“Step-Clipping” Technique Reported as Effective for Endoscopic Localization of Colonic Diverticular Bleed

Colonic diverticular bleeding (CDB) often stops spontaneously, and a meticulous colonoscopic search of the colon for the bleeding diverticulum is often unsuccessful. The “step-clipping” method is utilized when an initial CT angiography (CTA) shows colonic extravasation, but the initial colonoscopy is negative. 

In this study, a separate colonoscopy was then performed on an available weekday, and an average of 8 clips was placed in 5-cm increments to span the region of extravasation seen on the initial CTA. A non-contrast CT was repeated after the step-clipping technique was applied, and meticulous correlation of the initial CT showing extravasation with the non-contrast postclipping CT was performed to identify the candidate diverticulum and its relationship to the clips. Colonoscopy was then repeated to identify and treat (band ligation and, if that failed, clip closure). The study included 10 years of historical controls with extravasation and 36 patients over a 3-year period who had extravasation and were eligible for step-clipping. Of these patients, one was excluded for cecal location and two for active bleeding during colonoscopy.

Overall, the step-clipping method led to the detection of the responsible diverticulum in 94% of cases versus 63% of historical controls. The total colonoscopy examination time decreased from 65 to 38 minutes. The total search time during colonoscopy decreased from 41 to 10 minutes. Both rebleeding and the need for blood transfusion after the initial colonoscopy decreased from 26% to 6% by step-clipping, and the mean hospital stay decreased from 6.8 to 5.4 days.