Updates in Diagnosis and Management of Acute Gastrointestinal Hemorrhage

  • Alberto TringaliEmail author
  • Silvia Gheda


Acute upper gastrointestinal bleeding (UGIB) is a common cause of hospitalization, with incidences ranging from 48 to 160 cases per 100,000 adults per year.

Adequate resuscitation and risk stratification before endoscopy are important in optimizing the care of patients with UGIB.

The management of acute non-variceal UGIB includes the performance of an early endoscopy within 24 h and the treatment of high-risk lesions using various endoscopic mono- or combination therapies (all favored over epinephrine injection alone).

The management of the acute variceal bleeding is a multidisciplinary process that includes the initial assessment of the patient, effective resuscitation, timely diagnosis, control of bleeding, and prevention of rebleeding.

Antibiotic prophylaxis, vasoactive drugs, and endoscopic treatments are the first-line measures; TIPS should be proposed early to high-risk patients or as a rescue therapy for first-line treatment failure.

Colonoscopy is the diagnostic procedure of choice in most patients with LGIB, and its role in the treatment of lower GI bleeding has been shown to be an efficacious and safe method even if a therapeutic endoscopy occurred in about 30% of patients.

The optimal timing of colonoscopy in LGIB remains to be determined.

Superselective mesenteric angiography remains the cornerstone of management of patients with acute LGIB, but it is an invasive and time-consuming procedure.

Emergent surgery should be considered only as a last resort and is rarely needed to prevent death from exsanguination.

This article reviews the causes, clinical presentation, diagnostic methods, and endoscopic treatment of UGIB and LGIB and management of specific lesions.

Supplementary material

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  1. 1.
    Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101–13.PubMedGoogle Scholar
  2. 2.
    Laine L, Yang H, Chang SC, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol. 2012;107(8):1190–5.PubMedGoogle Scholar
  3. 3.
    Sung JJ, Tsoi KK, Ma TK, et al. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010;105:84–9.PubMedGoogle Scholar
  4. 4.
    van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22:209–24.PubMedGoogle Scholar
  5. 5.
    Hearnshaw SA, Logan RF, Lowe D, et al. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011;60:1327–35.PubMedGoogle Scholar
  6. 6.
    Stevens PD, Finegold J, Garcia-Carrasquillo RJ, et al. Effectiveness of a protocol-based team approach to gastrointestinal hemorrhage. Gastrointest Endosc. 1997;45(4):AB 102 n 309.Google Scholar
  7. 7.
    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.PubMedGoogle Scholar
  8. 8.
    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:a1–a46.PubMedGoogle Scholar
  9. 9.
    Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. 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.PubMedGoogle Scholar
  10. 10.
    Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez- Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santalo M, Muniz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11–21.PubMedGoogle Scholar
  11. 11.
    Jairath V, Hearnshaw S, Brunskill SJ, Doree C, Hopewell S, Hyde C, Travis S, Murphy MF. Red cell transfusion for the management of upper gastrointestinal haemorrhage. Cochrane Database Syst Rev. 2010;9:CD006613.Google Scholar
  12. 12.
    Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP, Mur- phy MF. Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2010;32(2):215–24.PubMedGoogle Scholar
  13. 13.
    Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2013;37(3):316–22.PubMedGoogle Scholar
  14. 14.
    Laine L. Blood transfusion for gastrointestinal bleeding. N Engl J Med. 2013;368(1):75–6.PubMedGoogle Scholar
  15. 15.
    de Groot NL, Bosman JH, Siersema PD, et al. Prediction scores in gastro intestinal bleeding: a systematic review and quantitative appraisal. Endoscopy. 2012;44:731–9.PubMedGoogle Scholar
  16. 16.
    Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38:316–21.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356:1318–21.PubMedGoogle Scholar
  18. 18.
    Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E, et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet. 2009;373(9657):42–7.PubMedGoogle Scholar
  19. 19.
    Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;359(9):928–37.PubMedGoogle Scholar
  20. 20.
    Hwang JH, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014;80(2):221–7.PubMedGoogle Scholar
  21. 21.
    Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med. 2010;152:1–9.PubMedGoogle Scholar
  22. 22.
    ASGE Standards of Practice Committee, Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3–16.Google Scholar
  23. 23.
    Shingina A, Barkun AN, Razzaghi A, et al. Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding. Aliment Pharmacol Ther. 2011;33:1010–8.PubMedGoogle Scholar
  24. 24.
    Saltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc. 2011;74:1215–24.PubMedGoogle Scholar
  25. 25.
    Choudari CP, Rajgopal C, Palmer KR. Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment. Gut. 1994;35:464–6.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Barkun A, Sabbah S, Enns R, et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol. 2004;99:1238–46.PubMedGoogle Scholar
  27. 27.
    Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol. 2007;102:290–6.PubMedGoogle Scholar
  28. 28.
    Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P. International Consensus Upper Gastrointestinal Bleeding Conference Group International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101–13.PubMedGoogle Scholar
  29. 29.
    Abraham NS. Management of antiplatelet agents and anticoagulants in patients with gastrointestinal bleeding. Gastrointest Endosc Clin North Am. 2015;25:449–62.Google Scholar
  30. 30.
    Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383:955–62.PubMedGoogle Scholar
  31. 31.
    Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med 2015;373:511–520.Google Scholar
  32. 32.
    Majeed A, Schulman S. Bleeding and antidotes in new oral anticoagulants. Best Pract Res Clin Haematol. 2013;26:191–202.PubMedGoogle Scholar
  33. 33.
    Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta- analysis of randomized controlled trials. Mayo Clin Proc. 2007;82(3):286–96.PubMedGoogle Scholar
  34. 34.
    Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;7:CD005415.Google Scholar
  35. 35.
    Theivanayagam S, Lim RG, Cobell WJ, et al. Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a metaanalysis of randomized controlled trials. Saudi J Gastroenterol. 2013;19:205–10.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Aljebreen AM, Fallone CA, Barkun AN. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172–8.PubMedGoogle Scholar
  37. 37.
    Koch DG, Arguedas MR, Fallon MB. Risk of aspiration pneumonia in suspected variceal hemorrhage: the value of prophylactic endotracheal intubation prior to endoscopy. Dig Dis Sci. 2007;52:2225–8.PubMedGoogle Scholar
  38. 38.
    Rehman A, Iscimen R, Yilmaz M, et al. Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage. Gastrointest Endosc. 2009;69:55–9.Google Scholar
  39. 39.
    Rudolph SJ, Landsverk BK, Freeman ML. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003;57:58–61.PubMedGoogle Scholar
  40. 40.
    Waye JD. Intubation and sedation in patients who have emergency upper GI endoscopy for GI bleeding. Gastrointest Endosc. 2000;51(6):768–71.PubMedGoogle Scholar
  41. 41.
    Rajala MW. Trips and tricks on How to Optimally Manage Patients with Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am. 2015;25:607–17.Google Scholar
  42. 42.
    Hayat U, et al. Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. Gastrointest Endosc. 2017;86(3):500–509.e1.PubMedGoogle Scholar
  43. 43.
    Barkun AN, Bardou M, Kuipers EJ, Sung J. How early should endoscopy be performed in suspected upper gastrointestinal bleeding? Am J Gastroenterol. 2012;107(2):328–9.PubMedGoogle Scholar
  44. 44.
    Lim LG, Ho KY, Chan YH, Teoh PL, Khor CJ, Lim LL, Rajnakova A, Ong TZ, Yeoh KG. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy. 2011;43(4):300–6.PubMedGoogle Scholar
  45. 45.
    Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–60.PubMedGoogle Scholar
  46. 46.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922–38.PubMedGoogle Scholar
  47. 47.
    Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut. 2010;59(8):1022–9.PubMedGoogle Scholar
  48. 48.
    Marmo R, Del Piano M, Rotondano G, et al. Mortality from nonvariceal upper gastrointestinal bleeding: is it time to differentiate the timing of endoscopy? Digestive Disease Week, May 7–10 McCormick Place Convention Center, Chicago, IL, 2011.Google Scholar
  49. 49.
    Cook DJ, Guyatt GH, Salena BJ, Laine LA. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992;102(1):139–48.PubMedGoogle Scholar
  50. 50.
    Sacks HS, Chalmers TC, Blum AL, Berrier J, Pagano D. Endo-scopic hemostasis. An effective therapy for bleeding peptic ulcers. JAMA. 1990;264(4):494–9.PubMedGoogle Scholar
  51. 51.
    Lee JG, Turnipseed S, Romano PS, et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999;50:755–61.PubMedGoogle Scholar
  52. 52.
    Schacher GM, Lesbros-Pantoflickova D, Ortner MA, et al. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A “fortuitously controlled” study. Endoscopy. 2005;37:324–8.PubMedGoogle Scholar
  53. 53.
    Bjorkman DJ, Zaman A, Fennerty MB, et al. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointest Endosc. 2004;60:1–8.PubMedGoogle Scholar
  54. 54.
    Targownik LE, Murthy S, Keyvani L, et al. The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding. Can J Gastroenterol. 2007;21:425–9.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Tai CM, Huang SP, Wang HP, et al. High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis. Am J Emerg Med. 2007;25:273–8.PubMedGoogle Scholar
  56. 56.
    Lin HJ, Wang K, Perng CL, et al. Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study. J Clin Gastroenterol. 1996;22:267–71.PubMedGoogle Scholar
  57. 57.
    Cooper GS, Chak A, Way LE, et al. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999;49:145–52.PubMedGoogle Scholar
  58. 58.
    Cooper GS, Kou TD, Wong RC. Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis. Gastrointest Endosc. 2009;70:229–35.PubMedGoogle Scholar
  59. 59.
    Laursen SB, et al. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 85(5):936–944.e3.Google Scholar
  60. 60.
    Lau JY, Chung SC, Leung JW, Lo KK, Yung MY, Li AK. The evolution of stigmata of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study. Endoscopy. 1998;30(6):513–8.PubMedGoogle Scholar
  61. 61.
    Leung Ki EL, Lau JY. New endoscopic hemostasis methods. Clin Endosc. 2012;45(3):224–9.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Wong Kee Song L-M, et al. Emerging technologies for endoscopic hemostasis. Gastrointest Endosc. 75(5):933–93.Google Scholar
  63. 63.
    Lin HJ, Hsieh YH, Tseng GY, et al. A prospective, randomized trial of large versus small injection of epinephrine for peptic ulcer bleeding. Gastrointest Endosc. 2002;55(6):615–9.PubMedGoogle Scholar
  64. 64.
    Alis H, Oner OZ, Kalayci MU, et al. Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion? Surg Endosc. 2009;23:1465–9.PubMedGoogle Scholar
  65. 65.
    Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med. 1994;331:717–27.PubMedGoogle Scholar
  66. 66.
    Laine, Loren et al A prospective outcome study of patients with clot in an ulcer and the effect of irrigation . Gastrointest Endosc , Volume 43 , Issue 2 , 107–110.Google Scholar
  67. 67.
    Lin HJ, Wang K, Perng CL, et al. Natural history of bleeding peptic ulcers with a tightly adherent blood clot: a prospective observation. Gastrointest Endosc. 1996;43(5):470–3.PubMedGoogle Scholar
  68. 68.
    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;7:33–47.PubMedGoogle Scholar
  69. 69.
    Barkun AN, Martel M, Toubouti Y, et al. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc. 2009;69:786–99.PubMedGoogle Scholar
  70. 70.
    Sung JJ, Tsoi KK, Lai LH, et al. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut. 2007;56:1364–1373 138.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Calvet X, Vergara M, Brullet E, et al. Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers. Gastroenterology. 2004;126:441–450 139.PubMedGoogle Scholar
  72. 72.
    Marmo R, Rotondano G, Piscopo R, et al. Dual therapy versus mono-therapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol. 2007;102:279–89.PubMedGoogle Scholar
  73. 73.
    Vergara M, Bennett C, Calvet X, et al. **Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database Syst Rev. 2014;10:CD005584.Google Scholar
  74. 74.
    Hwang JH, Fisher DA, Ben-Menachem T, et al. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012;75:1132–8.PubMedGoogle Scholar
  75. 75.
    Barkun AN, Moosavi S, Martel M. Topical hemostatic agents: a systematic review with particular emphasis on endoscopic application in GI bleeding. Gastrointest Endosc. 2013;77:692–700.PubMedGoogle Scholar
  76. 76.
    Wong Kee Song LM, Banerjee S, Barth BA, et al. Emerging technologies for endoscopic hemostasis. Gastrointest Endosc. 2012;75:933–7.PubMedGoogle Scholar
  77. 77.
    Kirschniak A, Kratt T, Stüker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc. 2007;66:162–7.PubMedGoogle Scholar
  78. 78.
    Kirschniak A, Subotova N, Zieker D, et al. The over-the-scope clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc. 2011;25:2901–5.PubMedGoogle Scholar
  79. 79.
    Manta R, Galloro G, Mangiavillano B, et al. Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques. Surg Endosc. 2013;27:3162–4.PubMedGoogle Scholar
  80. 80.
    Giday SA, Kim Y, Krishnamurty DM, et al. Long-term randomized controlled trial of a novel nanopowder hemostatic agent (TC-325) for control of severe arterial upper gastrointestinal bleeding in a porcine model. Endoscopy. 2011;43:296–9.PubMedGoogle Scholar
  81. 81.
    Chen YI, Barkun AN, Soulellis C, et al. Use of the endoscopically applied hemostatic powder TC-325 in cancer-related upper GI hemorrhage: preliminary experience. Gastrointest Endosc. 2012;75:1278–81.PubMedGoogle Scholar
  82. 82.
    Leblanc S, Vienne A, Dhooge M, et al. Early experience with a novel hemostatic powder used to treat upper GI bleeding related to malignancies or after therapeutic interventions. Gastrointest Endosc. 2013;78:169–75.PubMedGoogle Scholar
  83. 83.
    Holster IL, Kuipers EJ, Tjwa ET. Hemospray in the treatment of upper gastrointestinal hemorrhage in patients on antithrombotic therapy. Endoscopy. 2013;45:63–6.PubMedGoogle Scholar
  84. 84.
    Yau AH, Ou G, Galorport C, et al. Safety and efficacy of Hemospray in upper gastrointestinal bleeding. Can J Gastroenterol Hepatol. 2014;28:72–6.PubMedPubMedCentralGoogle Scholar
  85. 85.
    Sung JJ, Luo D, Wu JC, et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy. 2011;43:291–5.PubMedGoogle Scholar
  86. 86.
    Smith LA, Stanley AJ, Bergman JJ, et al. Hemospray application in non-variceal upper gastrointestinal bleeding: results of the survey to evaluate the application of hemospray in the luminal tract. J Clin Gastroenterol. 2014;48:89–92.Google Scholar
  87. 87.
    Coumaros D, Tsesmeli N. Active gastrointestinal bleeding: use of hemostatic forceps beyond endoscopic submucosal dissection. Word J Gastroenterol. 2010;16(16):2061–4.Google Scholar
  88. 88.
    Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343:310–6.PubMedGoogle Scholar
  89. 89.
    Sung JJ, Barkun A, Kuipers EJ, et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med. 2009;150:455–64.PubMedGoogle Scholar
  90. 90.
    Vorder Bruegge WF, Peura DA. Stress-related mucosal damage: review of drug therapy. J Clin Gastroenterol. 1990;12(Suppl 2):S35–40.PubMedGoogle Scholar
  91. 91.
    Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174:1755–62.PubMedPubMedCentralGoogle Scholar
  92. 92.
    Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345–60.PubMedGoogle Scholar
  93. 93.
    Tringali A, et al. Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis. Br J Clin Pharmacol. 2017;83(8):1619–35.PubMedPubMedCentralGoogle Scholar
  94. 94.
    Savides TJ, Jensen DM. Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin N Am. 2000;29(2):465–87. viiGoogle Scholar
  95. 95.
    Marmo R, Rotondano G, Bianco MA, Piscopo R, Prisco A, Cipolletta L. Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis. Gastrointest Endosc. 2003;57(1):62–7.PubMedGoogle Scholar
  96. 96.
    Tsoi KK, Chan HC, Chiu PW, Pau CY, Lau JY, Sung JJ. Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis. J Gastroenterol Hepatol. 2010;25(1):8–13.PubMedGoogle Scholar
  97. 97.
    Spiegel BM, Ofman JJ, Woods K, Vakil NB. Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost- effectiveness of competing strategies. Am J Gastroenterol. 2003;98(1):86–97.PubMedGoogle Scholar
  98. 98.
    Jairath V, Kahan BC, Logan RF, Hearnshaw SA, Dore CJ, Travis SP, Murphy MF, Palmer KR. National audit of the use of surgery and radiological embolization after failed endoscopic haemostasis for non-variceal upper gastrointestinal bleeding. Br J Surg. 2012;99(12):1672–80.PubMedGoogle Scholar
  99. 99.
    Wong TC, Wong KT, Chiu PW, Teoh AY, Yu SC, Au KW, Lau JY. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc. 2011;73(5):900–8.PubMedGoogle Scholar
  100. 100.
    Ang D, Teo EK, Tan A, Ibrahim S, Tan PS, Ang TL, Fock KM. A comparison of surgery versus transcatheter angiographic embolization in the treatment of nonvariceal upper gastrointestinal bleeding uncontrolled by endoscopy. Eur J Gastroenterol Hepatol. 2012;24(8):929–38.PubMedGoogle Scholar
  101. 101.
    Ripoll C, Banares R, Beceiro I, Menchen P, Catalina MV, Echenagusia A, Turegano F. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol. 2004;15(5):447–50.PubMedGoogle Scholar
  102. 102.
    Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. 2002;346:2033–8.PubMedGoogle Scholar
  103. 103.
    Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med. 2010;152:1–9.PubMedGoogle Scholar
  104. 104.
    Lai KC, Chu KM, Hui WM, et al. Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications. Clin Gastroenterol Hepatol. 2006;4:860–5.PubMedGoogle Scholar
  105. 105.
    Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352:238–44.PubMedGoogle Scholar
  106. 106.
    Sanchez-Delgado J, Gene E, Suarez D, et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am J Gastroenterol. 2011;106:398–405.PubMedGoogle Scholar
  107. 107.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44(1):217–31.PubMedGoogle Scholar
  108. 108.
    Merli M, Nicolini G, Angeloni S, Rinaldi V, De Santis A, Merkel C, Attili AF, Riggio O. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003;38:266–72.PubMedGoogle Scholar
  109. 109.
    Zoli M, Merkel C, Magalotti D, Gueli C, Grimaldi M, Gatta A, Bernardi M. Natural history of cirrhotic patients with small esophageal varices: a prospective study. Am J Gastroenterol. 2000;95:503–8.PubMedGoogle Scholar
  110. 110.
    Vorobioff J, Groszmann RJ, Picabea E, Gamen M, Villavicencio R, Bordato J, Morel I, Audano M, Tanno H, Lerner E, Passamonti M. Prognostic value of hepatic venous pressure gradient measurements in alcoholic cirrhosis: a 10-year prospective study. Gastroenterology. 1996;111:701–9.PubMedGoogle Scholar
  111. 111.
    D’Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19:475–505.PubMedGoogle Scholar
  112. 112.
    North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988;319(15):983–9.Google Scholar
  113. 113.
    Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16:1343–9.PubMedGoogle Scholar
  114. 114.
    Calès P, Pascal JP. Natural history of esophageal varices in cirrhosis (from origin to rupture). Gastroenterol Clin Biol. 1988;12:245–54.PubMedGoogle Scholar
  115. 115.
    Bosch J, Gonzales-Abraldes J, Garcia-Pagan JC. Clinical manifestations and management of bleeding episodes in cirrhotics. In: Textbook of hepatology from basic science to clinical practice, vol. 1; 2007. p. 640–57.Google Scholar
  116. 116.
    Carbonell N, Pauwels A, Serfaty L, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40:652–9.PubMedGoogle Scholar
  117. 117.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362(9):823–32.PubMedGoogle Scholar
  118. 118.
    El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. Am J Gastroenterol. 2000;95:3566–73.PubMedGoogle Scholar
  119. 119.
    de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762–8.PubMedGoogle Scholar
  120. 120.
    Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29:1655–166.PubMedGoogle Scholar
  121. 121.
    Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M. Nor-floxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–56.PubMedGoogle Scholar
  122. 122.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102(12):922–38.Google Scholar
  123. 123.
    Bañares R, Albillos A, Rincón D, Alonso S, González M, Ruiz-del-Arbol L, Salcedo M, Molinero LM. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002;35:609–15.PubMedGoogle Scholar
  124. 124.
    de Franchis R. Updating consensus in portal hypertension: report of the Baveno IV consensus workshop on methodology of diagnosis and therapy of portal hypertension. J Hepatol. 2005;43:167–76.PubMedGoogle Scholar
  125. 125.
    de Franchis R, Pascal JP, Ancona E, Burroughs AK, Henderson M, Fleig W, Groszmann R, Bosch J, Sauerbruch T, Soederlund C. Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990. J Hepatol. 1992;15(1–2):256–61.PubMedGoogle Scholar
  126. 126.
    D’Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38:599–612.PubMedGoogle Scholar
  127. 127.
    Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding—an updated Cochrane review. Aliment Pharmacol Ther. 2011;34:509–18.PubMedGoogle Scholar
  128. 128.
    Chen PH, Chen WC, Hou MC, et al. Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study. J Hepatol. 2012;57:1207–13.PubMedGoogle Scholar
  129. 129.
    Cheung J, Soo I, Bastiampillai R, et al. Urgent vs. non-urgent endoscopy in stable acute variceal bleeding. Am J Gastroenterol. 2009;104:1125–9.PubMedGoogle Scholar
  130. 130.
    Helmy A, Hayes PC. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther. 2001;15:575–94.PubMedGoogle Scholar
  131. 131.
    Villanueva C, Colomo A, Aracil C, Guarner C. Current endoscopic therapy of variceal bleeding. Best Pract Res Clin Gastroenterol. 2008;22:261–78.PubMedGoogle Scholar
  132. 132.
    Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc. 2008;67:313–23.PubMedGoogle Scholar
  133. 133.
    de Franchis R, Primignani M. Endoscopic treatments for portal hypertension. Semin Liver Dis. 1999;19:439–55.PubMedGoogle Scholar
  134. 134.
    Westaby D. Emergency and elective endoscopic therapy for variceal haemorrhage. Baillieres Clin Gastroenterol. 1992;6:465–80.PubMedGoogle Scholar
  135. 135.
    Pushpanathan C, Idikio H. Pathological findings in the esophagus after endoscopic sclerotherapy for variceal bleeding. Am J Gastroenterol. 1986;81(1):9–13.PubMedGoogle Scholar
  136. 136.
    Sarin SK, Nanda R, Sachdev G. Intravariceal versus paravariceal sclerotherapy: a prospective, controlled, randomised trial. Gut. 1987;28(6):657–62.PubMedPubMedCentralGoogle Scholar
  137. 137.
    Bhargava DK, Singh B, Dogra R, Dasarathy S, Sharma MP. Prospective randomized comparison of sodium tetradecyl sulfate and polidocanol as variceal sclerosing agents. Am J Gastroenterol. 1992;87(2):182–6.PubMedGoogle Scholar
  138. 138.
    Akriviadis E, Korula J, Gupta S, Ko Y, Yamada S. Frequent endoscopic variceal sclerotherapy increases risk of complications. Prospective randomized controlled study of two treatment schedules. Dig Dis Sci. 1989;34(7):1068–74.PubMedGoogle Scholar
  139. 139.
    Sanowski RA, Waring JP. Endoscopic techniques and complications in variceal sclerotherapy. J Clin Gastroenterol. 1987;9:504–13.PubMedGoogle Scholar
  140. 140.
    Schuman BM, Beckman JW, Tedesco FJ, Griffin JW Jr, Assad RT. Complications of endoscopic injection sclerotherapy: a review. Am J Gastroenterol. 1987;82:823–30.PubMedGoogle Scholar
  141. 141.
    Cohen LB, Korsten MA, Scherl EJ, Velez ME, Fisse RD, Arons EJ. Bacteremia after endoscopic injection sclerosis. Gastrointest Endosc. 1983;29:198–200.PubMedGoogle Scholar
  142. 142.
    Sarles HE, Sanowski RA, Talbert G. Course and complications of endoscopic variceal sclerotherapy: a prospective study of 50 patients. Am J Gastroenterol. 1985;80:595–9.PubMedGoogle Scholar
  143. 143.
    Haynes WC, Sanowski RA, Foutch PG, Bellapravalu S. Esophageal strictures following endoscopic variceal sclerotherapy: clinical course and response to dilation therapy. Gastrointest Endosc. 1986;32:202–5.PubMedGoogle Scholar
  144. 144.
    Baillie J, Yudelman P. Complications of endoscopic sclerotherapy of esophageal varices. Endoscopy. 1992;24(4):284–91.PubMedGoogle Scholar
  145. 145.
    Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123(4):280–7.PubMedGoogle Scholar
  146. 146.
    Lo GH. The role of endoscopy in secondary prophylaxis of esophageal varices. Clin Liver Dis. 2010;14:307–23.PubMedGoogle Scholar
  147. 147.
    D’Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev. 2010;3:CD002233.Google Scholar
  148. 148.
    Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, Reveille RM, Sun JH, Lowenstein SR. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med. 1992;326:1527–32.PubMedGoogle Scholar
  149. 149.
    Cárdenas A. Management of acute variceal bleeding: emphasis on endoscopic therapy. Clin Liver Dis. 2010;14:251–62.PubMedGoogle Scholar
  150. 150.
    Young MF, Sanowski RA, Rasche R. Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy. Gastrointest Endosc. 1993;39:119–22.PubMedGoogle Scholar
  151. 151.
    Bosch J, García-Pagán JC. Prevention of variceal rebleeding. Lancet. 2003;361:952–4.PubMedGoogle Scholar
  152. 152.
    Hou MC, Lin HC, Kuo BI, Chen CH, Lee FY, Lee SD. Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: a prospective randomized trial. Hepatology. 1995;21:1517–22.PubMedGoogle Scholar
  153. 153.
    Sarin SK, Govil A, Jain AK, Guptan RC, Issar SK, Jain M, Murthy NS. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol. 1997;26:826–32.PubMedGoogle Scholar
  154. 154.
    Hou MC, Lin HC, Lee FY, Chang FY, Lee SD. Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation. J Hepatol. 2000;32:202–8.PubMedGoogle Scholar
  155. 155.
    Garcia-Pagan JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol. 2005;2:526–35.PubMedGoogle Scholar
  156. 156.
    Bolognesi M, Balducci G, Garcia-Tsao G, Gatta A, Gines P, Merli M, Rodes J, Stiegmann GV. Complications in the medical treatment of portal hypertension. Proceedings of the third Baveno international consensus workshop on definitions, methodology and therapeutic strategie. In: de Franchis R, editor. Portal hypertension III. Oxford: Blackwell Science; 2001. p. 180–201.Google Scholar
  157. 157.
    Lo GH, Lai KH, Shen MT, Chang CF. A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices. Gastrointest Endosc. 1994;40:675–9.PubMedGoogle Scholar
  158. 158.
    Ibrahim M, El Mikkawy A, Mostafa I, et al. Endoscopic treatment of acute variceal hemorrhage by using hemostatic powder TC-325: a prospective pilot study. Gastrointest Endosc. 2013;78:769–73.PubMedGoogle Scholar
  159. 159.
    Gonzalez R, Zamora J, Gomez-Camarero J, et al. Meta-analysis: combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med. 2008;149:109–22.PubMedGoogle Scholar
  160. 160.
    Gimson AE, Westaby D, Williams R. Endoscopic sclerotherapy in the management of gastric variceal haemorrhage. J Hepatol. 1991;13:274–8.PubMedGoogle Scholar
  161. 161.
    Sarin SK, Mishra SR. Endoscopic therapy for gastric varices. Clin Liver Dis. 2010;14(2):263–79.PubMedGoogle Scholar
  162. 162.
    Ramesh J, Limdi JK, Sharma V, Makin AJ. The use of thrombin injections in the management of bleeding gastric varices: a single-center experience. Gastrointest Endosc. 2008;68(5):877–82.PubMedGoogle Scholar
  163. 163.
    Przemioslo RT, McNair A, Williams R. Thrombin is effective in arresting bleeding from gastric variceal hemorrhage. Dig Dis Sci. 1999;44(4):778–81.PubMedGoogle Scholar
  164. 164.
    Datta D, Vlavianos P, Alisa A, Westaby D. Use of fibrin glue (beriplast) in the management of bleeding gastric varices. Endoscopy. 2003;35(8):675–8.PubMedGoogle Scholar
  165. 165.
    Zuccaro GJ. Management of the adult patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 1998;93(8):1202–8.PubMedGoogle Scholar
  166. 166.
    Das A, Ben-Menachem T, Cooper GS, et al. Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model. Lancet. 2003;362:1261–6.PubMedGoogle Scholar
  167. 167.
    Kollef MH, O’Brien JD, Zuckerman GR, et al. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med. 1997;25:1125–32.PubMedGoogle Scholar
  168. 168.
    Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med. 2003;163:838–43.PubMedGoogle Scholar
  169. 169.
    Strate LL, Saltzman JR, Ookubo R, et al. Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Am J Gastroenterol. 2005;100:1821–7.PubMedGoogle Scholar
  170. 170.
    Strate LL, Gralnek IM. ACG Clinical Guideline: Management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016;111:459–74.PubMedPubMedCentralGoogle Scholar
  171. 171.
    Velayos FS, Williamson A, Sousa KH, et al. Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study. Clin Gastroenterol Hepatol. 2004;2:485–90.PubMedGoogle Scholar
  172. 172.
    Newman J, Fitzgerald JE, Gupta S, et al. Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding. Color Dis. 2012;14:1020–6.Google Scholar
  173. 173.
    Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395–402.PubMedGoogle Scholar
  174. 174.
    Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology. 1988;95:1569–74.PubMedGoogle Scholar
  175. 175.
    Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342:78–82.PubMedGoogle Scholar
  176. 176.
    American Society for Gastrointestinal Endoscopy. The role of endoscopy in the patient with lower gastrointestinal bleeding. Gastrointest Endosc. 1998;48:685–8.Google Scholar
  177. 177.
    Laine L, Shah A. Randomized trial of urgent vs elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105(12):2636–41.PubMedGoogle Scholar
  178. 178.
    Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower gastrointestinal bleeding: a systematic review and meta-analysis. Gastrointest Endosc. 2017;
  179. 179.
    American Society for Gastrointestinal Endoscopy. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014;79(6):875–85.Google Scholar
  180. 180.
    Prakash C, Chokshi H, Walden DT, Aliperti G. Endoscopic hemostasis of in acute diverticular bleeding. Endoscopy. 1999;31(6):460–3.PubMedGoogle Scholar
  181. 181.
    Foutch PG, Zimmermann K. Diverticular bleeding protu- 59 berance (sentinel clot); clinical implication, histopathological correlation, and result of endoscopic interventions. Am J Gastroenterol. 1996;91(12):2589–93.PubMedGoogle Scholar
  182. 182.
    Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopy therapy of acute diverticular haemorrhage. Am J Gastroenterol. 2001;96(8):2367–72.PubMedGoogle Scholar
  183. 183.
    Ramirez FC Johnson DA, Zierer ST, Walker GJ, Sanowski RA. Successful endoscopic hemostasis of bleeding colonic 61 diverticula with epinephrine injection. Gastrointest Endosc. 1996;43(2):167–70.PubMedGoogle Scholar
  184. 184.
    Simpson PW, Nguyen NH, Lim JK, Soetikno RM. Use of endoclip in the treatment of massive colonic diverticula bleeding. Gastrointest Endosc. 2004;59(3):433–7.PubMedGoogle Scholar
  185. 185.
    Helmrich GA, Stalworth JR, Brown JJ. Angiodysplasia: characterization, diagnosis and advances in treatment. South Med J. 1990;83(12):1450–3.PubMedGoogle Scholar
  186. 186.
    Farrell JJ, Friedman LS. Gastrointestinal bleeding in the elderly. Gastroenterol Clin N Am. 2001;30(2):377–407.Google Scholar
  187. 187.
    Brandt LJ, Spinell MK. Ability of naloxone to enhance the colonoscopy appearance of normal colon vasculature and colon vascular ectasia. Gastrointest Endosc. 1999;49(1):79–83.PubMedGoogle Scholar
  188. 188.
    Parra-Blanco A, Kaminaga N, Kojima T, et al. Colonoscopic polypectomy with cutting current: is it safe? Gastrointest Endosc. 2000;51:676–81.PubMedGoogle Scholar
  189. 189.
    Bustamante-Balen M, Plume G. Role of hemostatic powders in the endoscopic management of gastrointestinal bleeding. World J Gastrointest Pathophysiol. 2014;5:284–92.PubMedPubMedCentralGoogle Scholar
  190. 190.
    Karaman A, Torun E, Gursoy S, et al. Efficacy of Ankaferd Blood Stopper in postpolypectomy bleeding. J Altern Complement Med. 2010;16:1027–8.PubMedGoogle Scholar
  191. 191.
    Holster IL, Brullet E, Kuipers EJ, et al. Hemospray treatment is effective for lower gastrointestinal bleeding. Endoscopy. 2014;46:75–8.PubMedGoogle Scholar
  192. 192.
    Huang R, Pan Y, Hui N, et al. Polysaccharide hemostatic system for hemostasis management in colorectal endoscopic mucosal resection. Dig Endosc. 2014;26:63–8.PubMedGoogle Scholar
  193. 193.
    Ibis M, Kurt M, Onal IK, et al. Successful management of bleeding due to solitary rectal ulcer via topical application of Ankaferd blood stopper. J Altern Complement Med. 2008;14:1073–4.PubMedGoogle Scholar
  194. 194.
    Kurt M, Onal I, Akdogan M, et al. Ankaferd Blood Stopper for controlling gastrointestinal bleeding due to distinct benign lesions refractory to conventional antihemorrhagic measures. Can J Gastroenterol. 2010;24:380–4.PubMedPubMedCentralGoogle Scholar
  195. 195.
    Jayaraman V, Hammerle C, Lo SK, et al. Clinical application and outcomes of over the scope clip device: initial US experience in humans. Diagn Ther Endosc. 2013;2013:381873.PubMedPubMedCentralGoogle Scholar
  196. 196.
    Anthony T, Penta P, Todd RD, et al. Rebleeding and survival after acute lower gastrointestinal bleeding. Am J Surg. 2004;188:485–90.PubMedGoogle Scholar
  197. 197.
    Jaeckle T, Stuber G, Hoffmann MH, et al. Acute gastrointestinal bleeding: value of MDCT. Abdom Imaging. 2008;33:285–93.PubMedGoogle Scholar
  198. 198.
    Zink SI, Ohki SK, Stein B, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J Roentgenol. 2008;191:1107–14.PubMedGoogle Scholar
  199. 199.
    Khanna A, Ognibene SJ, Koniaris LG. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg. 2005;9:343–52.PubMedGoogle Scholar
  200. 200.
    Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010;8:333–43; quiz e44PubMedGoogle Scholar
  201. 201.
    Strate LL, Syngal S. Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding. Gastrointest Endosc. 2005;61:46–52.PubMedGoogle Scholar
  202. 202.
    Vernava AM 3rd, Moore BA, Longo WE, et al. Lower gastrointestinal bleeding. Dis Colon Rectum. 1997;40:846–58.PubMedGoogle Scholar
  203. 203.
    Ansari MZ, Collopy BT, Hart WG, et al. In-hospital mortality and associated complications after bowel surgery in Victorian public hospitals. Aust New Zeal J Surg. 2000;70:6–10.PubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Endoscopy UnitASST GOM NIGUARDAMilanItaly
  2. 2.Department of Emergency MedicineASST GOM NIGUARDAMilanItaly

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