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

Figure 2 Stepwise clinical management algorithm for acute colonic diverticular bleeding. Initial resuscitation and hemodynamic assessment using the shock index (heart rate divided by systolic blood pressure) guide the primary diagnostic pathway. Hemodynamically unstable patients (shock index > 1) should proceed directly to computed tomographic angiography; a positive result prompts interventional radiology consultation and transcatheter arterial embolization within 60-90 minutes. Hemodynamically stable patients are risk-stratified using the Oakland score; a score ≤ 8 predicts a ≥ 95% probability of safe discharge. For low-risk patients discharged early, outpatient colonoscopy within 14 days is recommended; however, colonoscopy is not mandatory in all low-risk outpatients and the decision should be individualized based on clinical findings and the likelihood of identifying a treatable source. For admitted patients, colonoscopy with bowel preparation at the next available non-urgent opportunity remains the cornerstone of diagnosis and treatment. When stigmata of recent hemorrhage or active bleeding are identified, endoscopic hemostasis should be performed with endoscopic band ligation preferred over through-the-scope clipping, acknowledging that this recommendation is based predominantly on Japanese retrospective cohort data. Transcatheter arterial embolization and surgery are reserved for refractory or recurrent cases. All patients require individualized recurrence prevention planning at discharge. GI: Gastrointestinal; pts: Patients; CBC: Complete blood count; BMP: Basic metabolic panel; HR: Heart rate; SBP: Systolic blood pressure; SI: Shock index; CT: Computed tomography; STAT: Immediately; CTA: Computed tomographic angiography; TAE: Transcatheter arterial embolization; IR: Interventional radiology; SRH: Stigmata of recent hemorrhage; CDB: Colonic diverticular bleeding; EBL: Endoscopic band ligation; TTS: Through-the-scope; OTSC: Over-the-scope clip; NSAIDs: Non-steroidal anti-inflammatory drugs; f/u: Follow up.