Diverticulosis

Diverticulosis is a condition in which the colon contains outpouchings (little sacks).. The cause of
colonic diverticula is not entirely known, but may be due to years of high pressure within the
colon or a weakness in the wall of the colon. diverticula are most common in the sigmoid and
descending colon.
When bleeding occurs in a diverticulum located in the sigmoid colon, the bleeding tends to be
bright red. When bleeding occurs in a diverticulum located in the right ascending colon, the
bleeding may also be bright red if the bleeding is brisk; However, the color is more likely to be
dark red, maroon, or, sometimes, even black (melena).
Bleeding from diverticulosis is usually brief (it stops on its own). However, diverticular bleeding
tends to recur. For example, a patient may experience several episodes of rectal bleeding from
diverticula during the same hospitalization. Even after discharge from the hospital, approximately
25% of the patients who do not have the diverticula-containing part of their colon surgically
removed will experience another episode of diverticular bleeding within 4-5 years.

How is rectal bleeding treated?
Treatments for rectal bleeding include 1) correcting the low blood volume and anemia, 2)
diagnosing the cause and the location of the bleeding, and 3) stopping active bleeding and
preventing rebleeding.
Correcting low blood volume and anemia
Moderate to severe rectal bleeding can cause the loss of enough blood to result in
weakness, low blood pressure, dizziness, or fainting, and even shock. Patients with these
symptoms usually are hospitalized. They need to be quickly treated with intravenous fluids and/or
blood transfusions to replace the blood that has been lost so that diagnostic tests such as
colonoscopies and angiograms can be performed safely to determine the cause and location of
the bleeding.
Patients with severe iron deficiency anemia may need hospitalization for blood transfusions
followed by prolonged treatment with oral iron supplements (tablets). Patients with iron deficiency
anemia as a result of chronic gastrointestinal blood loss should undergo tests (such as
colonoscopy) to determine the cause of the chronic blood loss.
Unless anemia is severe, patients with mild rectal bleeding from colon polyps, colon cancers,
anal fissures, and hemorrhoids usually do not need hospitalization. Mild anemia can be treated
with oral iron supplements while tests are performed to diagnose the cause of bleeding.
Determining the cause and location of bleeding
Colonoscopy is the most widely used procedure for the diagnosis and treatment of rectal
bleeding. Most colonoscopies are performed after administration of oral laxatives to cleanse the
bowel of stool, blood, and blood clots. However, in emergency situations such as when the
bleeding is severe and continuous, a doctor may choose to perform an emergency colonoscopy
without first cleansing the large bowel. In trained and experienced hands, the risk of either
elective (delayed) or urgent colonoscopy is small. (Colon perforation, the most common
complication, is rare). The benefits usually far outweigh the potential risks.
Colonoscopy is useful for both diagnosing the cause and determining the location of the
bleeding. Locating the site of bleeding is especially important in diverticular bleeding. Even
though most diverticular bleeding stops spontaneously without the need for surgery, patients with
severe, recurrent, or continuous diverticular bleeding may need surgery to remove the bleeding
diverticulum. Since a patient typically has numerous diverticula scattered throughout the colon,
and colonoscopy may be able to determine which diverticulum is bleeding prior to surgery.
Without an accurate knowledge of the location of the bleeding diverticulum, the surgeon may
have to perform an extensive colon resection (which is not as desirable as removing a small
section of the colon) in order to make sure that the bleeding diverticulum is removed.
Nevertheless, colonoscopy has limitations. During colonoscopy doctors may not find active
bleeding from a specific diverticulum. He/she may only find a colon filled with blood along with
scattered diverticula. In such situations, the diagnosis of diverticular bleeding is assumed if no
other cause for the bleeding such as colitis or colon cancer is found. In these situations, there is
always some uncertainty about the location of the bleeding. Small, bleeding angiodysplasias also
may be difficult to see and may be missed in a colon filled with blood. This is when radionuclide
scans and visceral angiograms may be helpful. If the patient starts bleeding again, an urgent,
tagged RBC scan followed by a visceral angiogram may demonstrate the location of the
bleeding.
Colonoscopy also cannot positively diagnose bleeding from a Meckel's diverticulum because the
colonoscope usually cannot reach the part of the small intestine in which the Meckel's
diverticulum is located. But colonoscopy still can be helpful in establishing the diagnosis of a
bleeding Meckel's diverticulum. Thus, in a young patient with rectal bleeding, a colonoscopy
showing a blood filled colon without another source of bleeding, particularly if accompanied by an
abnormal Meckel's scan, makes the diagnosis of Meckel's diverticulum bleeding highly likely.
Surgical resection of the Meckel's diverticulum should result in permanent cure with no
recurrence of bleeding.
Stopping bleeding and preventing rebleeding
Colonoscopy is more than just a diagnostic tool; it can also be used to stop bleeding by removing
(snaring) bleeding polyps, by cauterizing (sealing with electrical current) bleeding
angiodysplasias or postpolypectomy ulcers and, occasionally, by cauterizing actively bleeding
blood vessels inside diverticula. Cauterization during colonoscopy is usually accomplished by
inserting a long cauterizing probe through the colonoscope. Colonoscopy with cauterization has
been used to stop bleeding in many patients with bleeding from diverticula or angiodysplasias,
thereby decreasing their need for blood transfusions, shortening their hospital stays, and
avoiding surgery.
When colonoscopy cannot identify the site of bleeding or is unable to stop recurrent or
continuous bleeding, visceral angiograms may be helpful. When a bleeding site is identified by
an angiogram, medications can be infused through the angiographic catheter to constrict the
bleeding blood vessel and stop the bleeding, Microscopic coils also can be infused through the
catheter to plug (embolize) the bleeding blood vessel, thereby stopping the bleeding.
If colonoscopy and visceral angiogram cannot stop continuous bleeding or prevent rebleeding,
then surgery becomes necessary. Ideally, the site of bleeding has been identified by
colonoscopy, nuclear scans, or visceral angiogram, so that the surgeon can target the site of
bleeding for exploration and excision. For example, a surgeon can usually resect a colon cancer,
a bleeding polyp, or a Meckel's diverticulum with precision. Sometimes, the exact site of bleeding
cannot be established, and the surgeon will have to perform an extensive colon resection under
the presumption that a diverticulum or angiodysplasia is the cause of the bleeding.
Mild rectal bleeding from anal fissures and hemorrhoids usually can be treated with local
measures such as sitz baths, hemorrhoidal creams, and stool softeners. If these measures fail,
several nonsurgical and surgical treatments are available.