Lower Gastrointestinal Bleeding Treatment & Management

Patients who are hemodynamically unstable with active bleeding should be admitted to the medical intensive care unit (MICU). Early consultation with both a gastroenterologist and a surgeon is recommended.

The management of lower gastrointestinal bleeding (LGIB) has three components, as follows:

• Resuscitation and initial assessment

• Localization of the bleeding site

• Therapeutic intervention to stop bleeding at the site

With advances in diagnostic and therapeutic endoscopy and angiography, the ability to localize and subsequently treat LGIB has resulted in improved patient outcomes and reduced healthcare costs. ^[23] The need for surgery also has been significantly reduced.

The sequence of using these modalities depends on the patient's clinical status, the rate of bleeding, and local expertise in specific surgical and nonsurgical procedures. Using any one modality should not preclude the subsequent use of another modality if required. In case of surgery, preoperative localization of bleeding is essential, because segmental colectomies performed after bleeding is localized are associated with the lowest morbidity and mortality.

Massive LGIB is a life-threatening condition; although this condition manifests as maroon stools or bright red blood from the rectum, patients with massive upper GI bleeding (UGIB) may also present with similar findings. Regardless of the level of the bleeding, one of the most important elements in the management of patients with massive UGIB or LGIB is the initial resuscitation. These patients should receive two large-bore intravenous (IV) catheters and isotonic crystalloid infusions. Meanwhile, perform rapid assessment of vital signs, including heart rate, systolic blood pressure, pulse pressure, and urine output. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL.

The 2016 American Academy of Family Physicians (AAFP) guidelines recommend the following for the initial evaluation, risk stratifcation, and hemodynamic resuscitation ^[5] :

• Obtain a focused history, physical examination, and laboratory studies at the time of patient presentation (to determine bleeding severity and potential causes and site), while concurrently performing hemodynamic resuscitation.
• In the presence of hematochezia and hemodynamic instability, which may indicate an upper gastrointestinal bleeding (UGIB) site, perform an upper endoscopy; if there is a moderate suspicion of UGIB, use nasogastric aspirate/lavage to help determine a potential upper GI source.
• Perform risk assessment and stratification.
• Administer intravenous (IV) fluid resuscitation in patients with hemodynamic instability and/or suspicion of active bleeding.
• Transfuse packed red blood cells (PRBCs) to maintain the hemoglobin level above 7 g/dL.

Initial resuscitation involves establishing large-bore IV access and administration of normal saline. Besides ordering routine laboratory studies (eg, complete blood cell (CBC) count, electrolyte levels, and coagulation studies), blood should be typed and cross-matched. The patient's blood loss and hemodynamic status should be ascertained, and in cases of severe bleeding, the patient may require invasive hemodynamic monitoring to direct therapy.

Patients in shock should receive fluid volume replacement without delay. ^[5] Colloid or crystalloid solutions may be used to achieve volume restoration before administering blood products. PRBC transfusions should maintain the hemoglobin level above 7 g/dL, with a threshold of 9 g/dL in those with massive bleeding or significant comorbid conditions, or if there may be a delay in more definitive treatment. ^[5]

Signs of hemodynamic compromise include postural changes with dyspnea, tachypnea, and tachycardia. An orthostatic drop in systolic blood pressure of more than 10 mm Hg or an increase in heart rate of more than 10 beats per minute is indicative of at least 15% of blood volume loss. Severe postural dizziness with a postural pulse increase of at least 30 beats per minute is a sensitive and specific indicator of acute blood loss of more than 630 mL. ^[27]

A hematocrit level of less than 18% or a decrease of about 6% is indicative of significant blood loss that requires blood transfusions; the goal is to achieve a target hematocrit level of approximately 20-25% in young patients and a target hematocrit level of around 30% in high-risk, older patients. A coagulopathy, such as when an international normalized ratio (INR) is greater than 1.5, may require correction with fresh frozen plasma; thrombocytopenia can be corrected with platelet transfusions.

Transfer to intensive care unit

Patients who require admission to the intensive care unit and early involvement of both a gastroenterologist and a surgeon include the following:

• Patients in shock
• Patients with continuous active bleeding
• Patients at high risk, such as patients with serious comorbidities, those needing multiple blood transfusions, or those with an acute abdomen

In about 10% of patients presenting with lower gastrointestinal bleeding (LGIB), the source of bleeding is from the upper gastrointestinal (GI) tract. Some patients with LGIB should have a nasogastric (NG) tube placed, and if the aspirate or lavage does not show any blood or coffee ground–appearing material but does show bile, bleeding originating from the upper GI tract is unlikely. In case of high suspicion, obtain an esophagogastroduodenoscopy (EGD) evaluation (see Esophagogastroduodenoscopy).

In patients who are hemodynamically stable with mild to moderate bleeding or in patients who have had a massive bleed that has stabilized, colonoscopy should be performed initially. ^{[5, 41]} Once the bleeding site is localized, therapeutic options include coagulation and injection with vasoconstrictors or sclerosing agents.

In cases of diverticular bleeding, bipolar probe coagulation, epinephrine injection, and metallic clips may be used. ^[5] If recurrent bleeding is present, the affected bowel segment can be resected. In cases of angiodysplasia, thermal therapy, such as electrocoagulation or argon plasma coagulation, is generally successful. Angiodysplastic lesions may be missed at colonoscopy if the lesions are small or covered with blood clots.

Endoscopic hemostasis therapy is a safe and effective method to control high-risk indications of hemorrhage: active bleeding, nonbleeding visible vessel, or adherent clot. ^{[5, 60]} It is also effective for diverticular bleeding, angioectasia bleeding, and postpolypectomy bleeding. ^[5]

In patients with brisk, active lower gastrointestinal bleeding, obtain surgical consultation. ^[5]

Colonoscopy is useful in radiation therapy–induced gastrointestinal bleeding and in the treatment of colonic polyp lesions. Endoscopic treatment of radiation-induced bleeding includes topical application of formalin, Nd:YAG (neodymium-doped yttrium aluminium garnet) laser therapy, and argon plasma coagulation. Neoplastic bleeding due to polyps requires polypectomy. Patients diagnosed with colonic tumors may require surgical resection.

In patients in whom the bleeding site cannot be determined with the use of colonoscopy and in patients with active, brisk lower gastrointestinal bleeding (LGIB), angiography with or without a preceding radionuclide scan should be performed to locate the bleeding site as well as to intervene therapeutically.

Initially, vasoconstrictive agents, such as vasopressin (Pitressin), can be used. In an experimental study of treatment of LGIB by selective arterial infusion of vasoconstrictors, such as epinephrine with propranolol and vasopressin, although epinephrine and propranolol drastically reduced mesenteric blood flow, these agents also caused a rebound increase in blood flow and recurrent bleeding.

Vasopressin is a pituitary hormone that causes severe vasoconstriction in the splanchnic bed. Vasoconstriction reduces the blood flow and facilitates hemostatic plug formation in the bleeding vessel. Vasopressin infusions are more effective in diverticular bleeding, which is arterial, as opposed to angiodysplastic bleeding, which is of the venocapillary type. The results are less than satisfactory in patients with severe atherosclerosis and coagulopathy.

Intra-arterial vasopressin infusions begin at a rate of 0.2 U/min, with repeat angiography performed after 20 minutes. The bleeding stops in about 91% of patients receiving intra-arterial vasopressin but recurs in up to 50% of patients when the infusion is stopped. ^[56] If the bleeding persists, the rate of the infusion is increased to 0.4-0.6 U/min. Once the bleeding is controlled, the infusion is continued in an intensive care setting for 12-48 hours and then tapered over the next 24 hours. In patients with rebleeding, surgery should be considered.

Complications

During vasopressin infusion, monitor patients for recurrent hemorrhage, myocardial ischemia, arrhythmias, hypertension, and volume overload with hyponatremia. Nitroglycerine paste or drip can be used to overcome cardiac complications. Selective mesenteric infusion induces bowel wall contraction and spasms, which should not be confused with bowel wall ischemia.

Do not administer vasopressin into the systemic circulation intravenously, because this causes coronary vasoconstriction, diminished cardiac output, and tachyphylaxis. Vasopressin infusions are contraindicated in patients with severe coronary artery disease and peripheral artery disease.

An alternative to vasopressin infusion is embolization with agents such as gelatin sponges, coil springs, polyvinyl alcohol, and oxidized cellulose. Embolization involves superselective catheterization of the bleeding vessel to minimize necrosis, the most feared complication of ischemic colitis. This therapeutic modality is useful in patients in whom vasopressin is unsuccessful or contraindicated.

Early experience with embolization suggested that complications of intestinal infarction were as high as 20%. With the advent of superselective catheterization and embolization of the vasa recta, successful embolization has been performed without intestinal infarction. ^{[61, 62]} A 3 French (F) microcatheter is placed coaxially through a diagnostic 5F catheter, and the therapeutic catheter is advanced as far as the vasa recta over a 0.018-inch guidewire to reduce the risk of infarction.

Once the bleeding vessel is identified, microcoils are used to occlude the bleeding vessel and to achieve hemostasis. Although microcoils are most commonly used, polyvinyl alcohol and Gelfoam are also used alone or in conjunction with microcoils. ^{[8, 63, 64]} However, if terminal mural branches of the bleeding vessel cannot be catheterized, abort the procedure and immediately perform surgery.

Kuo et al concluded the superselective microcoil embolization for the treatment of LGIB is safe and effective. ^[65] They reported complete clinical success in 86% of patients, with a rebleeding rate of 14%. Minor ischemic complication rates were 4.5%, and 0% major ischemic complication rates were reported. The investigators also reviewed the data from 122 cases of lower gastrointestinal (GI) superselective microcoil embolization in the literature, with meta-analysis performed in 144 patients. The combined analysis revealed a minor ischemic complication rate of 9% and a major ischemic complication rate of 0%. ^[65]

Rossetti at al reviewed 11 years of experience in transarterial embolization of acute colonic bleeding in 24 Swiss patients and found the risk of bowel ischemia was 21%. ^[66] The patients underwent colonic embolization for diverticular disease, postpolypectomy, and bleeding, as well as bleeding from cancer, angiodysplasia, and hemorrhoids. All the different types of bleeding stopped except hemorrhoidal bleeding, requiring hemorrhoidal ligature. ^[66] In a separate study, 44 patients underwent microcoil embolization for arterial GI bleeding, with a technical success rate of 88% but a clinical success rate of 57%. ^[67] Intestinal ischemia occurred in 5% of patients. Overall mortality was 18%. The investigators concluded that microcoil embolization had a high success rate, and the number of preprocedural and postprocedural transfusions did not affect the technical success. ^[67]

In another study by Yap et al, 95 patients underwent embolization for acute GI hemorrhage, with immediate hemostasis obtained in 98% of patients. ^[68] Eighty percent of the patients had upper GI hemorrhage and the rest had lower GI hemorrhage. Vessels embolized included gastroduodenal (39%), pancreatoduodenal (20%), gastric (19%), superior mesenteric (11%), inferior mesenteric (11%), and splenic artery (4%). Complications included bowel ischemia in 4% and coil migration in 3% of patients. The overall 30-day mortality rate was 18%. ^[68]

Therapeutic upper (n=16) and lower GI (n=23) embolization was performed on 39 occasions in 37 Japanese patients using N-butyl-2-cyanoacrylate (1:1 and in 1:5 mixtures). ^[69] Recurrent bleeding occurred in two patients, hepatic abscess in two cases, and lower limb ischemia in one patient. No intestinal necrosis occurred. It was concluded that transcatheter arterial embolization was safe and effective with a high rate of complete hemostasis. ^[69]

Complications

Rosenkrantz et al reported three cases of colonic infarction following embolization. ^[70] One patient died following segmental colectomy, and the other patients revealed full-thickness bowel wall injury in the resected specimen. Intestinal ischemia and infarction have also been reported. To prevent this complication, perform embolization beyond the marginal artery as close as possible to the bleeding point in the terminal mural arteries. At least 139 cases have been collected from the medical literature since 1972.

The relevance of surgery after embolization of GI bleeding has also been examined. In a retrospective study, a total of 54 patients with 55 bleeding events were identified; only 25 patients (45%) had lower GI bleeding (LGIB). ^[71] Of those, 9 patients had bleeding in the small intestine, 14 in the colon, and 2 in the rectum. The rebleeding rate was 24% (n=6), and 50% of those with recurrent LGIB required surgery. ^[71]

This study revealed a primary clinical embolization success rate of 82%, an 18% rate of early recurrent bleeding (< 30 days), and a 3.6% rate of delayed bleeding (>30 days). ^[71] Surgery after embolization was required in 20% of patients (n=11). The investigators concluded that surgery has an important role after successful embolization. ^[71]

Endoscopic therapy for lower gastrointestinal bleeding (LGIB) is a minimally invasive and viable option in carefully selected patients. ^[72]

The 2016 American Academy of Family Physicians (AAFP) guidelines include the following recommendations for endoscopic hemostasis therapy ^[5] :

• Provide endoscopic therapy in patients with active bleeding, a nonbleeding visible vessel, or an adherent clot.
• Use mechanical (clip) or contact thermal endotherapy, with or without the use of dilute epinephrine injection, for postpolypectomy bleeding.
• In patients with diverticular bleeding, use through-the-scope endoscopic clips.
• In patients with angioectasia bleeding, use noncontact thermal therapy with argon plasma coagulation.

One of the advantages of upper or lower endoscopic evaluation is that it provides access to therapy in patients with gastrointestinal (GI) bleeding. Endoscopic control of bleeding can be achieved using thermal modalities or sclerosing agents. Absolute alcohol, morrhuate sodium, and sodium tetradecyl sulfate can be used for sclerotherapy of upper and lower GI lesions.

Endoscopic epinephrine injection is commonly used because of its low cost, easy accessibility, and low risk of complications. In a study of 175 patients who underwent endoscopic epinephrine injection, univariate analysis of 31 patients with rebleeding indicated that factors predictive of a high rebleeding rate included older age (≥60 y), American Society of Anesthesiology (ASA) category III-V; severe anemia greater than 8 g/dL; shock; a minimum epinephrine injection dose of 12 mL; and severe bleeding signs (hematemesis or hematochezia). ^[73] An additional hemostatic method such as clips or thermoregulation is needed to prevent subsequent bleeding. ^{[5, 73]}

Endoscopic thermal modalities (eg, laser photocoagulation, electrocoagulation, heater probe) can also be used to arrest hemorrhage. Endoscopic control of hemorrhage is suitable for GI polyps and cancers, arteriovenous malformations (AVMs), mucosal lesions, postpolypectomy hemorrhage, endometriosis, and colonic and rectal varices. Postpolypectomy hemorrhage can be managed by electrocoagulation of the polypectomy site bleeding with either a snare or hot biopsy forceps or by epinephrine injection.

When the authors of this chapter reviewed the medical literature for endoscopic treatment of significant lower GI bleeding (at the time, n=286 over 8 publications), hemorrhage was successfully arrested in 70% of patients, with a rebleeding rate of 15%.

Hunter et al evaluated 222 GI endoscopic laser procedures in 122 patients and reported hemorrhage was arrested in 84% of the patients with GI bleeding. ^[74] No perforations were reported in this series, but one death occurred and was attributed to laser therapy in a patient with duodenal ulcer and gastroduodenal artery bleeding.

Forty patients with GI AVMs underwent 72 photocoagulation sessions with mostly argon laser; 15 of the 40 patients had significant hemorrhage from colonic AVMs; of those 15, there were no deaths following ablation.

Although the treatment options for angiodysplasias are numerous, including segmental bowel resection and selective mesenteric embolization, endoscopic coagulation of angiodysplasias is becoming a treatment of choice using either heated probe or lasers, such as Nd:YAG (neodymium-doped yttrium aluminium garnet) and argon. Argon laser treatment is recommended for mucosal or superficial lesions, because the energy penetrates only 1 mm. Nd:YAG lasers are more useful for deeper lesions, because they penetrate 3-4 mm.

Emergency surgery is required in some patients with lower gastrointestinal bleeding (LGIB) in whom nonoperative management was unsuccessful or unavailable. ^{[5, 19]} Failure of embolization warrants surgical intervention. ^[41]

Surgical indications

The indications for surgery include the following ^{[15, 25]} :

• Persistent hemodynamic instability with active bleeding

• Persistent, recurrent bleeding

• Transfusion of more than 4 units packed red bloods cells in a 24-hour period, with active or recurrent bleeding

Clinicians should also consider the extent and success of previous bleeding control interventions, bleeding severity and source, and the degree of comorbid conditions, ^[5] as well as take into account individual surgical practices, all of which play a role in deciding which patient requires surgery. No contraindications exist with regard to surgery in hemodynamically unstable patients with active bleeding. In fact, if the patient is hemodynamically unstable because of ongoing hemorrhage, perform an emergency operation before any diagnostic study.

Segmental bowel resection and subtotal colectomy

Segmental bowel resection following precise localization of the bleeding point is a well-accepted surgical practice in hemodynamically stable patients. Subtotal colectomy is the procedure of choice in patients who are actively bleeding from an unknown source.

Intraoperative esophagogastroduodenoscopy (EGD), surgeon-guided enteroscopy, and colonoscopy may be helpful in detecting undiagnosed massive GI bleeding. Depending on the availability of local resources and the patient's condition, it may sometimes be better to proceed with subtotal colectomy with distal ileal inspection than to try to perform these tests, particularly if the surgeon is not privileged or comfortable with endoscopy.

Patients who are hemodynamically stable should have preoperative localization of the bleeding site; patients who are hemodynamically unstable with active bleeding may undergo emergency exploratory laparotomy with intraoperative endoscopy. In patients who are hemodynamically stable, once the bleeding site is preoperatively localized, intra-arterial vasopressin is used as a temporizing measure to reduce the bleeding before patients undergo segmental colectomy. Using this approach the operative morbidity rate is approximately 8.6%, the mortality rate is around 10%, and the rate of rebleed ranges from 0% to 14%. ^[56]

In patients undergoing emergency laparotomy, every attempt should be made to localize the bleeding intraoperatively, because segmental colectomy is the preferred procedure. If the bleeding site is not localized, a subtotal colectomy is performed with an inherent morbidity rate of around 37% and a mortality rate of about 11-33%. In unstable patients, a two-stage procedure is preferred: temporary end ileostomy and delayed ileoproctostomy. In a small group of hemodynamically stable patients with minimal medical morbidity, this procedure can be performed as a single-stage procedure with ileoproctostomy. In addition, postoperative diarrhea can be a significant problem in elderly patients who undergo subtotal colectomy and ileoproctostomy.

In a subset of patients, surgery is still required, but with the use of nonsurgical diagnosis and intervention, the morbidity rate has been substantially reduced from around 37% to 8.6% in patients undergoing segmental colectomy. With advances in endoscopy and angiography, the rate of preoperative bleeding localization has steadily improved, impacting surgical outcomes in a positive way.

Contraindicated: Blind segmental resection

Blind segmental resection should not be performed because of a prohibitively high rate of rebleeding up to 75%, morbidity up to 83%, and mortality up to 60%. Once the bleeding point is identified, a limited segmental resection should be performed.

Acute lower gastrointestinal bleeding (LGIB) is a common clinical entity and is associated with significant morbidity and mortality (10-20%). As noted earlier, high-risk factors are advanced patient age (>60 y), the presence of multiorgan system disease, transfusion requirements (>4 units), need for operation, and recent physiologic/physical stress (eg, surgery, trauma, sepsis).

As discussed earlier, three major aspects are involved in managing LGIB. The initial priority is to treat the shock. Second, localization of the source of bleeding is required to perform the third task—formulating an interventional plan.

Insert a nasogastric (NG) tube in all patients. A clear bile-stained aspirate generally excludes bleeding proximal to the Treitz ligamentum. After the initial resuscitation, undertake a search for the cause of the bleeding to precisely locate the bleeding point.

Following accurate localization by angiography, bleeding can be temporarily controlled with either angiographic embolization or vasopressin infusion to stabilize the patient in anticipation of semiurgent segmental bowel resection. Segmental bowel resection is performed in the next 24-48 hours following correction of the patient's physiologic parameters, which include hypotension, hypothermia, acute hemorrhagic anemia, and deficient coagulation factors.

Use selective mesenteric embolization in high-risk patients for whom the operative management is associated with a prohibitive risk of morbidity and mortality. If mesenteric embolization is used, these patients must be carefully monitored for bowel ischemia and perforation. Any evidence of ongoing bowel ischemia and/or unexplained sepsis following mesenteric embolization requires exploratory laparotomy to resect the affected bowel segment. Perform subtotal colectomy with ileoproctostomy in patients with nonlocalized LGIB or bilateral sources of colonic hemorrhage.

Surgical intervention is required in only a small percentage of patients with lower gastrointestinal bleeding. The surgical option depends on whether the bleeding source has been accurately identified preoperatively; if so, it is then possible to perform segmental intestinal resection.

If the bleeding source is unknown, an upper GI endoscopy should be performed before any surgical exploration. At celiotomy, identifying the bleeding point is often impossible, as blood refluxes into the proximal and distal bowel.

The abdominal cavity is explored through a midline vertical incision. The assistance of a gastroenterologist or another surgical endoscopist or surgeon is required for intraoperative endoscopic evaluation. The colonoscope is introduced, and the surgeon assists its passage. On-table colonic lavage and colonoscopy may identify the colonic source of bleeding. Surgeon-guided intraoperative small bowel enteroscopy is also performed when no colonic source of bleeding is identified. Again, the colonoscope can be used for this procedure.

Unlike colonoscopy, enteroscopy is performed during the advancement of the scope. Colonoscopic manipulation of the small bowel may cause iatrogenic mucosal tears and hematomas, which may be mistakenly identified as a source of bleeding. Another intraoperative strategy is to clamp segments of the bowel with noncrushing intestinal clamps to identify the segment that fills with blood. If the bleeding point cannot be diagnosed through intraoperative pan-intestinal endoscopy and examination, and if evidence points to a colonic bleeding, perform a subtotal colectomy with end ileostomy.

Hypotension and shock are the eventual consequences of blood loss, but this depends on the rate of bleeding and the patient's response. Clinical development of shock may precipitate myocardial infarction, cerebrovascular accident, and renal or hepatic failure. Azotemia occurs in patients with gastrointestinal blood loss.

Complications of blood transfusions can be summarized as acute and delayed hemolytic reactions, nonhemolytic reactions, and infectious diseases transmission. Complications related to massive blood transfusions are hypothermia, hypocalcemia, hyperkalemia, dilutional thrombocytopenia, and coagulation factor deficiencies.

Patients who have had surgery of the lower gastrointestinal (GI) tract are prone to the development of complications. The most common early postoperative complications are intra-abdominal or anastomotic bleeding, ileus, mechanical small bowel obstruction (SBO), intra-abdominal sepsis, localized or generalized peritonitis, wound infection and/or dehiscence, Clostridium difficile colitis, pneumonia, urinary retention, urinary tract infection (UTI), deep venous thrombosis (DVT), and pulmonary embolism (PE).

Intra-abdominal sepsis following colorectal surgery is a life-threatening complication and requires aggressive resuscitation. Systemic conditions (eg, severe blood loss and shock, poor bowel preparation, irradiation, diabetes, malnutrition, hypoalbuminemia) may adversely affect anastomotic healing. Changes in the anatomy and physiology of the large bowel, high bacterial content, improper operative technique, tension at the anastomosis, and ischemia can cause anastomotic leak associated with abscess and intra-abdominal sepsis. This condition requires either laparotomy (if the sepsis is generalized) or percutaneous drainage (if the sepsis is localized).

Delayed complications usually occur more than 1 week after surgery, the most common of which are anastomotic stricture, incisional hernia, and incontinence.

The management of lower gastrointestinal bleeding (LGIB) can be challenging in patients who refuse transfusions of blood or blood products. However, transfusion-free management of GI bleeding is possible with an acceptable mortality rate. ^[75]

In a retrospective review of 96 patients with LGIB who did not accept transfusions of blood and blood products, 30 of 37 patients (81%) with hemoglobin levels below 6 g/dL, and 4 of 7 patients (57%) with hemoglobin levels lower than 3 g/dL survived. ^[75] The inclusion criteria were frank LGIB, presenting hemoglobin levels lower than 12 g/dL, or a decrease in hemoglobin of more than 1.5 g/dL. Forty-one patients had upper GI bleeding and the remaining 48 had LGIB. ^[75]

The mean hemoglobin level was 8.8 g/dL. ^[75] Surviving patients were treated with epoetin alfa (Procrit) once daily for 5 days, intravenous (IV) iron dextran infusion once daily for 10 days, IV folic acid daily, vitamin C twice daily, as well as intramuscular vitamin B12 injection once. These patients also received beta-blockers (to reduce the cardiac workload) and supplemental oxygen (100%) with intubation (to improve the oxygen delivery as much as possible without blood transfusions). The overall mortality was 10%. ^[75]

Postoperative office visits every 2 weeks are essential to ensure proper wound healing. Upon discharge, a general diet abundant in fruits and vegetables is recommended. Patients are instructed to drink 6-8 glasses of fluid per day. Psyllium seed preparations should also be started. The American Academy of Family Physicians (AAFP) recommends increased intake of dietary fiber. ^{[26, 27]}

Nonsteroidal anti-inflammatory drugs, thienopyridines, anticoagulants, and proton-pump inhibitors increase the risk of acute small intestinal bleeding. ^[76]

Increased levels of physical activity may prevent the progression of diverticular disease. ^[26] Aspirin and NSAID use increase the risk of diverticulitis ^[26] and/or diverticular bleeding. ^[27]

The need for a follow-up colonoscopy is determined by a recurrence of symptoms. Angiodysplasia is more likely to rebleed if untreated and may require follow-up intervention to localize and treat recurrent bleeding. Colonoscopic electrocoagulation is generally successful in such situations.