A 79 yo AAF with a PMH of diverticulosis, diagnosed by colonoscopy 2 years ago, is admitted to the hospital with CC: intermittent rectal bleeding for 3 days. She also c/o lower abdominal pain but no fever or chills.
Diverticulosis, GERD, seizures, DM2, gout.
Dilantin, Nexium, Colchicine, Seroquel.
Lives alone, no EtOH, smoking or drugs.
VSS, no orthostatic changes. Please remember to check for orthostatic changes in all patients with a suspected GI problem.
What do you think is going on?
Diverticulosis? (very likely)
Diverticulitis? The abdominal pain points to diverticulitis but the patient does not have fever or chills, CBCD is also important to make the diagnosis.
Other causes of lower GI bleed seem less likely.
Remember the mnemonic H-DRAIN for DDx of lower GI bleed:
Diverticulosis / Diverticulits
Infection / IBD / Ischemic gut
What tests would you order?
CBCD, CMP, INR/PTT
H&H q 8 hrs
Type and screen 2U PRBC. Please do not "type and cross" since if the units are not transfused, that blood is wasted.
H&H was relatively stable but she continued to have bloody BM.
What is the next step?
Colonoscopy report (click to enlarge)
In terms of procedure length, a colonoscopy is reminiscent of a long journey as opposed to an EGD which resembles a short commute. The colonoscope has to go all the way to the ileocecal valve and back. In this patient, there was some old brown blood in the rectum. The further north it went, the more blood we saw, and it became fresher and brighter. There were a lot of diverticuli and you have to be very careful not to take a side road in one of the blind diverticuli pouches. Most of the blood was in the upper descending and transverse colon. Going further, and the blood disappeared. By the time the colonoscope reached the ileocecal valve, the mucosa was pale and shiny, with no sign of blood whatsoever. It looked like a low grade continuous oozing somewhere in the transverse colon but there was no focal source of bleeding.
What is usually the bleeding source in diverticulosis?
Usually, the source is one ruptured vessel in one of the diverticuli and it is very difficult to see which one of the may diverticuli pouches is to blame.
How do you anesthetize the patient during the procedure?
All patients are hooked to a portable monitor which shows their HR, BP and SpO2, they have supplemental O2 by NC. Versed and Demerol are the standard sedatives. Patients are often uncomfortable due to the gas inflation of the bowel during the colonoscopy and they are encouraged to pass gas during the procedure.
Hemoglobin slowly decreased to 9.1 mg/dL and stayed there, this was a drop of 3 grams since admission. Patient was hemodynamically stable but continued to have a small amount of rectal bleeding with stools. This made us a little nervous and we ordered a RBC Tc-tagged scan which was negative (no evidence of active bleeding). Patient was stable and was D/C'd home with a stool softener and MoM PRN.
Q & A
Does inflammation of diverticulitis and bleeding of diverticulosis occur in the same area?
No. Diverticulitis affects the sigmoid colon almost exclusively although you can certainly find diverticuli all over the colon. The bleeding on the other hand most commonly occurs in the descending to transverse colon.
What did we learn from this case?
Common things happen commonly. This patient had a typical picture of diverticulosis as expected by history.
Usually the bleeding stops spontaneously, in this patient it just took a little more time (4 days).
Nuts, Popcorn, and Corn Don't Increase Complications of Diverticular Disease. WebMD, 08/2008.
Diverticulitis, Mayo Clinic. Dr. David Larson, a colon and rectal surgeon at Mayo Clinic discusses diverticulitis, its diagnosis and minimally invasive treatment options.