Meta-Analysis
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Aug 16, 2025; 17(8): 109313
Published online Aug 16, 2025. doi: 10.4253/wjge.v17.i8.109313
Endoscopic treatment modalities for colonic diverticular bleeding: A systematic review with direct and network meta-analyses
Zahid Ijaz Tarar, Mustafa Gandhi, Faisal Inayat, Umer Farooq, Baltej Singh, Ahtshamullah Chaudhry, Aun Muhammad, Ahmad Zain, Faisal Kamal
Zahid Ijaz Tarar, Mustafa Gandhi, Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
Faisal Inayat, Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
Umer Farooq, Division of Gastroenterology and Hepatology, St. Louis University, St. Louis, MO 63104, United States
Baltej Singh, Department of Internal Medicine, ChristianaCare Union Hospital, Elkton, MD 21921, United States
Ahtshamullah Chaudhry, Department of Internal Medicine, St. Dominic’s Hospital, Jackson, MS 39216, United States
Aun Muhammad, Department of Hospital Medicine, Christus Southeast Texas Hospital-St. Elizabeth, Beaumont, TX 77702, United States
Ahmad Zain, Department of Internal Medicine, UC Health Parkview Medical Center, Pueblo, CO 81003, United States
Faisal Kamal, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
Author contributions: Tarar ZI, Gandhi M, Inayat F, Farooq U concepted and designed the study, participated in the acquisition of data, interpretation of results, writing of the original draft, and critical revisions of the important intellectual content of the final manuscript; Singh B, Chaudhry A, Muhammad A, Zain A, contributed to the analysis and interpretation of results and drafting of the manuscript; Kamal F reviewed, revised, and improved the manuscript by suggesting pertinent modifications; all authors critically assessed, edited, and approved the final manuscript and are accountable for all aspects of the work.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2020 Checklist, and the manuscript was prepared and revised according to the PRISMA 2020 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Faisal Inayat, MBBS, Senior Researcher, Department of Internal Medicine, Allama Iqbal Medical College, Allama Shabbir Ahmad Usmani Road, Faisal Town, Lahore, Punjab 54550, Pakistan. faisalinayat@hotmail.com
Received: May 7, 2025
Revised: June 6, 2025
Accepted: July 18, 2025
Published online: August 16, 2025
Processing time: 100 Days and 4.5 Hours
Abstract
BACKGROUND

Colonic diverticular bleeding (CDB) is a leading cause of lower gastrointestinal hemorrhage that has a high risk of recurrence. The endoscopic clipping and endoscopic band ligation (EBL) methods are widely used for hemostasis in patients with CDB. Endoscopic detachable snare ligation (EDSL) has also become an increasingly common treatment option. The data remain inconsistent regarding the comparative efficacy of these endoscopic therapies in achieving initial hemostasis and reduction of early and late rebleeding rates.

AIM

To study the effectiveness and complications of endoscopic clipping, EBL, and EDSL for CDB.

METHODS

We conducted a systematic search of PubMed/MEDLINE, Scopus, Web of Science, Embase, Google Scholar, and the Cochrane database for clinical trials to find studies that reported CDB and endoscopic clipping, EBL, or EDSL as treatment methods. The pooled estimates of initial hemostasis, early and late rebleeding, and the need for transarterial embolization or surgery between these groups were calculated.

RESULTS

We analyzed 28 studies with 5224 patients. Of these, 4526 had active CDB and required one of the three endoscopic interventions. The pooled prevalence of early rebleeding was 23.5%, 10.7%, and 10.6% in the endoscopic clipping, EBL, and EDSL groups, respectively. Patients who underwent endoscopic clipping had a significantly higher rate of early rebleeding compared to those who received EBL [odds ratio (OR) = 3.76 (95%CI: 2.13-6.63)] and EDSL (OR = 3.30, 95%CI: 1.28-8.53). There was no difference in the initial hemostasis between the three groups. The pooled prevalence of late rebleeding was 27.2% in the clipping, followed by 13.8% in the EBL and 2.7% in the EDSL group. Compared to 2.6% in the EBL group, 4.0% of patients who received endoscopic clipping subsequently underwent surgery or transarterial embolization. These results were consistent in the network meta-analysis. Based on the ranking of the indirect comparison of modalities, the snare technique was better at achieving initial hemostasis and had a lower late rebleeding rate.

CONCLUSION

The findings of this direct and indirect pairwise comparison suggest that EDSL is superior to endoscopic clipping and EBL in achieving initial hemostasis and lowering the rate of late rebleeding in patients with CDB.

Keywords: Colonic diverticular bleeding; Endoscopic clipping; Endoscopic band ligation; Endoscopic detachable snare ligation; Hemostasis; Rebleeding; Meta-analysis

Core Tip: The comparative efficacy of different endoscopic treatments for colonic diverticular bleeding (CDB) remains under-researched. This network meta-analysis compares the clinical outcomes of CDB in patients treated with endoscopic clipping, banding, and detachable snare ligation. Our findings indicate the superiority of endoscopic detachable snare ligation over endoscopic clipping and banding in achieving initial hemostasis and reducing the rate of late rebleeding. Band ligation had the fewest early rebleeding events with the highest P-score calculated using the frequentist approach. Future studies with large sample sizes should explore CDB outcomes based on the bleeding site and the timing of intervention.