Usefulness of water immersion observations to identify the stigmata of hemorrhage in colonic diverticular bleeding

Step-clipping method can improve the detectability of the target lesion in colonic diverticular bleeding

Background and study aims  Despite the information regarding extravasation from contrast-enhanced computed tomography (CECT), the detectability of the target diverticulum by colonoscopy remains unsatisfactory in colonic diverticular bleeding (CDB). The lack of common signs recognizable on CT and endoscopic images makes it difficult to set a region of interest; however, this can be overcome with the "step-clipping" method, a strategic marking technique for revealing the target. We aimed to investigate the clinical performance of the step-clipping method in patients with CDB. Patients and methods  Eighty-seven patients diagnosed with CDB with extravasation using CECT who underwent colonoscopy between August 2007 and February 2020 were included. Patients were divided into two categories: the traditional group (those who underwent colonoscopy from August 2007 to May 2017, n = 54) and the step-clipping group (those who underwent colonoscopy from June 2017 to February 2020, n = 33). Results  The detection rate for the responsible diverticulum was significantly higher in the step-clipping group than in the traditional group (94 % vs 63 %; P  = .0013). The step-clipping group had a shorter average search time during colonoscopy (9.6 vs 40.5 minutes; P  < .0001) and lower re-bleeding rate after the initial colonoscopy (6 % vs 26 %; P  = .02) than the traditional group, which facilitated earlier hospital discharge (5.4 vs 6.8 days; P  = .027). Conclusions  Colonoscopy using the step-clipping method can improve the detectability of the target lesion within a shorter time, thus leading to lower re-bleeding rates and earlier hospital discharge.

Usefulness of direct clipping for the bleeding source of colonic diverticular hemorrhage (with videos)

Background and study aims  The efficacy of endoclips for colonic diverticular hemorrhage remains unclear. The aim of the current study was to evaluate the safety and efficacy of endoclips versus endoscopic band ligation (EBL) for the treatment of colonic diverticular hemorrhage. Patients and methods  At Nara City Hospital, 93 patients with colonic diverticular hemorrhage with stigmata of recent hemorrhage (SRH) were treated using endoclips or EBL between January 2013 and December 2018. We classified the patients treated by endoclips into the direct clipping group and indirect clipping group. Endoclips were placed directly onto the vessel if technically feasible (direct clipping). When direct placement of endoclips onto the vessel was not possible, the diverticulum was closed in a zipper fashion (indirect clipping). Patient demographics, rate of early rebleeding within 30 days after initial treatment, and complications were retrospectively evaluated. Results  Of the 93 patients, 34, 28, and 31 were in the direct clipping group, indirect clipping group, and EBL group, respectively. Rates of early rebleeding in the direct clipping, indirect clipping, and EBL groups were 5.9 % (2/34), 35.7 % (10/28), and 6.5 % (2/31), respectively ( P  = 0.006: direct clipping vs indirect clipping, P  = 1: direct clipping vs EBL). No complications occurred in any groups. All patients who had early rebleeding in the direct clipping group underwent EBL, and no further bleeding occurred after repeat therapy. Conclusions  Direct clip placement is acceptable as the first treatment choice for colonic diverticular hemorrhage. When direct placement of endoclips is not possible, EBL should be performed instead of indirect clipping.