Management of colonic diverticular bleeding: A narrative review with literature search of current evidence and therapeutic strategies

Table 10 Summary of key clinical questions, supporting evidence, study types, quality of evidence, and strength of recommendation

Clinical question	Supporting evidence	Study types	Quality of evidence	Strength of recommendation
Transfusion threshold (Hb 7 g/dL stable LGIB)	Villanueva RCT; 5-RCT meta-analysis; United Kingdom LGIB audit post hoc	2 RCTs (UGIB); 1 post hoc LGIB analysis	Moderate extrapolated from UGIB; LGIB-specific data very limited	Conditional 7 g/dL; 8 g/dL in CVD
CTA first in hemodynamically unstable patients	Meta-analysis 14 studies (90% sensitivity, 92% specificity); ACG-SAR consensus[14]	Systematic review; consensus guideline	Moderate	Strong
Elective colonoscopy (not urgent) for stable patients	Niikura et al[9] RCT (n = 170); second RCT (increased rebleeding with early scope)	2 RCTs	Moderate	Conditional urgent only in selected high-risk patients
EBL preferred over TTS clipping	Nagata et al[31] meta-analysis; CODE-BLUE J[7]; Meine et al[30]	Meta-analyses of observational data; large multicenter retrospective cohort	Moderate no RCTs; predominantly Japanese data	Conditional EBL may be preferred; prospective Western trials needed
OTSC as alternative to EBL	Ohashi et al[32]: PSM cohort n = 303; 1 single-center series	1 PSM retrospective cohort; 1 case series	Very low	Emerging insufficient evidence for routine use
TAE for failed endoscopy or active CTA extravasation	Sun et al[11]: 58 trials/3530 pts; Kitamura et al[36]	Meta-analysis + retrospective cohort	Moderate	Strong as salvage; conditional as primary
Antithrombotic resumption within 7-14 days (high TE risk)	Sengupta et al[5] retrospective cohort, 1329 pts	Retrospective cohort only; no RCTs	Low	Conditional individualize TE vs rebleeding risk
Elective colectomy for recurrent localized CDB	ACG guideline[5]; retrospective comparative series; You et al[37]; Vajravelu et al[38]; Sato et al[39]	Guideline; retrospective series; cohort studies	Low	Conditional after 2 + episodes, localized source, suitable candidate

Hb: Hemoglobin; LGIB: Lower gastrointestinal bleeding; CTA: Computed tomographic angiography; EBL: Endoscopic band ligation; TTS: Through-the-scope; OTSC: Over-the-scope clip; TAE: Transcatheter arterial embolization; TE: Thromboembolic; CDB: Colonic diverticular bleeding; RCT: Randomized controlled trial; ACG: American College of Gastroenterology; SAR: Society of Abdominal Radiology; PSM: Propensity score matched; pts: Patients; UGIB: Upper gastrointestinal bleeding; CVD: Cardiovascular disease.