Gastrointestinal hemorrhage, embolization, diverticulum

53 years old / male

The patient was referred to us for the management of massive lower gastrointestinal (GI) bleeding for two days. He was healthy enough and denied any other past medical history.

Bleeding colonic diverticulum and its embolization

Emergent CT was done and the possibility of bleeding from ascending colonic diverticulum was found (Fig. 1).

Contrast-enhanced CT. An axial CT scan reveals higher density (arrow) filling-in the lumen of the diverticulum in the ascending colon. No direct extravasation is seen.

Superior mesenteric angiography (Fig. 2A) was performed via a 5-F angiocatheter through the right common femoral arterial approach. Active bleeding with gush out of contrast material through the colonic lumen was seen on angiography. Abrupt cut-off the proximal portion of vasa recta at the distal ascending colonic branch was seen on selective angiography. No cannulation and passing of the bleeding point was successful because the vessel caliber too small to be passed by a 3-F microcatheter. Several gelfoam pledgets and one microcoil (3*2mm, Tornado embolization microcoil: Cook, Bloomington, IN, USA) was dropped from the proximal portion of the bleeder, and then complete hemostasis was achieved (Fig. 2B).

A, B. Superior mesenteric artery and post-embolization selective colonic angiography. It shows direct extravasation of the contrast material filling-in the lumen of the ascending colon on SMA angiography. The proximal portion of vasa recta is completely discontinued (arrow). The bleeding point could not be passed by the catheter, so the proximal part was embolized by several gelfoam pledgets and microembolization coil. Complete exclusion of the bleeder is seen on the post-embolization angiography.

Bleeding from colonic diverticula is one of well known causes of life-threatening lower GI bleeding. It is also known that even through higher tendency of development of diverticula in descending and sigmoid colon, there is a disproportionate higher tendency of diverticula of the ascending colon to bleed. Rupture of vasa recta, main branches of the colonic connective tissue, in diverticula always occur asymmetrically toward the diverticulum itself. This results in colonic hemorrhage rather than bleeding into the peritoneal cavity. Contrast-enhanced abdominal CT can easily be performed in an emergency, even without any preparation. It can exactly show the bleeding site of lower gastrointestinal bleeding; it is a good tool in the management of gastrointestinal bleeding, before prepared colonoscopy, particularly in massive GI bleeding. An experimental study demonstrated that helical CT could detect arterial bleeding of 0.07 ml/min suggesting that helical CT could be more sensitive than angiography. In the review of 25 literatures and their own experience with 26 patients’ data, Khanna A, et al. revealed that embolization for lower GI bleeding is most effective for the treatment of diverticular bleeding. The pooled odds ratio for arteriovenous dysplastic lesions and other diseases was 3.53 compared with rebleeding after localization and embolization for diverticular disease (95% confidence interval odds ratio, 1.33, 9.41; P < 0.01). Embolization for diverticular bleeding was successful in 85% of patients. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in greater than 40% of patients and over a more protracted period.

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