Upper gastrointestinal bleeding endoscopic intervention

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Upper gastrointestinal bleeding Microchapters


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]


In UGIB, it is recommended to perform diagnostic and therapeutic endoscopy simultaneously. The common procedures used to manage upper GI bleeding caused by the peptic ulcer disease and esophageal varices are sclerotherapy (EIS), coagulation (thermal, electric, and argon plasma), hemostatic clips and variceal band ligation.

Endoscopic intervention

In UGIB, it is recommended to perform both diagnostic and therapeutic endoscopy simultaneously. Endoscopic intervention undertaken within 24 hours is not only associated with less transfusion needs but also reduced the length of stay in hospital.[1]

  • The American Society of Gastrointestinal Endoscopy guidelines recommend the use of two different endoscopic procedures, rather than a single procedure to better control bleeding and decrease the incidence of re-bleeding.[2]

Management of upper GI bleeding caused by the peptic ulcer disease

The most common procedures used to manage upper GI bleeding caused by the peptic ulcer disease are:[3][4][5]

  • Sclerotherapy (EIS)
  • Coagulation (thermal, electric, and argon plasma)
  • Hemostatic clips

Endoscopic Coagulation

  • Thermal contact probes are the mainstay of endoscopic hemostasis in upper GI bleeding.[6]
    • Contact types :Heater probe, monopolar and bipolar electrocoagulation
    • Noncontact types :Laser treatment, argon plasma coagulation 

Contact probes

  • The most commonly employed contact probe in the management of upper GI bleeding is a multipolar electrocoagulation probe.
  • With contact probes blood flow is stopped by clamping followed by induction of heat for the occlusion of the bleeding vessel.
  • The most feared complication of thermal probes is perforation of arteries and surrounding tissue.

Noncontact types

Endoscopic Hemostatic clips

  • Endoscopic hemoclips differ from surgical clips in that they do not have as much compressive strength
  • Hemostatic clips apply mechanical pressure using  a surgical scissors with a locking clamp to control the bleeding.[7]
  • Hemoclips are useful for patients with malnutrition or coagulopathy.
  • Hemoclips cannot be used in situations where bleeding site is deeper or unable to access using endoscopic procedure.


Management of upper GI bleeding caused by the esophageal varices

The most common procedures used to manage esophageal varices are:[8]

  • Sclerotherapy
  • Variceal band ligation

Endoscopic band ligation (EBL)

  • EBL involves the placement of elastic circular ring ligatures around the varices to cause strangulation.[9][10]
  • Follow-up endoscopies are recommended at various intervals depending on the size/appearance of varices and severity of liver disease.
  • EBL is equivalent to EIS in establishing initial control of bleeding.
  • EBL is widely favored over EIS for primary prevention due to similar or superior efficacy with fewer complications.
  • The primary drawback of EBL is that during active bleeding, operator visibility is limited by the device holding the bands prior to their delivery.

Endoscopic injection sclerotherapy (EIS)

  • Comprises endoscopic delivery of a sclerosant to induce fibrosis of the bleeding vessel
  • Most common sclerosants include ethanol, polidocanol, and sodium tetradecyl sulfate.[11][12]
  • Sclerosants are delivered intravariceally or endoscopically into the esophageal wall near the bleeding varices.
  • Typical 1 to 2 mL of sclerosant is sufficient to control bleeding.
  • After an initial injection follow-up injection is done weekly until complete obliteration of the varices is achieved.

Second Look endoscopy

  • Second-look endoscopy refers to the practice of performing a planned follow-up endoscopy, generally within 24 hours of the initial endoscopy.[13]
  • The 2010 recommendations on the management of patients with nonvariceal UGIB from the International Consensus Upper Gastrointestinal Bleeding Conference Group, however, do not recommend the use of routine second-look endoscopy


  1. Garber A, Jang S (2016). "Novel Therapeutic Strategies in the Management of Non-Variceal Upper Gastrointestinal Bleeding". Clin Endosc. 49 (5): 421–424. doi:10.5946/ce.2016.110. PMC 5066413. PMID 27744662.
  2. Hwang, Joo Ha; Shergill, Amandeep K.; Acosta, Ruben D.; Chandrasekhara, Vinay; Chathadi, Krishnavel V.; Decker, G. Anton; Early, Dayna S.; Evans, John A.; Fanelli, Robert D.; Fisher, Deborah A.; Foley, Kimberly Q.; Fonkalsrud, Lisa; Jue, Terry; Khashab, Mouen A.; Lightdale, Jenifer R.; Muthusamy, V. Raman; Pasha, Shabana F.; Saltzman, John R.; Sharaf, Ravi; Cash, Brooks D. (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. ISSN 0016-5107.
  3. Fujii-Lau LL, Wong Kee Song LM, Levy MJ (2015). "New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding". Gastrointest. Endosc. Clin. N. Am. 25 (3): 553–67. doi:10.1016/j.giec.2015.02.005. PMID 26142038.
  4. Laine L, McQuaid KR (2009). "Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials". Clin. Gastroenterol. Hepatol. 7 (1): 33–47, quiz 1–2. doi:10.1016/j.cgh.2008.08.016. PMID 18986845.
  5. Park CH, Lee SJ, Park JH, Park JH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ (2004). "Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding". Gastrointest. Endosc. 60 (6): 875–80. PMID 15605000.
  6. Szura M, Pasternak A (2015). "Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods". World J Gastrointest Endosc. 7 (13): 1088–95. doi:10.4253/wjge.v7.i13.1088. PMC 4580950. PMID 26421105.
  7. Albert JG, Peiffer KH (2016). "[New methods for endoscopic hemostasis: focus on non-variceal gastrointestinal bleeding]". Z Gastroenterol (in German). 54 (3): 250–5. doi:10.1055/s-0035-1566987. PMID 26894683.
  8. Cook DJ, Guyatt GH, Salena BJ, Laine LA (1992). "Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis". Gastroenterology. 102 (1): 139–48. PMID 1530782.
  9. Zepeda-Gómez S, Marcon NE (2008). "Endoscopic band ligation for nonvariceal bleeding: a review". Can. J. Gastroenterol. 22 (9): 748–52. PMC 2661278. PMID 18818787.
  10. Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K (2002). "Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage". J Laparoendosc Adv Surg Tech A. 12 (1): 41–5. doi:10.1089/109264202753486911. PMID 11905861.
  11. Shi B, Wu W, Zhu H, Wu YL (2008). "Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol". World J. Gastroenterol. 14 (22): 3598–601. PMC 2716629. PMID 18567095.
  12. Al-Ali J, Pawlowska M, Coss A, Svarta S, Byrne M, Enns R (2010). "Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population". Can. J. Gastroenterol. 24 (10): 593–6. PMC 2975471. PMID 21037987.
  13. Tano S, Horiki N, Omata F, Tanaka K, Hamada Y, Katsurahara M, Ninomiya K, Nishikawa K, Nojiri K, Yamada R, Inoue H, Gabazza EC, Katayama N, Takei Y (2015). "Second and third-look endoscopy for the prevention of post-ESD bleeding". Medicine (Baltimore). 94 (6): e491. doi:10.1097/MD.0000000000000491. PMC 4602741. PMID 25674738.