63 years old female known case of diabetes mellitus and systemic hypertension presented with complaints of abdominal pain, loose stools for 5 days. On examination BP – 140/80/PR-86 bpm/SPO2 – 98 percent. Per abdomen examination showed tenderness in umbilical region, no guarding and rigidity. Other system examination were normal. Blood investigation showed elevated WBC counts [14500], CRP [53], RFT and LFT were normal. She was started on intravenous antibiotics and other supportive measures. In the view of persistent abdominal pain CT abdomen with oral contrast was done which showed multiple diverticulosis along the stomach, dueodenum, jejunum, ascending and descending colon. On third day of admission she developed per rectal bleeding which was massive/painless and bright red in colour. Sigmoidoscopy was done immediately which showed clots along the sigmoid colon and source of bleeding could not be identified. Her hemoglobin and hematocrit were progressively dropping hence upper and lower GI scopy was done which does not reveal the site of bleeding. Her HB was significantly dropping and also she continued to have per rectal bleeding. She was transfused with PRBC and then planned for CT abdominal angiography which showed a bleeding source from jejunal branches of SMA artery into the jejunum. Immediately angioembolization of the bleeding vessel was done and post procedure her HB and HCT was stable. Melena was also settling gradually.
DISCUSSION
What is Diverticulitis?
Diverticulosis are the outpouchings of the mucosa and submucosa into muscularis propria. Diverticulitis results from microperforation of a diverticulum and intramural inflammation. Most common site for diverticulitis is the sigmoid colon.
Does Diverticular Bleed Requires Active Intervention?
Diverticular bleed is a complication of diverticulitis and 70 percent of the bleed will resolve on its own and only 30 percent with persistent bleed requires intervention like angioembolization of the bleeding vessel or cauterization.
How a diverticulitis present?
Most commonly diverticulitis presents with left lower abdominal pain and it varies with the site of diverticulitis / fever / altered bowel habits / nausea / vomiting. Diverticulitis can present with complications like per rectal bleeding [bleeding will be a painless intermittent and large volume lower GI bleed] perforation and features of peritonitis and features of colonic obstruction.
How to approach and manage a case of diverticular bleed?
Diverticular bleed is the most common cause for lower GI bleed. Algorithm for managing a diverticular bleed includes the initial resuscitation which is the foremost part and diagnostic evaluation of the source of bleed has to be done .colonoscopy is the initial diagnostic procedure. Investigations like upper GI scopy , CT angiography, radionucleotide with technetium 99 can be done.
Endoscopic band ligation of the artery can be done if active bleeding is identified with upper or lower GI scopy .other intervention like angioembolization of the bleeding vessel [it also carries a risk of bowel ischemia] .If the bleeding is persistent with less invasive methods and if patient presents with recurrent bleed resection and anastomosis is considered.
Dr. Rajavanjinayaki
DNB 1st Year Post Graduate (General Medicine)
Kauvery Hospital Chennai