A 72-year-old man on aspirin for ischemic heart disease presents with sudden painless large-volume hematochezia and mild hypotension (BP 92/56). After resuscitation with crystalloid and 2 units of packed cells, urgent colonoscopy within 24 hours reveals a single bleeding diverticulum in the descending colon with a visible vessel and adherent clot. The structure marked **A** in the diagram represents the recommended initial management approach for this patient. Which of the following best describes the endoscopic hemostasis technique most appropriate for this diverticular bleed?
A. Long-term oral antibiotics to prevent inflammation and recurrent bleeding episodes
B. Clipping of the visible vessel with endoscopic clips, with angiographic embolisation reserved for failed endoscopy
C. Emergent total colectomy without prior localisation to prevent recurrent bleeding
D. Outpatient observation with serial hemoglobin monitoring and no acute intervention
Explanation
Why Clipping of the visible vessel with endoscopic clips, with angiographic embolisation reserved for failed endoscopy is right
The structure marked A represents colonoscopic localisation with endoscopic clip placement as the first-line definitive intervention, with angiographic embolisation as the rescue strategy if endoscopy fails. In acute colonic diverticular bleeding with a visible vessel and adherent clot confirmed on urgent colonoscopy, endoscopic hemostasis is the standard of care. Clipping of the visible vessel, epinephrine injection followed by thermal or clip therapy, or band ligation are preferred modalities. If endoscopy fails to achieve hemostasis or rebleeding occurs, super-selective transcatheter embolisation of the responsible vasa recta is the next step. This stepwise approach (endoscopy → angiography if needed) is endorsed by the ACG Guideline on Acute Lower GI Bleeding 2023 and has proven superior outcomes compared to surgery-first strategies in haemodynamically stable patients with localised bleeding.
Why each distractor is wrong
Emergent total colectomy without prior localisation to prevent recurrent bleeding: This represents option B (excessive surgery). Total colectomy is reserved for failure of both endoscopy and angiography, or for recurrent bleeding from the same segment after failed localisation. It is not the initial management and carries significant morbidity in an elderly patient. Segmental colectomy after localisation is preferred if surgery becomes necessary.
Outpatient observation with serial hemoglobin monitoring and no acute intervention: This represents option C (unsafe observation). A patient with active large-volume hematochezia, hemodynamic instability (hypotension, tachycardia), and a confirmed bleeding diverticulum with visible vessel requires urgent endoscopic intervention. Observation alone risks massive rebleeding and death. Only about 75% of diverticular bleeds stop spontaneously, and 25-40% rebleed within years.
Long-term oral antibiotics to prevent inflammation and recurrent bleeding episodes: This represents option D (misunderstanding of pathophysiology). Diverticular bleeding is caused by rupture of the penetrating artery (vasa recta) at the site of diverticula due to chronic mechanical trauma—not by inflammation. Antibiotics are not indicated for acute hemorrhage. Long-term management focuses on aspirin/NSAID risk-benefit discussion, hypertension control, and high-fibre diet, not antibiotics.
High-YieldNEET PG
Acute colonic diverticular bleeding in a haemodynamically compromised patient requires urgent colonoscopy for localisation and endoscopic hemostasis (clipping, epinephrine, or band ligation); angiographic embolisation is the rescue for failed endoscopy; surgery is a last resort.
ACG Guideline on Acute Lower GI Bleeding 2023; Strate & Gralnek NEJM 2017; Setoyama et al. Endoscopy 2011
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
