BACKGROUND AND AIMS Few prospective reports describe the short term natural history of colon diverticular hemorrhage based upon stigmata of recent hemorrhage and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes are to report the 30 day natural history of definitive diverticular hemorrhage based upon stigmata and to describe Doppler probe blood flow detection and as a guide to definitive hemostasis. METHODS Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30 day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. Natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after washing away clots are reported. Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis is also reported in a recent cohort. RESULTS For natural history patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. Doppler probe detected arterial blood flow in 92% of major stigmata, none after hemostasis and no one rebled. CONCLUSIONS 1. Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. 2. Patients with clean diverticula or only flat spots had no rebleeding. 3. High rates of arterial blood flow were detected under major stigmata with Doppler probe but with obliteration by hemostasis no rebleeding occurred.

Gastrointestinal (GI) bleeding from the colon is a common reason for hospitalization and is becoming more common in the elderly. While most cases will cease spontaneously, patients with ongoing bleeding or major stigmata of hemorrhage require urgent diagnosis and intervention to achieve definitive hemostasis. Colonoscopy is the primary modality for establishing a diagnosis, risk stratification, and treating some of the most common causes of colonic bleeding, including diverticular hemorrhage which is the etiology in 30 % of cases. Other interventions, including angiography and surgery, are usually reserved for instances of bleeding that cannot be stabilized or allow for adequate bowel preparation for colonoscopy. We discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia.

BACKGROUND & AIMS For 4 decades, stigmata of recent hemorrhages in patients with non-variceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata is rarely monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe non-variceal upper gastrointestinal hemorrhage. METHODS In a single-blind study performed at 2 referral centers, we assigned 148 patients with severe non-variceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy’s lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n=76) or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n=72). The primary outcome was rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. RESULTS There was a significant difference in rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P=.0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% CI, 0.143–0.8565) and number needed to treat was 7. There were also significant differences in rates of surgery and major complications (5.3% in the control group vs no patients in the Doppler monitoring group for each, P=.048) CONCLUSIONS In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe-guided endoscopic hemostasis significantly reduced 30 day rates of rebleeding, surgery, and major complications compared to standard, visually guided hemostasis. Guidelines for non-variceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F)