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High-Dose Barium Enemas Prevent Recurrent Diverticular Bleeding


 

Clinical question

Does barium impaction therapy using high-dose barium enemas prevent recurrent diverticular bleeding?

Bottom line

This small study demonstrates that barium impaction therapy using high-dose barium enemas is safe and effective at reducing the rate of recurrent diverticular bleeding. Note that this study was conducted in Japan, where the rate of rebleeding for patients with diverticulosis is much higher than in Western populations. (LOE = 1b-)

Reference: Nagata N, Niikura R, Shimbo T, et al. High-dose barium impaction therapy for the recurrence of colonic diverticular bleeding. Ann Surg 2015;261(2):269-275.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location)

Synopsis

A high-dose barium enema is thought to prevent recurrent diverticular bleeding through a physical tamponade of bleeding vessels, as well as by a direct hemostatic effect of the barium itself. Retained barium in colonic diverticula over time has previously been shown to be safe.

In this trial, patients hospitalized with diverticular bleeding who had spontaneous cessation of bleeding were randomized, using concealed allocation, to receive either barium impaction therapy (n = 27) or conservative treatment (n = 27). In the barium impaction therapy group, barium sulfate was administered by gastroenterologists via an enema bag at a concentration of 200 g barium per 100 mL tap water for a total volume of 400 mL. X-ray imaging confirmed filling of multiple colonic diverticula with barium and the patient was asked to rotate positions to ensure filling of all diverticula.

Baseline characteristics were similar in the 2 groups: the majority of patients were male, the average age was 70 years, and half had a prior history of diverticular bleeding. The severity of initial bleeding was also similar, as measured by number of units of blood transfused prior to randomization and the number of days until spontaneous cessation of bleeding.

For the primary outcome of recurrence of bleeding at the 1-year follow-up, the barium group fared better than the conservative treatment group (15% vs 43%; P = .04). You would have to treat 4 patients with barium impaction therapy to prevent 1 episode of recurrent bleeding. After adjusting for factors associated with recurrent bleeding, including hypertension, nonsteroidal anti-inflammatory drug use, and chronic renal failure, the risk of bleeding was decreased in the barium group (hazard ratio = 0.34, 95% CI 0.12-0.97). Barium impaction therapy did not result in any complications. Furthermore, over the course of the follow-up period, the barium group had a decreased number of re-hospitalizations, transfusions, and repeat colonoscopies.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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