A 71-year-old man on aspirin for stable ischemic heart disease presents with three episodes of large-volume painless hematochezia. After resuscitation and exclusion of upper GI source, urgent colonoscopy within 24 hours reveals extensive sigmoid diverticulosis. Most diverticula appear quiescent, but in one sigmoid diverticulum at 30 cm from the anal verge, the endoscopist identifies the structure marked **B** in the diagram—a visible, non-bleeding, pigmented protuberance at the dome of the diverticular sac. According to current ACG and ESGE guidelines for colonic diverticular bleeding, what is the most appropriate endoscopic management of this high-risk stigma?
A. Through-the-scope hemoclips (with or without submucosal saline injection) or band ligation
B. Immediate surgical resection of the involved sigmoid colon segment
C. Thermal coagulation (argon plasma coagulation or monopolar electrocautery) applied directly to the dome
D. Observation alone with repeat colonoscopy in 48 hours if rebleeding occurs
Explanation
Why Through-the-scope hemoclips or band ligation is right
The visible vessel at the dome of the diverticulum (marked B) is a non-bleeding visible vessel (NBVV)—a high-risk stigma of recent hemorrhage analogous to Forrest IIa in upper GI bleeding, with significant rebleed risk if untreated. Per ACG 2023 and ESGE 2021 guidelines for acute lower GI bleeding, endoscopic therapy is indicated for diverticular bleeding when high-risk stigmata (including visible vessels) are identified. The preferred modalities are through-the-scope hemoclips (often combined with submucosal saline injection to evert the diverticulum) and band ligation. These techniques achieve hemostasis while minimizing the risk of full-thickness injury and perforation that is inherent to thermal coagulation at the dome.
Why each distractor is wrong
Thermal coagulation (APC or monopolar electrocautery) applied directly to the dome: Thermal coagulation at the dome of a diverticulum is explicitly avoided in guideline-recommended practice because the thin muscular wall and limited depth of the diverticular sac create high risk of full-thickness injury and iatrogenic perforation, which can lead to peritonitis and sepsis. Hemoclips and band ligation are safer alternatives.
Observation alone with repeat colonoscopy in 48 hours if rebleeding occurs: A visible vessel at the dome is a high-risk stigma with substantial rebleed risk (analogous to Forrest IIa in peptic ulcer disease). Observation without endoscopic therapy is inappropriate and exposes the patient to unnecessary morbidity from recurrent hemorrhage, hemodynamic instability, and potential need for emergency surgery or angiographic intervention.
Immediate surgical resection of the involved sigmoid colon segment: Surgical resection is reserved for patients with recurrent or refractory bleeding despite endoscopic therapy, hemodynamic instability despite resuscitation, or perforation. In a patient who has responded to resuscitation and in whom endoscopic hemostasis is feasible and indicated, surgery is not the first-line approach and carries higher morbidity and mortality than endoscopic management.
High-YieldNEET PG
A visible vessel at the dome of a colonic diverticulum is a high-risk stigma requiring endoscopic hemostasis with hemoclips or band ligation—never thermal coagulation due to perforation risk.
Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Updated 2023. ESGE 2021 LGIB.
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