Simple Summary Hemorrhagic bowel syndrome (HBS) is a poorly understood, sporadic and often fatal disease in cattle. Although HBS is considered an important disease in dairy cattle, studies about the occurrence and the distribution of this disease in the population (epidemiology) are lacking. This study describes the epidemiology of HBS in Belgium and the Netherlands, based on necropsy records from 2009 to 2022, and reports characteristics about cows and dairy farms with HBS through a questionnaire. A total of 291 confirmed HBS cases in 259 herds in Belgium and the Netherlands were enrolled. There was a significant increase in the annual incidence of HBS in both individual cows and herds from 2009 to 2022. In most recent years, about 1 in 30 necropsied dairy cows died because of HBS. The incidence was higher in the Netherlands compared to Belgium, possibly due to larger herd size. In fall, HBS occurrence was most common. In 35 Flemish dairy herds, HBS mainly manifested as individual cases, with a very variable time between consecutive cases. Most affected cows were in more than 100 days of lactation. In conclusion, HBS is a relevant disease in dairy cattle in Belgium and the Netherlands, with potentially rising occurrence.Abstract Hemorrhagic bowel syndrome (HBS) is a poorly understood, sporadic and often fatal disease in cattle. Although, HBS is considered an important disease in dairy cattle, epidemiological data is largely lacking. This study describes the epidemiology of HBS in Belgium and the Netherlands, based on necropsy records from 2009 to 2022, and reports characteristics from 27 cows and 35 dairy operations with HBS, gathered through a survey. The annual incidence of HBS has a significantly increasing trend both at cow and herd level, with incidence above 3.2% in necropsied mature dairy cattle in the most recent years. Estimated herd-level incidence in the Netherlands was double the estimated incidence in Belgium, which might be explained by higher herd size in the Netherlands. Occurrence of HBS was ...