Published online Dec 7, 2026. doi: 10.3748/wjg.124008
Revised: June 28, 2026
Accepted: September 17, 2026
Published online: December 7, 2026
Processing time: 133 Days and 23.7 Hours
Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding in Western populations, accounting for 30%-65% of cases. Its management has evolved substantially over the past two decades, shifting from emergent surgery toward a structured stepwise approach that combines risk stratification, endoscopic hemostasis, transcatheter arterial embolization (TAE), and surgery reserved for refractory cases.
To synthesize current evidence on the epidemiology, diagnostic evaluation, risk stratification, endoscopic and radiologic management, surgical intervention, antithrombotic management, and recurrence prevention of CDB, and to provide a practical evidence-based framework for clinicians.
We conducted a narrative review with systematic literature search of the literature using PubMed/MEDLINE, EMBASE, and the Cochrane Library from database inception through January 2026 in accordance with the preferred reporting items for systematic reviews and meta-analyses 2009 Statement guidelines. Search terms combined controlled vocabulary and free text for “colonic diverticular bleeding”, “lower gastrointestinal bleeding”, “endoscopic band ligation”, “transcatheter arterial embolization”, “Oakland score”, and related concepts. Eligible studies included randomized controlled trials, systematic reviews and meta-analyses, multicenter cohort studies, and major society guidelines. Two reviewers independently screened titles, abstracts, and full texts. Data on study design, interventions, outcomes (technical and clinical success, rebleeding, mortality, complications), and effect estimates were extracted. A narrative synthesis was performed given clinical and metho
Twenty-six studies met inclusion criteria. Non-steroidal anti-inflammatory drugs [odds ratio (OR) = 6.90, 95% confidence interval (CI): 3.86-12.35] and aspirin (OR = 2.84, 95%CI: 2.19-3.67) are the strongest pharmacologic risk factors. The Oakland score (≤ 8 points) predicts safe outpatient discharge with an area under the receiver operating characteristic curve of 0.87. Computed tomographic angiography (CTA) achieves 90% sensitivity and 92% specificity for active bleeding and is recommended first-line in hemodynamically unstable patients. Endoscopic band ligation (EBL) demonstrated lower early and late rebleeding rates compared with through-the-scope clipping (8% vs 19%, P = 0.012; and 9% vs 29%, P = 0.02, respectively) in meta-analytic data; however, these findings derive predominantly from Japanese retrospective cohorts, and prospective Western validation is lacking. Over-the-scope clips show promise (OR = 0.16 vs EBL for early rebleeding). The largest TAE meta-analysis (n = 3530 patients across 58 trials) reported 90.4% technical success, 73.5% clinical success, and 19.9% 30-day rebleeding. A restrictive transfusion strategy (hemoglobin threshold 7 g/dL; 8 g/dL in cardiovascular disease) is supported across major guidelines. Surgery is now required in fewer than 5% of contemporary cases.
Contemporary management of CDB rests on early risk stratification with the Oakland score, judicious use of CTA in unstable patients, colonoscopy with bowel preparation at the next non-urgent opportunity for stable patients, and preferential use of EBL over clipping when hemostasis is required, acknowledging the predominantly Japanese evidence base. Long-term recurrence approaches 40% at 4 years, mandating individualized antithrombotic review and selective elective colectomy in appropriate candidates.
Core Tip: Colonic diverticular bleeding (CDB) is the leading cause of acute lower gastrointestinal bleeding in Western populations, yet management remains inconsistently applied. This review synthesizes current evidence across the full CDB care pathway from risk stratification using the Oakland score to endoscopic, radiologic, and surgical decision-making. Endoscopic band ligation outperforms clipping for hemostasis, transcatheter arterial embolization achieves high technical success, and early antithrombotic resumption reduces mortality without excess rebleeding. A practical, evidence-based framework is provided to guide clinicians toward more standardized, outcome-driven care.