing the target. We aimed to investigate the clinical performance of the step-clipping method in patients with CDB. Patients and methods  Eighty-seven patients diagnosed with CDB with extravasation using CECT who underwent colonoscopy between August 2007 and February 2020 were included. Patients were divided into two categories: the traditional group (those who underwent colonoscopy from August 2007 to May 2017, n = 54) and the step-clipping group (those who underwent colonoscopy from June 2017 to February 2020, n = 33). Results  The detection rate for the responsible diverticulum was significantly higher in the step-clipping group than in the traditional group (94 % vs 63 %; P  = .0013). The step-clipping group had a shorter average search time during colonoscopy (9.6 vs 40.5 minutes; P  < .0001) and lower re-bleeding rate after the initial colonoscopy (6 % vs 26 %; P  = .02) than the traditional group, which facilitated earlier hospital discharge (5.4 vs 6.8 days; P  = .027). Conclusions  Colonoscopy using the step-clipping method can improve the detectability of the target lesion within a shorter time, thus leading to lower re-bleeding rates and earlier hospital discharge.

There is the East-West paradox in prevalence and phenotype of colonic diverticula, but colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding worldwide. Death from CDB can occur in elderly patients with multiple comorbidities, thus the management of CDB is clinically pivotal amid the aging populations in the East and West. Colonoscopy is the key modality for managing the condition appropriately; however, conventional endoscopic hemostasis by thermal coagulation and clipping cannot achieve the expected results of preventing early rebleeding and conversion to intensive intervention by surgery or transcatheter arterial embolization. Ligation therapy by endoscopic band ligation or endoscopic detachable snare ligation has emerged recently to enable more effective hemostasis for CDB, with an early rebleeding rate of approximately 10% and very rare conversion to intensive intervention. Ligation therapy might in turn reduce long-term rebleeding rates by eliminating the target diverticulum itself. Adverse events have been reported with ligation therapy including diverticulitis of the ascending colon in less than 1% of cases and perforation of the sigmoid colon in a few cases, thus more data are necessary to verify the safety of ligation therapy. Endoscopic hemostasis is indicated only for diverticulum with stigmata of recent hemorrhage (SRH), but the detection rates of SRH are relatively low. Therefore, efforts to increase detection are also key for improving CDB management. Urgent colonoscopy and triage by early contrast-enhanced computed tomography may be candidates to increase detection but further data are necessary in order to make a conclusion.

Background and study aims  Unsatisfactory detectability of a previously bleeding diverticulum by colonoscopy results from difficulty in precisely locating the target lesion, even with presence of an extravasation on contrast-enhanced computed tomography (CECT). This study aimed to evaluate the usefulness of the step-clipping method to overcome this limitation. Patients and methods  Step-clipping was indicated for patients with colonic diverticular bleeding and presence of extravasation on CECT, but with absence of active bleeding on subsequent colonoscopy. The target diverticulum was identified by comparing computed tomography images before and after step clipping, which provided a positional relationship between each clip and the target lesion. Results  Based on data from 21 consecutive cases meeting our inclusion criteria (14 men and 7 women; mean age, 73.2 years), the target diverticulum was endoscopically identified in 20 cases (95 %), in a median time of 5 minutes, and successfully treated. No adverse events were observed with the step-clipping method. Conclusion  Step-clipping provided easy guidance to the target site for treatment in a short time, despite spontaneous cessation of bleeding at the diverticulum.

Objective Endoscopic band ligation (EBL) is commonly performed to treat colonic diverticular bleeding (CDB). However, EBL is not suitable for other disorders that cause acute lower gastrointestinal bleeding (ALGIB), and the safety and efficacy of the procedure are not well known. This study aimed to evaluate the efficacy and safety of EBL for non-colonic diverticular bleeding (non-CDB) and investigate the application of EBL to ALGIB. Methods This study was a retrospective evaluation of the success rate of EBL, the rate of early re-bleeding (within 30 days of the initial EBL), and complications such as perforation and abscess formation. Patients Thirty patients who presented with non-CDB and underwent EBL as the first-line treatment in our hospital from June 2009 to December 2017 were included in the present study. Results The success rate of EBL was 93% (28/30). The rate of early re-bleeding after EBL was 20% (6/30). Repeat EBL, endoscopic clipping, or conservative therapy was performed in the event of re-bleeding. No emergency surgery or interventional hemostatic treatments were required for hemostasis. No complications such as perforation or abscess formation were observed in any patient. Conclusion Our results suggest that EBL is an effective and safe endoscopic treatment for non-CDB.

The risk factors for early rebleeding following the management of colonic diverticular bleeding (CDB) are unclear. This study aimed to determine the risk factors for early rebleeding following initial colonoscopy.

Overall, 370 patients with CDB were divided as having presumptive (229) or definite CDB with stigmata of recent hemorrhage (141) on the basis of initial colonoscopy. Definite CDB cases were treated by either endoscopic clipping (EC) or endoscopic band ligation (EBL) as a first-line treatment. Time-to-event analysis for early rebleeding was performed by Kaplan-Meier methods with log-rank test between the three groups (presumptive, EC, and EBL). Multivariate Cox proportional hazards regression was used to identify risk factors for early rebleeding.

There were 38 and 103 patients in the EC and EBL groups, respectively. Early rebleeding developed in 61 cases (16.5%). The cumulative incidence rates of early rebleeding at 1, 5, and 30 days were 7.7%, 16.4%, and 17.9% in the presumptive group; 1.9%, 7.0%, and 9.5% in the EBL group; and 2.6%, 34.9%, and 37.7% in the EC group, respectively (log-rank test, P = 0.00059). Moreover, 90.2% of early rebleeding occurred within 5 days. Adjusted hazard ratio (HR) was marginally lower in the presumptive group (HR = 0.50; 95% confidence interval, 0.26-1.01; P = 0.052) and significantly lower in the EBL-treated group than in the EC group (HR = 0.21; 95% confidence interval, 0.09-0.50; P = 0.0004).

Most early rebleeding occurred within 5 days after initial colonoscopy. EC was less effective than EBL in terms of early rebleeding.

Objective This historical control study was performed to evaluate i) the rebleeding rate of bleeding colon diverticula treated with endoscopic band ligation (EBL) versus endoscopic clipping (EC) and ii) risk factors for rebleeding of diverticula initially treated by endoscopic hemostasis. Methods From January 2010 to December 2012, 68 patients were treated with EC, and from January 2013 to August 2016, 67 patients were treated with EBL. All patients in each group were followed up for one year to check for rebleeding. Results The rebleeding rate was lower in the EBL group (7 of 67, 10%) than in the EC group (21 of 68, 31%; p<0.01). This difference was mainly due to the lower rebleeding rate from the same hemorrhagic diverticulum initially treated by hemostasis (EBL: 4 of 67, 6%; EC: 15 of 68, 22%; p<0.01). The time span until rebleeding in the EBL group was ≤1 week. A multivariate analysis indicated that bleeding from the diverticula on the right side of the colon was a high-risk factor for rebleeding from the diverticula (odds ratio, 4.48; 95% confidence interval, 1.22-16.46; p=0.02). Conclusion The low rebleeding rate in the EBL group was attributed to the low degree of rebleeding from the same diverticulum, indicating that EBL was superior to EC in preventing rebleeding of an initially treated diverticulum.

We previously reported preliminary safety results for a new method, endoscopic detachable snare ligation (EDSL), for diverticular hemorrhage. This method does not need endoscope removal to attach a ligation device after detection of the bleeding site. The aim of the present study was to evaluate the efficacy and safety of EDSL in a larger patient population.

This prospective study was conducted in 12 institutions. Patients suspected of having diverticular hemorrhage without serious systemic disease were enrolled. The primary endpoint was early (within 30 days) recurrent bleeding rate in patients treated with EDSL. The secondary endpoints were overall early recurrent bleeding rate in patients with definite diverticular bleeding and adverse events in patients treated with EDSL.

From June 2015 to March 2017, bleeding diverticula were detected in 123 of 205 enrolled patients (60%), of whom 101 (82%) were treated with EDSL. Most patients (20/22) in whom EDSL was not successful were treated with clipping. The early recurrent bleeding rate was 7.9% (95% confidence interval, 2.6%-13.2%; 8/101) in patients who could be treated with EDSL. The median total endoscopic and EDSL procedure time was 40 minutes (interquartile range, 15-71) and 4 minutes (interquartile range, 1-7), respectively. Two mild adverse events, colonic diverticulitis and temporary abdominal pain, were observed.

EDSL was confirmed to be useful and safe for treatment of colonic diverticular hemorrhage. (Clinical trial registration number: UMIN 000001858.).

Acute severe lower gastrointestinal bleeding (LGIB) can be treated by endoscopy safely and effectively. At present, the data on the efficacy of endoscopy in the treatment of patients with LGIB are still being collected. Thus, guidelines to manage patients with LGIB are still in development. Herein, based on the recent literature and their twenty year experience in their units in the US and in Japan, the authors summarize the role of endoscopic hemostasis therapy in acute severe LGIB with a focus on how to perform the hemostasis techniques.

Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.

Several endoscopic modalities have been used for the treatment of colonic diverticular bleeding (CDB). The aim of this study was to evaluate the effectiveness of endoscopic treatment for CDB.

We performed a systematic review and meta-analysis of the English literature. Main outcomes were initial hemostasis, early recurrent bleeding (recurrent bleeding within 30 days after endoscopic treatment), and need for transcatheter arterial embolization (TAE) or surgery. Proportions were collected from each study and were used to calculate pooled estimates. Heterogeneity was evaluated by I².

Sixteen studies (384 patients with CDB) were included. Pooled estimates of initial hemostasis were coagulation, 1.00 (95% CI, .91-1.00) (I² = .0%); clipping, .99 (95% CI, .97-1.00) (I² = .0%); and ligation, .99 (95% CI, .95-1.00) (I² = .0%). Pooled estimates of early recurrent bleeding were coagulation, .21(95% CI, .01-.51) (I² = 61.2%); clipping, .19 (95% CI, .07-.35) (I² = 77.3%); and ligation, .09 (95% CI, .04-.15) (I² = .0%). Pooled estimates of need for TAE or surgery were coagulation, .18 (95% CI, .00-.61) (I² = 68.9%); clipping, .08 (95% CI, .03-.16) (I² = 36.8%); and ligation, .00 (95% CI, .00-.01) (I² = .0%). The proportion of need for TAE or surgery in the ligation group was significantly lower than that in the clipping group (P = .003) and marginally lower than in the coagulation group (P = .086). No significant difference was found between coagulation and clipping groups (P = .44).

Ligation therapy was more effective compared with clipping to avoid TAE or surgery. Coagulation, clipping, and ligation were equivocal in terms of effectiveness for initial hemostasis and preventing early recurrent bleeding.

Lower gastrointestinal bleeding (LGIB) is a common problem that can be treated via a number of endoscopic, radiological and surgical approaches. Although traditionally managed by the colorectal surgeons, surgery should be considered a last resort given the variety of endoscopic and radiological approaches available. This article provides an overview on the common causes of acute LGIB and the various techniques at our disposal to control it.

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Endoscopic band ligation (EBL) has been used to achieve hemostasis in patients with colonic diverticular bleeding. The safety and effectiveness of EBL when performed by non-expert endoscopists have not been sufficiently verified. This study aimed to elucidate the feasibility of the EBL technique when performed by non-expert endoscopists and of considering EBL as a standard treatment for colonic diverticular bleeding.

A retrospective cohort study was conducted in a tertiary referral center in Tokyo, Japan, between June 2009 and October 2014. A total of 95 patients treated with EBL were included in the study and were divided into two groups according to whether they had been treated by expert or non-expert endoscopists. Comorbidities, medications, shock index, hemoglobin level on admission, location of the bleeding diverticula, rate of bowel preparation, procedure time, and EBL-associated adverse events were evaluated in each group. Multivariate linear regression analyses were used to investigate factors related to EBL procedure time, which is the time elapsed between marking the site of bleeding with hemoclips and completion of the band release.

A total of 47 (49.5 %) procedures were performed by expert endoscopists. In a bivariate analysis, the median EBL procedure times in the expert and non-expert groups were 15 minutes (range 4 - 45) and 11 minutes (range 4 - 36), respectively (P = 0.03). When a multivariate linear regression model was used, EBL for right-sided diverticula was the factor most significantly affecting EBL procedure time. No adverse events were encountered.

EBL can be safely and effectively performed by non-expert endoscopists. A right-sided location of diverticula was the factor most significantly affecting EBL procedure time.

Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model.

We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination.

The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis.

EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Colonoscopy can be used for both diagnosis and treatment of colonic diverticular bleeding. Identification of the stigmata of recent hemorrhage allows for various endoscopic hemostasis methods. Clipping, endoscopic band ligation, injection therapy, and thermal contact are available methods for endoscopic hemostasis. However, the optimal technique remains to be determined. Herein, we review the techniques and clinical outcomes of endoscopic hemostasis for colonic diverticular bleeding.

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.

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.

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).

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.

Long-term outcomes of endoscopic band ligation (EBL) for colonic diverticular hemorrhage have not been reported to date. The aim of this study was to determine the long-term outcomes of EBL and to retrospectively compare them with those of endoscopic clipping (EC) in the treatment of colonic diverticular hemorrhage.

The study included patients with colonic diverticular hemorrhage who were treated with EBL or EC from January 2004 to November 2014 and followed up more than 1 year (61 patients in the EBL group and 39 patients in the EC group). Time-to-event analysis of rebleeding was performed with the Kaplan-Meier method. A follow-up colonoscopy was performed to confirm the disappearance of the banded diverticula in the EBL group.

Rebleeding occurred in 21 patients in the EBL group and in 26 patients in the EC group. The cumulative incidence of rebleeding at 1, 12, 24, and 36 months after first treatments was 14 %, 23 %, 26 %, and 41 % in the EBL group and 38 %, 49 %, 59 %, and 68 % in the EC group, respectively. Time-to-event analysis revealed statistically significant data (Log-rank test, P = 0.0036). Scar formation with fold convergence at the previously banded site was observed in 11 of 24 patients who underwent follow-up colonoscopy (46 %). However, late rebleeding (rebleeding more than 30 days after EBL) occurred in five of these 11 cases.

EBL was superior to EC in the treatment of colonic diverticular hemorrhage. However, the risk of rebleeding was not avoided even after the diverticula had been resolved using EBL.

A 72-year-old woman presented with massive hematochezia. Colonoscopy revealed active bleeding from a diverticulum in the ascending colon, diagnosed as colonic diverticular hemorrhage. Endoscopic band ligation (EBL) was performed for the hemostasis. The patient developed abdominal pain in the right lower quadrant 1 day after EBL. Computed tomography (CT) demonstrated dirty fat around the ascending colon and thickened peritoneum without perforation or abscess formation, consistent with uncomplicated diverticulitis. The patient was discharged with intravenous antibiotic therapy 5 days after EBL. Attention should be given to the occurrence of colonic diverticulitis after EBL for colonic diverticular hemorrhage.

Diverticular disease is increasingly prevalent in Western societies and is associated with significant morbidity.

Two-stage endoscopic device development for inversion and secured ligation of colonic diverticula; first, human cadaver studies were performed to measure forces required for diverticular inversion; second, a novel set of devices (elastic spiked O-ring with delivery system) was tested in animals.

Prospective, observational study of human cadavers and prospective, interventional study of a porcine model.

University hospital pathology laboratory and animal facility.

Full-thickness inversion of the colonic wall with a pipelike delivery instrument to produce an inverted pseudodiverticulum that was secured with a spiked O-ring.

The forces required for diverticular inversion, the secured closure of inverted pseudodiverticula, and the time until necrotic tissue falls off.

A total of 248 of 248 of cadaveric sigmoid diverticula could be inverted by means of vacuum or forceps. The forces required for inversion ranged from 0.28 to 0.47 N (median, 0.37 N). Twenty-four spiked O-rings were delivered in 6 living pigs to produce 24 inverted pseudodiverticula. One animal died the day after the procedure of a pulmonary thromboembolism. In the remaining 5 pigs, all delivered spiked O-rings remained in place for 7 to 22 days. At necropsy, none of the inverted sites showed signs of perforation but rather full-thickness reparative scarring with ingrowth of connective tissue.

Animal model, stiff pipelike delivery instrument, variations in diverticular location, diameter, and size.

Endoluminal inversion and securing of colonic diverticula induces tissue necrosis, diverticular sloughing, and full-thickness scarring.

Diverticular hemorrhage is the most common reason for lower gastrointestinal bleeding (LGIB) with substantial cost of hospitalization and a median length of hospital stay of 3 days. Bleeding usually is self-limited in 70-80% of cases but early rebleeding is not an uncommon problem that can be reduced with proper endoscopic therapies. Colonoscopy is recommended as first-line diagnostic and therapeutic approach. In the vast majority of patients diverticular hemorrhage can be readily managed by interventional endotherapy including injection, heat cautery, clip placement, and ligation to achieve endoscopic hemostasis. This review will serve to highlight the various interventions available to endoscopists with specific emphasis on superior modalities in the endoscopic management of diverticular bleeding.

Recent reports have indicated several instances of successful treatment of bowel perforation by using endoscopic band ligation (EBL) when treatment with endoclipping is unsuccessful, but this salvage method has not been investigated in any prospective model. Herein we aimed to compare the technical feasibility and efficacy of EBL and endoclip use in intraluminal closure of colon perforation, in an ex vivo model.

Standardized colonic perforations were created using fresh porcine colon and subsequently closed by full-thickness interrupted sutures, endoclip (QuickClip2(TM)), or EBL. Each closure site was tested with compressed air by using a digital pressure monitor for evaluating leak pressure.

No significant differences were noted between the endoclip and EBL in leak pressures. Mean (± SD) pressures for air leakage from the perforations closed using the different devices were as follows: normal colon samples, 52.0 ± 13.2 mmHg; perforations closed with hand-sewn sutures, 32.3 ± 8.3 mmHg; perforations closed with endoclipping, 53.5 ± 22.7 mmHg; and perforations closed with EBL, 50.4 ± 12.5 mmHg. Time taken for closure by EBL was significantly less than that for closure by endoclipping (3.2 ± 1.7 min vs 6.8 ± 1.3 min, P < 0.01). Further, the number of devices used to achieve complete closure in the EBL group was lower than that with endoclipping (1.6 ± 0.5 vs 3.7 ± 0.8, P < 0.01).

Endoluminal closure of a 1.5-cm colon perforation with EBL decreased procedure time and was not inferior in leak pressure compared with endoclipping in this ex vivo porcine model.