Digestive Disease Interventions 2018; 02(04): 314-320
DOI: 10.1055/s-0038-1675414
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Endoscopic Management of Gastrointestinal Bleeding

Ramon Diaz
1   Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Duke University, Durham, North Carolina
Gerardo Davalos
1   Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Duke University, Durham, North Carolina
Alfredo D. Guerron
1   Division of Metabolic and Weight Loss Surgery, Department of Surgery, Duke University Health System, Duke University, Durham, North Carolina
› Author Affiliations
Further Information

Publication History

16 August 2018

26 September 2018

Publication Date:
31 October 2018 (online)


Background Gastrointestinal bleeding (GIB) represents a significant cause of morbidity and mortality. The primary diagnostic and therapeutic tool is endoscopy. New devices are being developed and employed that facilitate the management of this pathology. In this review, we show the status of endoscopic management of digestive hemorrhage, current practices, and future directions.

Methods We explore the management of patients with GIB (upper and lower). Besides, we analyzed the diagnostic methods in occult digestive hemorrhage. We show the evidence collected so far, and how each therapeutic method can be applied.

Results GIB constitutes a challenge for the attending physician. Different therapeutic procedures are available. Less invasive devices have a role in the diagnosis but not therapy. The use of risk stratification is well established for upper bleeding, but for lower bleeding, there is still no evidence to support the use of these scores. Knowledge of altered anatomy is crucial in special populations.

Conclusion A variety of procedures are available for the treatment of GIB. Emphasis should be placed on less invasive diagnostic techniques as well as on new and more efficient therapies. Attention should be given to the initial management, with timely diagnosis and effective resuscitation to decrease the morbidity and mortality.

  • References

  • 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 (02) 97-104
  • 2 Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003. Clin Gastroenterol Hepatol 2006; 4 (12) 1459-1466
  • 3 Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia A, Amundson DE. Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities. Am J Gastroenterol 1995; 90 (04) 568-573
  • 4 Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015; 81 (04) 882-8.e1
  • 5 Annane D, Siami S, Jaber S. , et al; CRISTAL Investigators. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013; 310 (17) 1809-1817
  • 6 Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; (02) CD000567
  • 7 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 (11) 1755-1762
  • 8 Monteiro S, Gonçalves TC, Magalhães J, Cotter J. Upper gastrointestinal bleeding risk scores: who, when and why?. World J Gastrointest Pathophysiol 2016; 7 (01) 86-96
  • 9 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107 (03) 345-360 , quiz 361
  • 10 Gralnek IM, Dumonceau JM, Kuipers EJ. , et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47 (10) a1-a46
  • 11 Barkun AN, Bardou M, Kuipers EJ. , et al; 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 (02) 101-113
  • 12 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356 (9238): 1318-1321
  • 13 Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011; 74 (06) 1215-1224
  • 14 Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38 (03) 316-321
  • 15 Saeed ZA, Winchester CB, Michaletz PA, Woods KL, Graham DY. A scoring system to predict rebleeding after endoscopic therapy of nonvariceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection. Am J Gastroenterol 1993; 88 (11) 1842-1849
  • 16 Hay JA, Lyubashevsky E, Elashoff J, Maldonado L, Weingarten SR, Ellrodt AG. Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay. Am J Med 1996; 100 (03) 313-322
  • 17 Marmo R, Koch M, Cipolletta L. , et al; Italian registry on upper gastrointestinal bleeding (Progetto Nazionale Emorragie Digestive--PNED 2). Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score. Am J Gastroenterol 2010; 105 (06) 1284-1291
  • 18 Budimir I, Stojsavljević S, Baršić N. , et al. Scoring systems for peptic ulcer bleeding: which one to use?. World J Gastroenterol 2017; 23 (41) 7450-7458
  • 19 Stanley AJ, Laine L, Dalton HR. , et al; International Gastrointestinal Bleeding Consortium. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017; 356: i6432
  • 20 Hein L, Petersen CC, Rolighed Larsen JK, Keld DB, Nielsen MB. Pericarditis and inflammatory bowel disease [in Danish]. Ugeskr Laeger 1998; 160 (32) 4651-4652
  • 21 Jairath V, Kahan BC, Logan RF. , et al. Outcomes following acute nonvariceal upper gastrointestinal bleeding in relation to time to endoscopy: results from a nationwide study. Endoscopy 2012; 44 (08) 723-730
  • 22 Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc 2017; 85 (05) 936-944.e3
  • 23 Sung JJ, Tang RS, Ching JY, Rainer TH, Lau JY. Use of capsule endoscopy in the emergency department as a triage of patients with GI bleeding. Gastrointest Endosc 2016; 84 (06) 907-913
  • 24 Marya NB, Jawaid S, Foley A. , et al. A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to nonhematemesis GI bleeding (with videos). Gastrointest Endosc 2018 Doi: 10.1016/j.gie.2018.06.016
  • 25 Centers for Disease Control and Prevention (CDC). HIV testing--United States, 1996. MMWR Morb Mortal Wkly Rep 1999; 48 (03) 52-55
  • 26 Beckly DE, Casebow MP, Pettengell KE. The use of a Doppler ultrasound probe for localising arterial blood flow during upper gastrointestinal endoscopy. Endoscopy 1982; 14 (04) 146-147
  • 27 Jensen DM, Kovacs TOG, Ohning GV. , et al. Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes of patients with severe nonvariceal upper gastrointestinal hemorrhage. Gastroenterology 2017; 152 (06) 1310-1318.e1
  • 28 Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2 (7877): 394-397
  • 29 de Groot NL, van Oijen MG, Kessels K. , et al. Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified?. Endoscopy 2014; 46 (01) 46-52
  • 30 Bleau BL, Gostout CJ, Sherman KE. , et al. Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy. Gastrointest Endosc 2002; 56 (01) 1-6
  • 31 Conway JD, Adler DG, Diehl DL. , et al; Asge Technology Committee. Endoscopic hemostatic devices. Gastrointest Endosc 2009; 69 (06) 987-996
  • 32 Park CH, Lee SJ, Park JH. , et al. Optimal injection volume of epinephrine for endoscopic prevention of recurrent peptic ulcer bleeding. Gastrointest Endosc 2004; 60 (06) 875-880
  • 33 Baracat F, Moura E, Bernardo W. , et al. Endoscopic hemostasis for peptic ulcer bleeding: systematic review and meta-analyses of randomized controlled trials. Surg Endosc 2016; 30 (06) 2155-2168
  • 34 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 (01) 33-47 , quiz 1–2
  • 35 Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67 (02) 313-323
  • 36 Garcia-Pagán JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol 2005; 2 (11) 526-535
  • 37 van Buuren HR, Rasch MC, Batenburg PL. , et al. Endoscopic sclerotherapy compared with no specific treatment for the primary prevention of bleeding from esophageal varices. A randomized controlled multicentre trial [ISRCTN03215899]. BMC Gastroenterol 2003; 3: 22
  • 38 Vargo JJ. Clinical applications of the argon plasma coagulator. Gastrointest Endosc 2004; 59 (01) 81-88
  • 39 Condorelli M, Rengo F, Trimarco B. , et al. Mechanisms underlying pulmonary hypertension by hypoxemia. Adv Exp Med Biol 1984; 164: 309-323
  • 40 Sung JJ, Tsoi KK, Lai LH, Wu JC, Lau JY. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007; 56 (10) 1364-1373
  • 41 Alis H, Oner OZ, Kalayci MU. , et al. Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion?. Surg Endosc 2009; 23 (07) 1465-1469
  • 42 Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24 (26) 2902-2914
  • 43 de Franchis R. ; Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
  • 44 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 (05) 428-431
  • 45 Karaman A, Baskol M, Gursoy S. , et al. Endoscopic topical application of Ankaferd Blood Stopper® in gastrointestinal bleeding. J Altern Complement Med 2012; 18 (01) 65-68
  • 46 Volenec K, Kuna P. Modification of toxic effects of cystamine by adrenergic agents in rats. Sb Ved Pr Lek Fak Karlovy Univerzity Hradci Kralove 1981; 24 (04) 541-547
  • 47 Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34 (04) 643-664
  • 48 Yamada A, Niikura R, Yoshida S, Hirata Y, Koike K. Endoscopic management of colonic diverticular bleeding. Dig Endosc 2015; 27 (07) 720-725
  • 49 Seth A, Khan MA, Nollan R. , et al. Does urgent colonoscopy improve outcomes in the management of lower gastrointestinal bleeding?. Am J Med Sci 2017; 353 (03) 298-306
  • 50 Roshan Afshar I, Sadr MS, Strate LL, Martel M, Menard C, Barkun AN. The role of early colonoscopy in patients presenting with acute lower gastrointestinal bleeding: a systematic review and meta-analysis. Therap Adv Gastroenterol 2018; 11: X18757184
  • 51 Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000; 118 (01) 201-221
  • 52 Szold A, Katz LB, Lewis BS. Surgical approach to occult gastrointestinal bleeding. Am J Surg 1992; 163 (01) 90-92 , discussion 92–93
  • 53 Raju GS, Gerson L, Das A, Lewis B. ; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133 (05) 1697-1717
  • 54 Bonnet S, Douard R, Malamut G, Cellier C, Wind P. Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. Dig Liver Dis 2013; 45 (04) 277-284
  • 55 Angrisani L, Santonicola A, Iovino P. , et al. Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014. Obes Surg 2017; 27 (09) 2279-2289
  • 56 Guerron AD, Ortega CB, Portenier DD. Anastomotic leak following gastric bypass. In: Camacho D, Zundel N. , eds. Complications in Bariatric Surgery. Cham, Switzerland: Springer; 2018: 77-84
  • 57 Guerron AD, Rodriguez JH, Kroh M. Endoscopic management of complications. In: Rogula T, Schauer PR, Fouse T. , eds. Prevention and Management of Complications in Bariatric Surgery. New York: Oxford University Press; 2018: 228-235
  • 58 Rabl C, Peeva S, Prado K. , et al. Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies. Obes Surg 2011; 21 (04) 413-420
  • 59 Jamil LH, Krause KR, Chengelis DL. , et al. Endoscopic management of early upper gastrointestinal hemorrhage following laparoscopic Roux-en-Y gastric bypass. Am J Gastroenterol 2008; 103 (01) 86-91
  • 60 Lord RV, Edwards PD, Coleman MJ. Gastric cancer in the bypassed segment after operation for morbid obesity. Aust N Z J Surg 1997; 67 (08) 580-582
  • 61 Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis 2006; 2 (04) 460-463
  • 62 Pope GD, Goodney PP, Burchard KW. , et al. Peptic ulcer/stricture after gastric bypass: a comparison of technique and acid suppression variables. Obes Surg 2002; 12 (01) 30-33