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

Abstract

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.

Transcatheter Arterial Embolization Using Cone-beam Computed Tomography during Angiography and Automated Vessel Detection Software for Obscure Colonic Diverticular Hemorrhage after Unsuccessful Endoscopic Clipping: A Report of Two Cases

“…Endoscopic clipping is safer and easier to perform than other endoscopic treatments, such as band ligation, detachable snare ligation therapy, injection therapy, and thermal contact band ligation [3]. When clips are placed directly on the bleeding stigma, the reported early rebleeding rate is only 5.9%; however, when direct clipping is difficult and the diverticular orifice is closed in a zipper-like fashion, the rebleeding rate is 35.7% [1].…”

“…Endoscopic clipping is a safe and widely used method for treating colonic diverticular hemorrhage. When a clip is placed directly on the bleeding vessel (direct method), complete hemostasis is achieved in a high proportion of cases [1]. However, direct clipping is not always achieved; for ex-ample, it is difficult to establish a visual field and blind clipping is forced due to massive bleeding.…”

“…However, direct clipping is not always achieved; for ex-ample, it is difficult to establish a visual field and blind clipping is forced due to massive bleeding. In such cases, the diverticular opening is closed with clips using the zipper method (indirect method), which reduces the proportion of cases in which complete hemostasis is achieved [1].…”

Endoscopic clipping for gastrointestinal bleeding: emergency and prophylactic indications

“…The clip may also serve as an anatomical marker for angiography or surgery in the case of recurring bleeding. If clipping is not possible, elastic band ligation is an acceptable alternative [ 27 ]. A recent cohort study enrolling 108 patients evaluated the risk of recurrent bleeding up to a year post elastic band ligation versus endoscopic clipping.…”

Ligation or clipping for diverticular bleeding?

“…The hemostatic effect of direct clipping was as good as that of ligation therapy. They recommend direct clipping as the first choice of hemostatic method, because the bleeding point can be easily treated with the subsequent EBL even in case of rebleeding after direct clipping [10].…”