Massive Lower GI Bleed from

Ascending Colon Diverticulum

Martin Gunn

University of Washington

SAR GI Bleeding DFP

Clinical History:

77 year old man with an episode of lower gastrointestinal

bleeding (LGIB) believed to be due diverticulosis diagnosed 5

years ago, presented to the ED in the evening with two episodes

of bright red blood per rectum (BRBPR) over the prior couple of

hours. On arrival in the ED he was hypotensive (BP = 92/74) and

tachycardic (HR = 88). His hematocrit (Hct) was 36. In the ED

he had two further episodes of BRBPR and his Hct dropped to

29. Overnight he had further episodes of BRBPR and required

packed red cells. IR was consulted and a CTA was performed for

interventional planning purposes.

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Axial and coronal images from a CTA of the abdomen and pelvis during the arterial phase of contrast, showing arterial bleeding from a diverticulum in the ascending colon (arrow).

Axial image from a CTA of the abdomen and pelvis 120 seconds after intravenous contrast injection, showing rapid accumulation of extravasated contrast in the lumen of the ascending colon (arrow).

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Catheter angiography (SMA injection) and super-selective injection showing active extravasation from the ascending colon. A superselective angioembolization was performed using a single coil.

After angioembolization, the patient settled clinically. A colonoscopy performed two days later reveal diverticula, but no ongoing bleeding.

Teaching Points:

CT angiography has a high diagnostic accuracy and is an excellent diagnostic tool

for detection and localizing of intestinal bleeding sites1.

Superselective angioembolization, with reembolization if necessary, is an effective

rescue treatment modality for hemodynamically unstable patients with active LGIB2.

Diverticulosis is the most common etiology of acute LGIB in the adult population. Angiodysplasia causes 0-3% acute LGIB, compared to diverticulosis which causes up to 45% of cases3.

The reported recurrence rate for conservatively managed acute LGIB varies, but ranges from 9-47% based on prior studies4.

GI Bleeding

References

1. García-Blázquez V et al, Accuracy of CT angiography in the diagnosis of acute gastrointestinal

bleeding: systematic review and meta-analysis, Eur Radiol. 2013 May;23(5):1181-90.

2. Mejaddam AY et al, Outcomes following "rescue" superselective angioembolization for

gastrointestinal hemorrhage in hemodynamically unstable patients, J Trauma Acute Care Surg.

2013 Sep;75(3):398-403

3. Strate LL, Lower GI bleeding: epidemiology and diagnosis, Gastroenterol Clin North Am. 2005

Dec;34(4):643-64.

4. Vajravelu RK, et al; Incidence, Risk Factors, and Clinical Effects of Recurrent Diverticular

Hemorrhage: A Large Cohort Study. Gastroenterology. 2018 Nov;155(5):1416-1427.

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