Diverticular Hemorrhage - An Overview

Introduction:

Diverticular bleeding remains the most common cause of lower gastrointestinal bleeding. Diverticular bleeding or diverticular hemorrhage occurs as a side effect of diverticulosis. The associated bleeding appears all of a sudden and can resolve on its own but if the bleeding is severe, one must consult a physician. Diverticular hemorrhage can occur in three to five percent of patients with diverticulosis. Acute lower gastrointestinal bleeding is responsible for approximately 20 % of all gastrointestinal bleeding.

What Is Diverticulosis?

Numerous tiny pockets or diverticula that form in the lining of the bowel are called diverticulosis. The size of these diverticula is either pea-sized or larger and develops as a result of increased pressure in the weakened spots of the walls of the intestine by waste, gas, or liquid. Diverticula are usually formed as a result of straining like with constipation. They are prevalent in the lower portion of the large intestine called the sigmoid colon.

Diverticulosis can occur in 10 % of people above 40 years of age and in 50 % of people above 60 years of age. A majority of people will experience few or no symptoms. Complications can happen in 20 % of individuals with diverticulosis. One such complication is called rectal bleeding or diverticular hemorrhage. If an infection develops, it is called diverticular infection or diverticulitis.

What Are the Risk Factors of Diverticular Hemorrhage?

The risk factors include:

• Elderly people.

• Diabetic individuals.

• Individuals with vascular (related to blood vessels) diseases.

• Those who consume non-steroidal anti-inflammatory drugs (NSAIDs) frequently.

• Those who take anticoagulants, calcium channel blockers, or antithrombotics.

What Are the Causes of Diverticular Hemorrhage?

The causes are as follows:

• The reason why diverticula or pouches develop in the wall of the large intestine is not known.

• It is believed that diverticula or pouches evolve when high pressure in the colon or large intestine pushes against the weak walls of the colon.

• A diet that is rich in fiber called roughage produces a bulky stool that travels smoothly through the colon.

• On the other hand, if the diet lacks sufficient fiber, the stools can stay in the bowel or large intestine for a long time which increases the pressure.

• Weak spots are present in areas where blood vessels pass through the muscular layer of the wall of the large intestine and supply blood to the inner wall. With increased pressure, when the blood vessel supplying the pouch bursts open, bleeding occurs.

• The diverticular disease that occurs on the right side is linked wither a higher rate of bleeding complications. The reason is that the right colon has a diverticulum that is dome-shaped and has wider necks. The vasa recta (long, hair-pin-shaped blood vessels) present in this region come in contact with many injurious factors that arise from the colon.

Is It Normal to Bleed With a Bowel Movement?

It is abnormal to bleed with a bowel movement and it can signify many health conditions, a majority of which are not serious like hemorrhoids but a few can be serious and might require immediate medical intervention. If one notices blood in the stool, they must consult a healthcare professional right away it examine and evaluate the issue further.

Can Diverticulitis Result in Bleeding?

An infection that develops in the diverticula is called diverticulitis. Mostly, older people are affected by diverticulitis. A majority of people do not experience any signs or symptoms but some may experience symptoms like stomach cramps, bloating, one-sided abdominal pain, and bleeding. Less than 5% of people with diverticulosis can suffer from diverticular bleeding.

What Are the Symptoms of Diverticular Hemorrhage?

The following are the symptoms of diverticular hemorrhage:

• The bleeding can vary from mild to severe.

• Some people may observe a little fresh blood mixed with the stool.

• Some might observe large blood clots.

• The blood in the stools can be dark red, maroon, or in the form of bright red clots.

• Abdominal pain is rare.

• Some might feel lightheaded, dizzy, or weak.

How Can Diverticular Hemorrhage Be Diagnosed?

A complete physical examination and medical history will be taken by the healthcare provider. Diverticular hemorrhage can be diagnosed in the following ways:

• Angiography (an X-ray to check blood vessels) will be suggested to identify the location of continuous bleeding.

• A colonoscopy (examination of the large intestine) will be done by examining the large intestine using a long, flexible, light-viewing scope called a colonoscope. This is considered to be effective in detecting the source of bleeding in the lower intestinal area.

• A technetium-labeled red blood cell bleeding scan may be suggested to identify the origin of the bleeding. In this test, blood is obtained from the individual, and a small amount of radioactive material called technetium is added to the blood. The blood which contains the technetium is injected into the bloodstream and the source of bleeding is identified.

• The physical examination must involve evaluating the hemodynamic (flow of blood) and volume status along with the recording of vital signs, signs of postural hypotension (a low blood pressure that occurs when standing after sitting or lying down), cardiopulmonary, anorectal, and abdominal examination.

• Laboratory investigation involves complete blood count, renal function, coagulation studies, and liver function tests. Nasogastric suctioning should be done to rule out gastric bleeding.

How Can Diverticular Hemorrhage Be Treated?

Diverticular hemorrhage is treated as follows:

• A majority of the cases of diverticular hemorrhage will get corrected on their own within one or two days. In severe cases, medical intervention may be crucial to stop the bleeding and restore the lost blood.

• Intravenous fluids, blood transfusions, medicine, and rarely surgery may be required to remove the affected portion or segment of the colon.

• Apart from detecting active bleeding, endoscopic procedures like colonoscopy can be used to treat diverticular hemorrhage without opting for surgery.

• In angiography, a wire traverses through the blood vessels to trace the origin of the bleeding. Substances that stop bleeding can be injected during angiography.

What Are the Complications of Diverticular Hemorrhage?

The following are a few complications:

• About 10 to 20 percent of people may suffer from severe bleeding where there can be a large amount of blood loss.

• It can be serious at times and lead to dehydration and blood loss.

• Very rarely, diverticular hemorrhage can result in fatalities.

What Are the Differential Diagnoses of Diverticular Hemorrhage?

The differential diagnoses include:

• Hemorrhoids.

• Colon cancer.

• Angiodysplasia (abnormal blood vessels in the gastrointestinal tract).

• Inflammatory bowel disease (IBD).

• Colitis (inflammation of colon lining).

• Colon cancer.

• Proctitis (it is the inflammation of the lining of the rectum).

What Is the Prognosis of Diverticular Hemorrhage?

Diverticular hemorrhage will resolve on its own in about 80 % of individuals. However, about 22 to 38 percent might experience a relapse in the future. The elderly who are over 80 years of age are susceptible to rebleeding episodes.

Can Diverticular Hemorrhage Be Prevented?

Diverticular hemorrhage can be prevented in the following ways:

• Following good and regular bowel habits to prevent constipation and straining.

• Including sufficient fiber in the diet. The American Dietetic Association suggests one take 20 to 35 grams of fiber a day. This applies to everyone. Fiber-rich foods include cereals, whole grain bread, crackers, fruits, berries, vegetables like cabbage, spinach, carrots, broccoli, squash, asparagus, beans bran products, brown rice, and cooked dried beans and peas.

• Exercising regularly.

Diet is not helpful in those people with a history of diverticulosis.

Conclusion:

Diverticular hemorrhage is the primary and common cause of lower gastrointestinal bleeding. The hemorrhage will resolve on its own but at times the situation can become unmanageable. In such circumstances, it is essential that one consult a physician and one might require an intravenous infusion of fluids or blood transfusions. A minimally invasive technique like angiography might also be effective and in extreme cases, surgery might be required. Deaths can occur but are very rare.