Skip to main content

Advertisement

SpringerLink
Log in

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

  • Endoscopy (P Siersema, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

Purpose of review

Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients.

Recent findings

Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common.

Summary

A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bardou M, Benhaberou-Brun D, Le Ray I, Barkun AN. Diagnosis and management of nonvariceal upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol. 2012;9(2):97–104.

    Article  CAS  Google Scholar 

  2. Marmo R, Del Piano M, Rotondano G, Koch M, Bianco MA, Zambelli A, et al. Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy. Gastrointest Endosc. 2012;75(2):263–72. 72.e1

    Article  Google Scholar 

  3. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011;60(10):1327–35.

    Article  Google Scholar 

  4. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47(10):a1–46.

    Article  Google Scholar 

  5. •• Leontiadis GI, Molloy-Bland M, Moayyedi P, Howden CW. Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(3):331–45. Systematic review and meta-analysis strongly emphasize the role of correct comorbidities management to improve the outcome in patients with UNVGIB.

    Article  Google Scholar 

  6. Marmo R, Koch M, Cipolletta L, Capurso L, Pera A, Bianco MA, et al. Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study. Am J Gastroenterol. 2008;103(7):1639–47.

    Article  Google Scholar 

  7. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38(3):316–21.

    Article  CAS  Google Scholar 

  8. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356(9238):1318–21.

    Article  CAS  Google Scholar 

  9. de Groot NL, Bosman JH, Siersema PD, van Oijen MG. Prediction scores in gastrointestinal bleeding: a systematic review and quantitative appraisal. Endoscopy. 2012;44(8):731–9.

    Article  Google Scholar 

  10. Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409–17.

    Article  Google Scholar 

  11. Baradarian R, Ramdhaney S, Chapalamadugu R, Skoczylas L, Wang K, Rivilis S, et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. Am J Gastroenterol. 2004;99(4):619–22.

    Article  Google Scholar 

  12. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010;105(1):84–9.

    Article  Google Scholar 

  13. Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;7:CD005415.

    Google Scholar 

  14. Theivanayagam S, Lim RG, Cobell WJ, Gowda JT, Matteson ML, Choudhary A, et al. Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. Saudi J Gastroenterol. 2013;19(5):205–10.

    Article  Google Scholar 

  15. Barkun AN, Bardou M, Martel M, Gralnek IM, Sung JJ. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc. 2010;72(6):1138–45.

    Article  Google Scholar 

  16. Altraif I, Handoo FA, Aljumah A, Alalwan A, Dafalla M, Saeed AM, et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest Endosc. 2011;73(2):245–50.

    Article  Google Scholar 

  17. Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol. 2009;7(1):33–47.

    Article  Google Scholar 

  18. Barkun AN, Martel M, Toubouti Y, Rahme E, Bardou M. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc. 2009;69(4):786–99.

    Article  Google Scholar 

  19. Church NI, Palmer KR. Injection therapy for endoscopic haemostasis. Baillieres Best Pract Res Clin Gastroenterol. 2000;14(3):427–41.

    Article  CAS  Google Scholar 

  20. Lau JY, Leung JW. Injection therapy for bleeding peptic ulcers. Gastrointest Endosc Clin N Am. 1997;7(4):575–91.

    Article  CAS  Google Scholar 

  21. Marmo R, Rotondano G, Piscopo R, Bianco MA, D’Angella R, Cipolletta L. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol. 2007;102(2):279–89.

    Article  Google Scholar 

  22. Savides TJ, Jensen DM. Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin N Am. 2000;29(2):465–87.

    Article  CAS  Google Scholar 

  23. Liu JJ, Saltzman JR. Endoscopic hemostasis treatment: how should you perform it? Can J Gastroenterol. 2009;23(7):481–3.

    Article  CAS  Google Scholar 

  24. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101–13.

    Article  Google Scholar 

  25. Vergara M, Bennett C, Calvet X, Gisbert JP. Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers. Cochrane Database Syst Rev. 2014;10:CD005584.

    Google Scholar 

  26. Walia SS, Sachdeva A, Kim JJ, Portocarrero DJ, Lewis TD, Zhao YS. Cyanoacrylate spray for treatment of difficult-to-control GI bleeding. Gastrointest Endosc. 2013;78(3):536–9.

    Article  Google Scholar 

  27. D’Imperio N, Papadia C, Baroncini D, Piemontese A, Billi P, Dal Monte PP. N-butyl-2-cyanoacrylate in the endoscopic treatment of Dieulafoy ulcer. Endoscopy. 1995;27(2):216.

    Article  Google Scholar 

  28. Bianco MA, Rotondano G, Marmo R, Piscopo R, Orsini L, Cipolletta L. Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial. Gastrointest Endosc. 2004;60(6):910–5.

    Article  Google Scholar 

  29. Chau CH, Siu WT, Law BK, Tang CN, Kwok SY, Luk YW, et al. Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers. Gastrointest Endosc. 2003;57(4):455–61.

    Article  Google Scholar 

  30. Wang HM, Hsu PI, Lo GH, Chen TA, Cheng LC, Chen WC, et al. Comparison of hemostatic efficacy for argon plasma coagulation and distilled water injection in treating high-risk bleeding ulcers. J Clin Gastroenterol. 2009;43(10):941–5.

    Article  CAS  Google Scholar 

  31. Cipolletta L, Bianco MA, Rotondano G, Piscopo R, Prisco A, Garofano ML. Prospective comparison of argon plasma coagulator and heater probe in the endoscopic treatment of major peptic ulcer bleeding. Gastrointest Endosc. 1998;48(2):191–5.

    Article  CAS  Google Scholar 

  32. Kirschniak A, Kratt T, Stüker D, Braun A, Schurr MO, Königsrainer A. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc. 2007;66(1):162–7.

    Article  Google Scholar 

  33. Chan SM, Chiu PW, Teoh AY, Lau JY. Use of the over-the-scope clip for treatment of refractory upper gastrointestinal bleeding: a case series. Endoscopy 2014;46(5):428–431.

    Article  Google Scholar 

  34. Manta R, Galloro G, Mangiavillano B, Conigliaro R, Pasquale L, Arezzo A, et al. Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques. Surg Endosc. 2013;27(9):3162–4.

    Article  Google Scholar 

  35. Repici A, Arezzo A, De Caro G, Morino M, Pagano N, Rando G, et al. Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract. Dig Liver Dis. 2009;41(6):406–10.

    Article  CAS  Google Scholar 

  36. Kirschniak A, Subotova N, Zieker D, Königsrainer A, Kratt T. The over-the-scope clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc. 2011;25(9):2901–5.

    Article  Google Scholar 

  37. Holster IL, van Beusekom HM, Kuipers EJ, Leebeek FW, de Maat MP, Tjwa ET. Effects of a hemostatic powder hemospray on coagulation and clot formation. Endoscopy. 2015;47(7):638–45.

    Article  Google Scholar 

  38. • Sung JJ, Luo D, Wu JC, Ching JY, Chan FK, Lau JY, et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy. 2011;43(4):291–5. Pilot study firstly described safety and effectiveness, in humans, of hemostatic procedure easy to apply endoscopically in challenging situations.

    Article  CAS  Google Scholar 

  39. Granata A, Ligresti D, Curcio G, Barresi L, Tarantino I, Orlando R, et al. Hemospray rescue treatment of gastroenteric anastomotic bleeding. Endoscopy. 2015;47:E327–E8.

    Article  Google Scholar 

  40. Granata A, Curcio G, Barresi L, Ligresti D, Tarantino I, Orlando R, et al. Hemospray rescue treatment of severe refractory bleeding associated with ischemic colitis: a case series. Int J Color Dis. 2016;31(3):719–20.

    Article  Google Scholar 

  41. Arena M, Masci E, Eusebi LH, Iabichino G, Mangiavillano B, Viaggi P, et al. Hemospray for treatment of acute bleeding due to upper gastrointestinal tumours. Dig Liver Dis. 2017;49(5):514–7.

    Article  CAS  Google Scholar 

  42. Smith LA, Stanley AJ, Bergman JJ, Kiesslich R, Hoffman A, Tjwa ET, et al. Hemospray application in nonvariceal upper gastrointestinal bleeding: results of the Survey to Evaluate the Application of Hemospray in the Luminal Tract. J Clin Gastroenterol. 2014;48(10):e89–92.

    PubMed  Google Scholar 

  43. Chen YI, Barkun AN, Soulellis C, Mayrand S, Ghali P. Use of the endoscopically applied hemostatic powder TC-325 in cancer-related upper GI hemorrhage: preliminary experience (with video). Gastrointest Endosc. 2012;75(6):1278–81.

    Article  Google Scholar 

  44. Yau AH, Ou G, Galorport C, Amar J, Bressler B, Donnellan F, et al. Safety and efficacy of Hemospray® in upper gastrointestinal bleeding. Can J Gastroenterol Hepatol. 2014;28(2):72–6.

    Article  Google Scholar 

  45. Huang R, Pan Y, Hui N, Guo X, Zhang L, Wang X, et al. Polysaccharide hemostatic system for hemostasis management in colorectal endoscopic mucosal resection. Dig Endosc. 2014;26(1):63–8.

    Article  Google Scholar 

  46. Park JC, Kim YJ, Kim EH, Lee J, Yang HS, Hahn KY, et al. Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: using propensity score matching. J Gastroenterol Hepatol. 2018;

  47. Beg S, Al-Bakir I, Bhuva M, Patel J, Fullard M, Leahy A. Early clinical experience of the safety and efficacy of EndoClot in the management of non-variceal upper gastrointestinal bleeding. Endosc Int Open. 2015;3(6):E605–9.

    Article  Google Scholar 

  48. Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, et al. Endoscopic closure devices. Gastrointest Endosc. 2012;76(2):244–51.

    Article  Google Scholar 

  49. Jirapinyo P, Watson RR, Thompson CC. Use of a novel endoscopic suturing device to treat recalcitrant marginal ulceration (with video). Gastrointest Endosc. 2012;76(2):435–9.

    Article  Google Scholar 

  50. Chiu PW, Chan FK, Lau JY. Endoscopic suturing for ulcer exclusion in patients with massively bleeding large gastric ulcer. Gastroenterology. 2015;149(1):29–30.

    Article  Google Scholar 

  51. Kantsevoy SV, Bitner M, Mitrakov AA, Thuluvath PJ. Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc. 2014;79(3):503–7.

    Article  Google Scholar 

  52. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–60.

    Article  CAS  Google Scholar 

  53. Marmo R, Bucci C, Rea M, Rotondano G. Treat the patient, not just the source of bleeding. Am J Gastroenterol. 2013;108(9):1533–4.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Endoscopy Unit, Ruesch Clinic, Via San Domenico, 24, 80127, Naples, Italy

    Livio Cipolletta MD

  2. Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy

    Fabio Cipolletta MD, Antonino Granata MD, Dario Ligresti MD, Luca Barresi MD, Ilaria Tarantino MD & Mario Traina MD

Authors
  1. Livio Cipolletta MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fabio Cipolletta MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Antonino Granata MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dario Ligresti MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Luca Barresi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ilaria Tarantino MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mario Traina MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Livio Cipolletta MD.

Ethics declarations

Conflict of Interest

Livio Cipolletta declares that he has no conflict of interest.

Fabio Cipolletta declares that he has no conflict of interest.

Granata Antonio declares that he has no conflict of interest.

Ligresti Dario declares that he has no conflict of interest.

Barresi Luca declares that he has no conflict of interest.

Tarantino Ilaria declares that she has no conflict of interest.

Mario Traina declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Endoscopy

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cipolletta, L., Cipolletta, F., Granata, A. et al. What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?. Curr Treat Options Gastro 16, 363–375 (2018). https://doi.org/10.1007/s11938-018-0192-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-018-0192-0

Keywords

Search

Navigation