Colonic diverticular hemorrhage: Etiology, diagnostic challenges, and evolving therapeutic strategies

Colonic diverticular hemorrhage is a major cause of acute lower gastrointestinal bleeding, particularly in aging populations with increasing prevalence of diverticulosis. Its pathogenesis is multifactorial, involving vascular fragility of the vasa recta, mechanical stress, and patient-related factors such as comorbidities and use of antithrombotic agents. Diagnosis remains challenging due to the intermittent nature of bleeding, with colonoscopy serving as the primary tool and computed tomography angiography providing complementary value for source localization. Endoscopic therapy, especially band ligation, has demonstrated superiority over clipping in reducing rebleeding, while transcatheter arterial embolization has emerged as an effective salvage approach when endoscopic treatment fails. Surgical intervention is reserved for refractory or complicated cases. Recent advances include risk stratification models to guide management and early feeding strategies to accelerate recovery. Despite these improvements, challenges remain in recurrence prevention and individualized treatment selection. This editorial synthesizes current evidence on the etiology, diagnostic modalities, and evolving therapeutic strategies of colonic diverticular hemorrhage, aiming to support clinical decision-making and optimize patient outcomes.