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

Abstract

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.

Key Words: Colonic diverticular hemorrhage; Etiology; Diagnostic techniques; Endoscopic therapy; Interventional embolization; Surgical treatment

Core Tip: Colonic diverticular hemorrhage is a leading cause of acute lower gastrointestinal bleeding, especially prevalent in aging populations with diverticulosis. Its pathogenesis involves multiple factors, diagnosis relies on colonoscopy and computed tomography angiography, and therapeutic advances including endoscopic band ligation, transcatheter embolization, and minimally invasive surgery have improved outcomes. This editorial summarizes key evidence to guide individualized management and recurrence prevention.

INTRODUCTION

Colonic diverticular disease represents a prevalent gastrointestinal disorder especially affecting middle-aged and elderly populations worldwide. It is characterized by the presence of diverticula, which are sac-like protrusions of the colonic mucosa and submucosa through weaknesses in the muscular wall of the colon. The incidence of colonic diverticulosis has shown a rising trend globally, with epidemiological data indicating that approximately 50% of individuals over 60 years of age in developed countries harbor diverticula, and increasing prevalence has also been reported in regions previously considered low-risk, such as Africa[1,2]. This demographic trend is attributed to aging populations and lifestyle changes, including dietary westernization, which may alter colonic motility and wall integrity. Notably, diverticulosis is often asymptomatic, but a substantial subset of patients develops complications, among which diverticular bleeding is the most frequent and clinically significant[3,4].

The pathogenesis of colonic diverticular bleeding (CDB) is multifactorial and complex. It involves structural abnormalities of the vasa recta vessels traversing the diverticular neck, leading to vulnerability and rupture, as well as mechanical factors such as increased intraluminal pressure and mucosal injury. Age-related changes in vascular elasticity and comorbidities that affect hemostasis, including the use of anticoagulants and antiplatelets, further predispose patients to bleeding events[3]. The right-sided colonic diverticulosis, more prevalent in Asian populations, may represent a distinct entity with differing epidemiology and etiology compared to the left-sided diverticulosis common in Western countries, though emerging evidence suggests overlapping pathogenic mechanisms[1]. The clinical impact of diverticular bleeding is considerable, with many patients requiring hospitalization, blood transfusions, and occasionally surgical intervention, underscoring the need for optimized diagnostic and therapeutic strategies[3,5].

Accurate and timely diagnosis of CDB remains challenging due to the intermittent nature of bleeding and the difficulty in localizing the bleeding source. Colonoscopy remains the cornerstone diagnostic modality, offering direct visualization and the opportunity for therapeutic intervention. Studies involving large cohorts have demonstrated that colonoscopy has a high diagnostic yield, identifying definitive or presumptive bleeding sources in the majority of cases, with diverticular bleeding being the most common etiology[6]. However, the timing of colonoscopy is subject to ongoing debate. While guidelines often recommend early colonoscopy within 24 hours to maximize the detection of stigmata of recent hemorrhage (SRH) and improve outcomes, recent large-scale retrospective and prospective studies have yielded mixed results regarding its impact on clinical endpoints such as length of hospital stay, rebleeding rates, and mortality[7,8]. The use of adjunctive tools such as computed tomography (CT) angiography enhances the identification of active bleeding and guides the need for urgent intervention[9,10]. Moreover, technical advancements in endoscopy, including the use of long attachment caps and water-jet scopes, have been shown to improve SRH detection rates, thereby facilitating targeted hemostatic therapy[11,12].

Therapeutic management of CDB has evolved significantly with improvements in endoscopic and interventional radiology (IR) techniques. Endoscopic hemostasis remains the first-line treatment, with modalities including clipping and endoscopic band ligation (EBL). Comparative studies indicate that EBL may offer superior outcomes with lower early and late rebleeding rates, reduced need for IR, and shorter hospital stays compared to clipping, without an increase in adverse events[13]. For cases refractory to endoscopic therapy or in patients with hemodynamic instability, ultraselective transcatheter arterial embolization (TAE) with small-sized microcoils has emerged as an effective and safe alternative, demonstrating high technical and clinical success with minimal complications[14]. In select cases, surgical intervention remains necessary, particularly for complications such as perforation or persistent bleeding unresponsive to less invasive measures[15,16]. Additionally, conservative management plays a critical role in non-severe cases, with evidence supporting its efficacy and safety, and selective use of early colonoscopy based on clinical parameters such as hypotension and imaging findings[9,10].

The clinical management of CDB continues to advance with ongoing research into risk stratification tools, such as the NOBLADS scoring system, which accurately predicts severe bleeding and guides the need for intensive management and early colonoscopy[17]. Recent multicenter studies, including external validations from both Asian and Western cohorts, have confirmed the reproducibility and reliability of this model across diverse populations, although further large-scale studies are warranted to refine its applicability in non-Asian settings[17]. Furthermore, studies have highlighted the importance of early feeding post-hemostasis in reducing hospital stay without increasing rebleeding risk, contributing to optimized patient recovery[18]. Despite these advances, challenges remain in preventing recurrence and managing complications, prompting exploration of novel therapeutic approaches, including biomaterial patch therapy aimed at reinforcing the colonic wall and preventing diverticular deformation[19]. Collectively, these developments underscore a dynamic landscape in the understanding and management of CDB, necessitating continued integration of emerging evidence to enhance patient outcomes.

In summary, CDB is a common and potentially serious complication of diverticular disease, predominantly affecting the elderly population. Its pathogenesis involves vascular and mechanical factors compounded by patient comorbidities. Diagnostic modalities, primarily colonoscopy complemented by imaging, have improved detection and risk stratification, although the optimal timing of intervention remains under investigation. Therapeutic strategies have progressed from conservative management to advanced endoscopic and radiologic interventions, with surgical options reserved for refractory or complicated cases. This editorial aims to synthesize current knowledge on the etiology, diagnosis, and treatment of CDB, integrating recent clinical studies to provide a comprehensive academic overview and inform future clinical practice (Figure 1 and Table 1).

Figure 1 The multifactorial pathogenesis of colonic diverticular hemorrhage, including increased intraluminal pressure, vascular fragility of the vasa recta, and age-related structural changes of the colonic wall. Diagnostic approaches are summarized, with colonoscopy serving as the first-line tool for direct visualization and therapy, complemented by computed tomography angiography for precise localization of active bleeding. Therapeutic strategies include endoscopic treatments such as band ligation and clipping, transcatheter arterial embolization for refractory bleeding, and surgical resection for complicated or persistent cases. The central role of risk stratification models (e.g., NOBLADS score) in guiding treatment decisions is highlighted, along with emerging measures for recurrence prevention, such as early feeding protocols and biomaterial patch therapy. TAE: Transcatheter arterial embolization; CT: Computed tomography.

Table 1 Comparison of endoscopic hemostatic modalities for colonic diverticular hemorrhage.

Modality	Initial hemostasis rate, %	Early rebleeding rate (≤ 30 days), %	Late rebleeding rate (> 30 days), %	Typical complications	Key advantages	Limitations/optimal indications
Endoscopic clipping	90-98	15-25	20-35	Rare perforation (< 1%), clip dislodgement	Simple, short procedure time; widely available	Limited durability; higher rebleeding in right-sided lesions or deep diverticula
Endoscopic band ligation	95-100	5-10	8-15	Ulcer formation (< 2%), transient pain	Superior long-term hemostasis; low recurrence; effective for right-sided bleeding	Technically difficult in narrow lumen; risk of post-ligation ulcer
Endoscopic detachable snare ligation	94-100	5-12	10-18	Rare perforation; mild post-procedure discomfort	Combines advantages of clipping + ligation; low recurrence	Requires specialized device; longer setup time
Over-the-scope clip	92-100	0-8	< 10 (limited data)	Local mucosal tear (< 1%), transient pain	Strong closure force; effective rescue for refractory bleeding	Higher cost; limited availability; bulky cap limits use in tortuous colon

ETIOLOGY AND PATHOGENESIS

Mechanisms of colonic diverticulum formation

Colonic diverticula predominantly represent pseudodiverticula, characterized by mucosal and submucosal herniation through weak points in the colonic muscularis propria. This structural anomaly arises because the diverticula do not include all layers of the colonic wall, distinguishing them from true diverticula. The formation of these pseudodiverticula is primarily driven by increased intraluminal pressure, which forces the mucosa and submucosa to protrude through areas of inherent weakness, such as sites where blood vessels penetrate the muscular layer. Age-related thinning of the colonic wall and loss of elasticity further increase susceptibility.

Dietary factors, particularly low fiber intake, promote constipation and elevated colonic pressure, exacerbating diverticular formation. Genetic predisposition also contributes, as transcriptomic analyses of colonic mucosal and stromal tissues have revealed differential expression of extracellular matrix, remodeling gene sets, such as those related to collagen synthesis, matrix metalloproteinases, and fibroblast activation, indicating that structural remodeling and impaired tissue integrity play key roles in diverticulosis development. Environmental and lifestyle influences, such as defecation habits, may modify risk by affecting colonic pressure dynamics, though their impact remains secondary to mechanical and structural mechanisms. Connective tissue disorders, including α-1-antitrypsin deficiency, have likewise been associated with reduced wall integrity, although definitive causal evidence is limited. Collectively, the formation of colonic diverticula is a multifactorial process involving mechanical stress, aging-related degeneration, dietary and genetic factors, and impaired connective tissue remodeling that weaken the colonic wall and predispose to mucosal herniation[20-24].

Pathophysiological mechanisms of bleeding

The pathophysiology of bleeding in colonic diverticula centers on the vulnerability of the blood vessels within the diverticular wall. These vessels, primarily the vasa recta, become exposed and susceptible to injury due to the absence of the muscularis propria in the diverticular sac. Chronic mechanical stress, such as friction from fecal material and peristaltic movements, leads to microtrauma and localized ischemia, which weaken the vessel walls and predispose them to rupture. Histopathological studies have demonstrated that arteriosclerosis and inflammatory changes within the vessel walls further exacerbate vascular fragility. Atherosclerotic changes, including intimal thickening and medial degeneration, compromise vessel elasticity and resilience, increasing the risk of hemorrhage. Inflammatory processes, possibly triggered by bacterial translocation or local tissue injury, augment vascular permeability and damage. Hemodynamic alterations, such as changes in local blood flow and pressure, also contribute to the propensity for bleeding. The interplay of these factors culminates in the rupture of fragile vessels, leading to acute diverticular hemorrhage. Moreover, the presence of comorbidities like hypertension and diabetes mellitus can impair microvascular health, compounding the risk of vessel rupture. The pathophysiological cascade involves not only mechanical and structural vulnerabilities but also systemic factors that influence vascular integrity and hemostatic balance[25-27].

Related risk factors

Several risk factors have been identified that increase the likelihood of CDB and its recurrence. Advanced age is a significant risk factor, likely due to cumulative degenerative changes in the vasculature and colonic wall, as well as the increased prevalence of comorbidities that affect vascular health. The use of antithrombotic agents, including antiplatelet drugs and anticoagulants, markedly elevates bleeding risk by impairing normal hemostasis. Multiple studies have shown that patients on these medications have higher rates of initial bleeding and rebleeding within both short- and long-term follow-up periods. Nonsteroidal anti-inflammatory drugs also contribute to bleeding risk by causing mucosal injury and affecting platelet function. Chronic diseases such as hypertension and diabetes mellitus negatively impact vascular integrity and microcirculation, further predisposing patients to bleeding episodes. The anatomical characteristics of diverticula, including their number and size, correlate positively with bleeding risk; patients with bilateral diverticula or diverticula located in the right colon tend to have more severe bleeding events and higher rates of intervention. Moreover, several laboratory indices, such as decreased platelet count and prolonged coagulation parameters, have been identified as predictors of early rebleeding following endoscopic therapy, although only a subset have been formally validated for clinical use.

In addition, adverse effects related to anti-cancer therapy have recently been recognized as emerging contributors to CDB. Pelvic irradiation and systemic chemotherapy can induce mucosal atrophy, vascular endothelial damage, and motility disorders, predisposing the colonic wall and submucosal vessels to injury. Cytotoxic and anti-angiogenic agents may impair mucosal repair and microcirculatory stability, thereby increasing bleeding risk in patients with pre-existing diverticula. Clinical reports have documented cases of delayed hemorrhage following chemoradiotherapy for pelvic malignancies, underscoring the need for careful surveillance and individualized risk assessment in oncology patients. Lifestyle factors and genetic predispositions may also modulate risk, although their contributions require further elucidation. Overall, the risk profile for CDB is multifactorial, encompassing patient demographics, medication use, comorbid conditions, and diverticular characteristics[28-31].

Regional variations in diverticular distribution and clinical implications

Marked geographical differences exist in the distribution and clinical presentation of colonic diverticulosis. In Asian populations, diverticula are predominantly right-sided, involving the cecum and ascending colon, whereas in Western populations, they are more often left-sided, especially in the sigmoid colon. These variations likely reflect differences in dietary habits, genetic predisposition, and colonic wall structure. Right-sided diverticula in Asian cohorts tend to be congenital or structural, often solitary and larger, while left-sided diverticula in Western patients are typically acquired pseudodiverticula associated with increased intraluminal pressure and low-fiber diets. Clinically, right-sided disease more frequently presents with acute bleeding, whereas left-sided disease is more prone to inflammatory complications such as diverticulitis. Recognizing these regional patterns is crucial for tailoring diagnostic and therapeutic strategies, as the prevalence of right-sided bleeding in Asian populations has informed the adoption of early colonoscopy and band ligation-based hemostasis, while Western guidelines continue to emphasize management of recurrent diverticulitis and segmental resection for left-sided disease.

CLINICAL PRESENTATION AND DIAGNOSIS

Clinical presentation characteristics

CDB typically manifests as painless, bright red rectal bleeding or hematochezia, which can range from mild to severe in volume. This painless nature is a hallmark clinical feature distinguishing diverticular hemorrhage from other causes of lower gastrointestinal bleeding. Patients may present with sudden onset of large-volume hematochezia without associated abdominal pain, which often leads to acute hospital admission. In some cases, the bleeding is self-limited, resolving spontaneously without intervention; however, the recurrence rate of diverticular bleeding remains high, posing challenges in long-term management. Additionally, a subset of patients develops anemia-related symptoms such as fatigue and dizziness due to chronic or significant blood loss. The clinical presentation can vary depending on the location of the diverticula; for example, right-sided diverticular bleeding is more common in younger patients and may present with more pronounced hemorrhagic episodes, whereas left-sided disease tends to occur in older individuals and may be associated with more complicated diverticulitis rather than bleeding. The natural history of colonic diverticulosis indicates that while the majority of individuals remain asymptomatic, approximately 3%-5% develop diverticular hemorrhage during their lifetime, with an incidence rate estimated at 0.46 per 1000 patient-years. The bleeding is often arterial in origin and may lead to hemodynamic instability in severe cases. Despite the high prevalence of diverticulosis in the elderly, the clinical manifestations of bleeding are variable, and some patients may present with subtle symptoms or anemia without overt bleeding. Understanding these clinical features is essential for timely recognition and appropriate management of CDB[32-37].

Laboratory tests and imaging-assisted diagnosis

Laboratory evaluation plays a critical role in assessing the severity of CDB and guiding management. Complete blood count is routinely performed to evaluate the degree of anemia and to monitor dynamic changes in hemoglobin levels, which reflect ongoing bleeding. Serial hemoglobin measurements help in assessing the bleeding rate and the need for transfusions. Coagulation profiles and other baseline labs are also important to identify any coagulopathies that may exacerbate bleeding. Imaging modalities have become indispensable in localizing the bleeding source and evaluating bleeding activity. CT, particularly contrast-enhanced CT and CT angiography, is widely used due to its accessibility and rapid acquisition. CT angiography can detect active extravasation of contrast, allowing precise localization of the bleeding diverticulum, which is critical for planning therapeutic interventions such as angiographic embolization. Nuclear medicine bleeding scans, including technetium-99m-labeled red blood cell scintigraphy, offer high sensitivity for detecting active bleeding, even at low rates (as low as 0.1 mL/minute), and are particularly useful in cases where CT fails to localize the source or when bleeding is intermittent. However, nuclear scans have limited spatial resolution, which can complicate precise localization. The choice of imaging depends on clinical stability, availability, and timing of bleeding. In some centers, urgent CT is the first-line diagnostic tool for suspected diverticular bleeding due to its rapidity and ability to assess complications. Additionally, imaging findings may differ based on the anatomical location of diverticula, with right-sided diverticula more prevalent in certain populations and associated with different bleeding patterns. Overall, combining laboratory data with imaging findings enhances diagnostic accuracy and informs therapeutic decisions[34,35,37-39].

Endoscopic diagnostic techniques

Colonoscopy remains the gold standard for diagnosing CDB, as it allows direct visualization of diverticula and identification of SRH, such as active bleeding, visible vessels, or adherent clots within diverticula. Early colonoscopy, ideally within 24 hours of presentation, improves diagnostic yield and facilitates therapeutic interventions. Endoscopic evaluation not only confirms the bleeding source but also assesses the activity of bleeding and vascular morphology, which guides the choice of endoscopic hemostatic techniques. Advances in endoscopic imaging, including the use of dye-based chromoendoscopy and virtual chromoendoscopy techniques such as narrow-band imaging, have enhanced the detection rate of bleeding points by improving mucosal visualization and contrast. Narrow-band imaging, by enhancing the visualization of superficial mucosal and vascular patterns, increases the sensitivity for detecting subtle bleeding lesions within diverticula. Furthermore, novel endoscopic modalities such as magnification endoscopy and confocal laser endomicroscopy provide detailed assessment of vascular structures and mucosal integrity, potentially improving diagnostic accuracy. The integration of these advanced imaging techniques into routine colonoscopy protocols has been shown to increase the detection rate of bleeding diverticula, reduce missed lesions, and optimize therapeutic outcomes. However, endoscopic diagnosis can be challenging due to active bleeding obscuring the field, multiple diverticula, and intermittent bleeding. Therefore, combining endoscopic findings with clinical and imaging data is essential. The development of standardized endoscopic scoring systems and training in advanced imaging techniques is critical to improve diagnostic consistency and patient outcomes in CDB[33-35].

THERAPEUTIC STRATEGIES

Endoscopic treatment methods

Endoscopic treatment is the cornerstone in managing CDB, with various hemostatic techniques including injection therapy, thermal coagulation, clipping, and band ligation employed to achieve hemostasis. Among these, endoscopic clipping, EBL, endoscopic detachable snare ligation (EDSL), and over-the-scope clip have gained widespread acceptance owing to their proven efficacy and safety.

Clipping involves mechanically closing the bleeding site using hemoclips, either directly on the bleeding vessel or indirectly by closing the diverticular orifice. Direct clipping, when technically feasible, offers rapid hemostasis and shorter procedure time, whereas EBL and EDSL provide more durable results and lower recurrence rates, particularly in right-sided lesions. Multiple large-scale studies and meta-analyses have confirmed that ligation-based methods achieve lower early and late rebleeding rates than clipping, without increasing adverse events[13,27,40-43]. The choice of modality depends on bleeding visibility, diverticular morphology, and operator expertise. Over-the-scope clip serves as a rescue therapy for refractory bleeding, achieving high procedural success and minimal complications[40,44]. Adequate colonoscopic observation time, approximately 19 minutes, remains critical to detect SRH and to guide targeted therapy[45].

Overall, the trend in endoscopic management has shifted toward mechanical hemostasis techniques, with EBL and EDSL favored for their long-term efficacy, while clipping remains useful in cases with limited access or shallow diverticula. Complications such as perforation are rare (< 1%), though vigilance is required, particularly with ligation or thermal methods[40,46]. Advances in water-jet scopes and distal attachment caps continue to enhance visualization and procedural precision[12].

In parallel, the surgical landscape has evolved with the integration of minimally invasive and robotic-assisted colectomy. Robotic platforms offer enhanced dexterity, precision suturing, and improved visualization in confined pelvic spaces, which may facilitate segmental resection for refractory or recurrent diverticular bleeding. Although evidence remains limited, early studies suggest comparable safety and recovery outcomes relative to laparoscopic colectomy, with potential benefits in operative precision and ergonomics. Future research should continue to define the role of robotic-assisted techniques in complex or recurrent CDB cases.

IR treatment

IR, particularly selective TAE, serves as a vital alternative when endoscopic hemostasis fails or is contraindicated. TAE involves catheterization of the mesenteric arteries supplying the bleeding diverticulum and embolization to achieve hemostasis. Recent technical refinements, such as ultraselective embolization using microcatheters and small-caliber coils, have improved safety by minimizing ischemic complications[47]. Clinical studies have identified right-sided bleeding and hemodynamic instability (systolic blood pressure < 80 mmHg) as risk factors for requiring IR intervention, underscoring the importance of appropriate patient selection[47]. The efficacy of TAE in achieving initial hemostasis is comparable to endoscopic methods, though minor intestinal ischemia and rare perforations may occur, necessitating careful post-procedural monitoring[47,48]. Early use of TAE in selected patients may improve outcomes, but optimal timing requires further investigation. Current evidence supports TAE as an effective salvage therapy that can obviate surgery in many cases, while ongoing research seeks to refine patient selection and integration of IR into multidisciplinary CDB management algorithms.

Surgical treatment and its indications

Surgical intervention remains a critical option for refractory or massive hemorrhage, recurrent bleeding despite less invasive methods, or coexisting complications such as perforation or diverticulitis. Minimally invasive colectomy, including laparoscopic and robotic approaches, has markedly reduced perioperative morbidity and accelerated recovery compared with open surgery[49]. Comparative studies show similar hemostatic efficacy and fewer transfusion requirements with minimally invasive techniques. Surgical timing should be individualized, early surgery is indicated for life-threatening bleeding or failed endoscopic/IR therapy, whereas delayed surgery may be reserved for recurrence or complications[48]. Perioperative optimization of hemodynamics and coagulation, as well as vigilant monitoring for infection or anastomotic leakage, are crucial to outcomes. Resection typically involves segmental colectomy with primary anastomosis, and the choice to ligate or preserve the inferior mesenteric artery should be based on intraoperative judgment, as current meta-analyses show no significant difference in leakage risk[50]. When appropriately indicated, surgery offers excellent long-term control of bleeding.

Emerging biomaterial approaches

Recent advances have explored innovative methods to prevent recurrence following hemostasis, among which biomaterial patch therapy has attracted growing attention. Pre-clinical studies have demonstrated that localized reinforcement of diverticular weak points using biocompatible polymeric or collagen-based patches can effectively reduce mucosal microtrauma and vascular exposure. For instance, Guo et al[19] developed a bioengineered collagen-elastin patch that enhanced wall tensile strength and reduced diverticular deformation in a swine model without causing inflammation or obstruction. This approach targets the vasa recta vulnerability underlying recurrent bleeding. However, clinical translation remains at an early stage. Challenges include optimizing biodegradability, improving endoscopic delivery systems, and ensuring long-term mucosal integration. Despite these hurdles, biomaterial-assisted reinforcement represents a promising future strategy for structural recurrence prevention, complementing pharmacologic and lifestyle interventions that enhance vascular and colonic wall resilience.

LONG-TERM STRATEGIES FOR RECURRENCE PREVENTION

Recurrence after initial hemostasis remains a major concern. Evidence suggests that a high-fiber diet can improve bowel motility, lower intraluminal pressure, and reduce the risk of rebleeding, while nonsteroidal anti-inflammatory drugs and antiplatelet agents should be avoided whenever possible to prevent mucosal injury. Post-treatment colonoscopic surveillance, typically within 6-12 months, helps identify high-risk diverticula and guide early intervention. Integrating dietary modification, rational medication use, and scheduled surveillance represents a practical and effective approach to minimize recurrence in patients with colonic diverticular hemorrhage (CDH).

FUTURE PERSPECTIVES

Looking ahead, advances in artificial intelligence and bioengineering are expected to further transform the management of CDH. Artificial intelligence-assisted colonoscopy and computer-aided bleeding detection can enhance lesion recognition, optimize endoscopic decision-making, and reduce missed diagnoses. In parallel, bioengineered endoscopic tools and smart hemostatic materials hold promise for improving precision, minimizing recurrence, and promoting mucosal healing. Integration of these technologies into clinical workflows will pave the way for more individualized and efficient treatment strategies in the future.

CONCLUSION

CDH remains a prevalent and challenging cause of lower gastrointestinal bleeding, requiring timely diagnosis and individualized management. Advances in colonoscopy, EBL, and TAE have improved outcomes, while surgery is reserved for refractory or complicated cases[51]. Despite these developments, recurrence and patient-specific variability underscore the need for refined risk stratification and personalized treatment strategies. Future research should focus on predictive models, novel endoscopic techniques, and patient-centered outcomes to further optimize care and long-term prognosis.