Upper gastrointestinal bleeding endoscopic intervention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Muhammad Saad, M.D.[2] Aditya Ganti M.B.B.S. [3]
Endoscopic Intervention
This microchapter covers procedural management of upper gastrointestinal bleeding (UGIB), including endoscopic hemostasis for non-variceal bleeding, endoscopic treatment of variceal hemorrhage, management of recurrent or refractory bleeding, transcatheter arterial embolization (TAE), transjugular intrahepatic portosystemic shunt (TIPS), and surgery. Pharmacologic therapy and diagnostic/risk-stratification aspects of endoscopy are covered in the Medical Therapy and Other Diagnostic Studies microchapters.
Endoscopic Hemostasis for Non-Variceal UGIB
Indications for Endoscopic Hemostasis
Therapeutic endoscopic hemostasis is indicated for peptic ulcers with active bleeding (Forrest Ia or Ib) or a nonbleeding visible vessel (Forrest IIa). Flat pigmented spots (Forrest IIc) and clean-based ulcers (Forrest III) do not require endoscopic hemostatic therapy.[1][2]
For an adherent clot (Forrest IIb), the ACG 2021 guideline did not reach a recommendation because of insufficient evidence. ESGE 2026 suggests clot removal followed by treatment of an underlying high-risk stigma when the endoscopist can safely manage conversion to active bleeding.[1][2]
| Forrest stigma | Procedural approach |
|---|---|
| Ia: spurting bleeding | Endoscopic hemostasis |
| Ib: oozing bleeding | Endoscopic hemostasis |
| IIa: nonbleeding visible vessel | Contact or noncontact thermal therapy, mechanical therapy with TTS or OTSC clips, or injection of a sclerosing agent; these may be used as monotherapy or combined with epinephrine according to lesion and technique.[2] |
| IIb: adherent clot | ESGE 2026: consider clot removal and treatment of an underlying high-risk stigma when technically appropriate; ACG 2021: insufficient evidence for a recommendation |
| IIc: flat pigmented spot | No endoscopic hemostatic therapy |
| III: clean-based ulcer | No endoscopic hemostatic therapy |
Standard Hemostatic Modalities
Accepted endoscopic modalities include contact thermal therapy, mechanical therapy with through-the-scope (TTS) clips, selected noncontact thermal techniques, and soft monopolar coagulation using hemostatic forceps.[1][2]
The ACG 2021 guideline strongly recommends bipolar electrocoagulation, heater probe, or injection of absolute ethanol for appropriate high-risk ulcer bleeding; TTS clips, argon plasma coagulation, and soft monopolar electrocoagulation are supported by conditional recommendations with lower-quality evidence.[1]
Thermal contact therapy reduces further bleeding compared with no endoscopic therapy. No definitive superiority of clips over thermal therapy has been established; modality selection should account for lesion characteristics and endoscopist expertise.[3]
Epinephrine Injection
Epinephrine injection should not be used as definitive monotherapy. It may provide temporary control through vasoconstriction but has a high risk of recurrent bleeding when used alone. If epinephrine is used, it should be combined with a definitive thermal or mechanical modality.[1][4]
Dual therapy consisting of epinephrine plus a second modality does not provide an established advantage over appropriately applied thermal or mechanical monotherapy when the latter can be performed effectively.[3]
Over-the-Scope Clips
Over-the-scope clips (OTSCs) are particularly useful for difficult or recurrent ulcer bleeding.
- ACG 2021 suggests OTSCs for recurrent ulcer bleeding after previous successful endoscopic hemostasis.[1]
- ESGE 2026 suggests OTSC monotherapy as an alternative first-line treatment for active ulcer bleeding (Forrest Ia/Ib).[2]
- A 2026 network meta-analysis of randomized trials found OTSCs had the lowest 30-day rebleeding rate among evaluated endoscopic strategies; the evidence also included cost-effectiveness analyses.[5]
Hemostatic Powders
The ACG suggests TC-325 hemostatic powder for actively bleeding ulcers when appropriate. ESGE 2026 recommends against hemostatic agents as routine first-line monotherapy for high-risk ulcer stigmata and supports their use as rescue therapy for persistent bleeding that is refractory to standard modalities.[1][2]
Hemostatic Forceps
ESGE 2026 supports hemostatic forceps using soft coagulation as monotherapy for Forrest Ia, Ib, and IIa lesions.[2]
In peptic ulcer bleeding, the closed forceps tip is applied directly to the bleeding point without opening the jaws to grasp, followed by soft coagulation. This differs from the grasping technique used in endoscopic submucosal dissection.[4]
Endoscopic Therapy for Variceal Hemorrhage
Esophageal Varices
Endoscopic variceal ligation (EVL) is the preferred endoscopic treatment for acute esophageal variceal hemorrhage. EVL is also used for endoscopic secondary prophylaxis after initial control of bleeding.[6][7]
Compared with endoscopic injection sclerotherapy (EIS), EVL is associated with lower rebleeding and fewer complications and higher variceal eradication rates. EIS is therefore not a co-equal first-line therapy when EVL is available.[6]
After initial control, repeat EVL is performed every 2–4 weeks (favoring 4 weeks to allow banding ulcers to heal) until variceal eradication, typically requiring multiple sessions. After eradication, endoscopic surveillance should be repeated every 6–12 months.[8]
Gastric Varices
Gastric variceal treatment should be selected according to variceal anatomy, vascular anatomy, and local expertise.
- GOV1 varices extending along the lesser curvature may be treated with EVL similarly to esophageal varices.[8]
- For GOV2 and isolated gastric varices (IGV1/IGV2), cyanoacrylate (CYA) injection is an established first-line endoscopic therapy where available and appropriate. CYA is not FDA-approved in the United States for this indication.[8][9]
- EVL can be used for selected gastric varices but may have higher rebleeding rates than cyanoacrylate therapy for fundal varices.[9]
- Thrombin injection is an alternative endoscopic injectate for gastric variceal bleeding and has demonstrated high initial hemostasis rates, although recurrent bleeding remains possible.[9]
- EUS-guided coil plus cyanoacrylate injection is an emerging advanced technique intended to provide a coil scaffold for glue delivery and may reduce embolic complications. Its use depends on local expertise and availability.[10]
- BRTO (balloon-occluded retrograde transvenous obliteration) is an alternative to TIPS for gastric fundal varices in patients with a suitable gastrorenal shunt and has demonstrated lower rebleeding rates than cyanoacrylate therapy in a randomized trial.[3]
Bridge Therapy for Uncontrolled Variceal Hemorrhage
When endoscopic control cannot be achieved, temporary mechanical bridge therapy may be used before definitive treatment such as TIPS.
- For esophageal variceal hemorrhage, balloon tamponade using a Sengstaken-Blakemore or Minnesota tube may provide temporary control. Balloon tamponade should be limited to a maximum of 24 hours.[8][7]
- For gastric variceal hemorrhage, a Linton-Nachlas tube or the gastric balloon of a Minnesota tube may be used for temporary tamponade when appropriate.[8]
- Covered self-expandable esophageal stents can remain in place for up to 1 week and provide temporary control with similar efficacy and improved safety compared with balloon tamponade in appropriate patients.[8]
Management of Recurrent or Refractory Bleeding
Recurrent Non-Variceal Bleeding
Routine second-look endoscopy is not recommended. Repeat endoscopy is appropriate when there is clinical evidence of recurrent bleeding or when initial hemostasis was technically uncertain or suboptimal, such as inadequate visualization or use of epinephrine alone.[3][2]
For recurrent peptic ulcer bleeding after initial successful endoscopic hemostasis, ESGE 2026 recommends OTSCs as the preferred endoscopic rescue modality. If repeat endoscopic therapy fails, TAE should be pursued when available.[2]
An RCT comparing repeat endoscopic therapy with surgery for recurrent ulcer bleeding found that repeat endoscopic treatment avoided surgery in most patients and was associated with fewer complications, without a demonstrated mortality difference.[3]
Recurrent Variceal Bleeding
For patients with recurrent variceal bleeding after initial endoscopic control, escalation to rescue TIPS is recommended in appropriate patients.[11]
Transcatheter Arterial Embolization
When endoscopic therapy fails for non-variceal UGIB, TAE is preferred over surgery as the initial rescue intervention when available.[1]
TAE and surgery have not demonstrated a clear mortality difference in comparative studies. TAE is associated with more recurrent bleeding but fewer major complications and shorter hospital stays than surgery.[12]
TAE is facilitated when the bleeding artery is localized angiographically or the site has been pre-localized endoscopically, for example with a hemoclip marker.[3]
ESGE 2026 suggests considering prophylactic TAE in selected high-risk ulcer bleeding, including hemodynamic instability at presentation, posterior duodenal wall ulcers, ulcer size greater than 2 cm, or situations in which durable endoscopic hemostasis is considered uncertain.[2]
Surgery should be considered when TAE is unavailable or after unsuccessful TAE.[1][2]
Transjugular Intrahepatic Portosystemic Shunt
TIPS has three principal procedural roles in acute variceal hemorrhage:
- Preemptive (early) TIPS: performed within 24–72 hours after admission and endoscopic assessment in selected high-risk patients, including Child-Pugh C patients with 10–13 points or Child-Pugh B patients with more than 7 points and active bleeding at endoscopy.[11][13]
- Rescue TIPS: used for recurrent variceal bleeding after initially successful endoscopic therapy.[11]
- Salvage TIPS: emergency TIPS for profuse variceal bleeding that cannot be controlled by endoscopic therapy.[14]
An updated individual-patient-data meta-analysis reported reduced 1-year mortality with preemptive TIPS in appropriately selected high-risk patients (hazard ratio 0.43; 95% CI 0.32–0.60).[13]
For gastric fundal varices, TIPS with or without variceal embolization/obliteration may be used when endoscopic therapy fails. BRTO is an alternative in selected patients with appropriate venous anatomy, particularly a gastrorenal shunt, depending on center expertise.[14][3]
Surgical Intervention
Surgery is now a last-resort treatment for non-variceal UGIB. Operative options may include ulcer oversewing, gastrectomy, or other definitive operative hemostatic procedures selected according to ulcer location, bleeding source, and patient factors.
Surgery is generally reserved for patients in whom endoscopic hemostasis and TAE have failed or when TAE is unavailable.[1][2]
Procedural Escalation
- Perform definitive endoscopic hemostasis for appropriate high-risk non-variceal lesions.
- For recurrent ulcer bleeding, perform repeat endoscopic therapy, with OTSC favored for recurrent bleeding.
- If endoscopic rescue fails, proceed to TAE when available.
- Consider surgery when TAE is unavailable or unsuccessful.
- For high-risk variceal hemorrhage, use appropriate endoscopic therapy and escalate to preemptive, rescue, or salvage TIPS according to clinical scenario and response.
- Use balloon tamponade or a self-expandable esophageal stent only as temporary bridge therapy when variceal bleeding cannot be controlled endoscopically.
Clinical Pearls
- Epinephrine is not definitive therapy. When used, combine it with a definitive thermal or mechanical modality.[1]
- OTSCs are established rescue therapy for recurrent ulcer bleeding; ESGE 2026 also supports OTSC monotherapy as an alternative first-line option for active Forrest Ia/Ib bleeding.[1][2]
- TAE is preferred over surgery as the initial rescue intervention after failed endoscopic therapy for non-variceal UGIB when available.[1]
- Preemptive TIPS within 72 hours should be considered for appropriately selected high-risk acute variceal bleeding and is associated with improved survival in this population.[13]
- Cyanoacrylate is an established first-line endoscopic therapy for fundal gastric varices where appropriate and available.[8][9]
- Routine second-look endoscopy is not recommended; repeat endoscopy is reserved for recurrent bleeding or selected situations in which initial hemostasis was inadequate or uncertain.[2]
Areas of Guideline Uncertainty
- Forrest IIb adherent clot: ACG 2021 found insufficient evidence for a recommendation, whereas ESGE 2026 suggests clot removal followed by treatment of an underlying high-risk stigma when technically appropriate.[1][2]
- OTSC first-line use: ACG 2021 primarily recommends OTSCs for recurrent ulcer bleeding, whereas ESGE 2026 supports OTSC monotherapy as an alternative first-line treatment for active Forrest Ia/Ib bleeding.[1][2]
- Doppler endoscopic probe: ESGE 2026 did not reach consensus regarding routine use for treatment decisions.[2]
- Preemptive TIPS in very high-risk cirrhosis: benefit is established in selected Child-Pugh C and Child-Pugh B patients meeting high-risk criteria, but outcomes remain poor in patients with very high MELD scores and optimal selection in this subgroup remains uncertain.[13]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI (2021). "ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding". The American Journal of Gastroenterology. 116 (5): 899–917. doi:10.14309/ajg.0000000000001245.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 Gralnek IM, Morris J, Laursen SB; et al. (2026). "Endoscopic Diagnosis and Management of Peptic Ulcer Bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2026". Endoscopy. 58 (8): 899–924. doi:10.1055/a-2863-8314.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Shung DL, Laine L (2024). "Review article: Upper gastrointestinal bleeding – review of current evidence and implications for management". Alimentary Pharmacology & Therapeutics. 59 (9): 1062–1081. doi:10.1111/apt.17949.
- ↑ 4.0 4.1 Mullady DK, Wang AY, Waschke KA (2020). "AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review". Gastroenterology. 159 (3): 1120–1128. doi:10.1053/j.gastro.2020.05.095.
- ↑ Siranart N, Chumpangern Y, Pajareya P; et al. (2026). "Endoscopic Management for Non-Variceal Upper Gastrointestinal Bleeding: A Network Meta-Analysis of Randomized Controlled Trials and Cost-Effectiveness Analyses of 2 Health Care Systems". The American Journal of Gastroenterology. doi:10.14309/ajg.0000000000004000.
- ↑ 6.0 6.1 Dai C, Liu WX, Jiang M, Sun MJ (2015). "Endoscopic Variceal Ligation Compared With Endoscopic Injection Sclerotherapy for Treatment of Esophageal Variceal Hemorrhage: A Meta-Analysis". World Journal of Gastroenterology. 21 (8): 2534–2541. doi:10.3748/wjg.v21.i8.2534.
- ↑ 7.0 7.1 Hwang JH, Shergill AK, Acosta RD; et al. (2014). "The Role of Endoscopy in the Management of Variceal Hemorrhage". Gastrointestinal Endoscopy. 80 (2): 221–227. doi:10.1016/j.gie.2013.07.023.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Kaplan DE, Ripoll C, Thiele M; et al. (2024). "AASLD Practice Guidance on Risk Stratification and Management of Portal Hypertension and Varices in Cirrhosis". Hepatology. 79 (5): 1180–1211. doi:10.1097/HEP.0000000000000647.
- ↑ 9.0 9.1 9.2 9.3 Luo X, Hernández-Gea V (2022). "Update on the management of gastric varices". Liver International. 42 (6): 1250–1258. doi:10.1111/liv.15181.
- ↑ ASGE Technology Committee, Trikudanathan G, Rahimi EF; et al. (2025). "Endoscopic Devices and Techniques for the Management of Gastric Varices (With Videos)". Gastrointestinal Endoscopy. 101 (3): 496–510. doi:10.1016/j.gie.2024.06.038.
- ↑ 11.0 11.1 11.2 Boike JR, Thornburg BG, Asrani SK; et al. (2022). "North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension". Clinical Gastroenterology and Hepatology. 20 (8): 1636–1662.e36. doi:10.1016/j.cgh.2021.07.018.
- ↑ Sverdén E, Mattsson F, Lindström D; et al. (2019). "Transcatheter Arterial Embolization Compared With Surgery for Uncontrolled Peptic Ulcer Bleeding: A Population-Based Cohort Study". Annals of Surgery. 269 (2): 304–309. doi:10.1097/SLA.0000000000002565.
- ↑ 13.0 13.1 13.2 13.3 Nicoară-Farcău O, Han G, Rudler M; et al. (2024). "Pre-Emptive TIPS in High-Risk Acute Variceal Bleeding. An Updated and Revised Individual Patient Data Meta-Analysis". Hepatology. 79 (3): 624–635. doi:10.1097/HEP.0000000000000613.
- ↑ 14.0 14.1 Lee EW, Eghtesad B, Garcia-Tsao G; et al. (2024). "AASLD Practice Guidance on the Use of TIPS, Variceal Embolization, and Retrograde Transvenous Obliteration in the Management of Variceal Hemorrhage". Hepatology. 79 (1): 224–250. doi:10.1097/HEP.0000000000000530.