Therapeutic endoscopy for acute upper gastrointestinal bleeding


Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease—the most common etiology of UGIB—endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

Key Points

  • Esophogastroduodenoscopy is the prime diagnostic and therapeutic procedure for acute upper gastrointestinal bleeding (UGIB), which accounts for nearly 400,000 admissions to hospital annually in the US

  • The performance of endoscopic therapy for acute UGIB for peptic ulcer disease largely depends on findings of stigmata of recent hemorrhage (SRH); major SRH generally mandate endoscopic therapy, whereas minor SRH or absence of SRH generally require no endoscopic therapy

  • Endoscopic therapies include injection therapy, ablative therapy, and mechanical therapy; combination therapy (usually injection therapy followed by ablative therapy or mechanical therapy) is performed to maximally reduce the risk of rebleeding

  • Combined therapeutic endoscopy can reduce the risk of ongoing or recurrent bleeding from 80% to 15% for an actively bleeding ulcer and from 50% to 10% for an ulcer with a nonbleeding visible vessel

  • Although originally designed for peptic ulcer disease, endoscopic therapeutic techniques and protocols have increasingly been adapted for other etiologies of UGIB and for many types of lower gastrointestinal bleeding

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Figure 1: Endoscopic argon plasma coagulation therapy for extensive gastric antral vascular ectasia.
Figure 2: Stigmata of variceal hemorrhage and endoscopic band ligation.


  1. 1

    Lewis, J. D., Bilker, W. B., Brensinger, C., Farrar, J. T. & Strom, B. L. Hospitalization and mortality rates from peptic ulcer disease and GI bleeding in the 1990s: relationship to sales of nonsteroidal anti-inflammatory drugs and acid suppression medications. Am. J. Gastroenterol. 97, 2540–2549 (2002).

  2. 2

    Cappell, M. S. & Friedel, D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med. Clin. North Am. 92, 491–509 (2008).

  3. 3

    Kovacs, T. O. Management of upper gastrointestinal bleeding. Curr. Gastroenterol. Rep. 10, 535–542 (2008).

  4. 4

    Cappell, M. S. Safety and efficacy of nasogastric intubation for gastrointestinal bleeding after myocardial infarction: an analysis of 125 patients at two tertiary cardiac referral hospitals. Dig. Dis. Sci. 50, 2063–2070 (2005).

  5. 5

    Rudolph, S. J., Landsverk, B. K. & Freeman, M. L. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest. Endosc. 57, 58–61 (2003).

  6. 6

    Bhatti, N., Amoateng-Adjepong, Y., Qamar, A. & Manthous, C. A. Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes. Chest 114, 1137–1142 (1998).

  7. 7

    Laine, L. & Cook, D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis. Ann. Intern. Med. 123, 280–287 (1995).

  8. 8

    Olmos, J. A. et al. Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia. Dis. Colon Rectum 49, 1507–1516 (2006).

  9. 9

    Kolkman, J. J. & Meuwissen, S. G. A review of bleeding peptic ulcer: a collaborative task of gastroenterologist and surgeon. Scand. J. Gastroenterol. Suppl. 218, 16–25 (1996).

  10. 10

    Podilla, P. V. et al. Managing patients with acute nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway. Am. J. Gastroenterol. 96, 208–219 (2001).

  11. 11

    Romagnuolo, J., Barkun, A. N., Enns, R., Armstrong, D. & Gregor, J. Simple clinical predictors may obviate urgent endoscopy in patients with nonvariceal upper gastrointestinal bleeding. Arch. Intern. Med. 167, 265–270 (2007).

  12. 12

    Adler, D. G. et al. ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest. Endosc. 60, 497–504 (2004).

  13. 13

    Chak, A. et al. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest. Endosc. 53, 6–13 (2001).

  14. 14

    Cappell, M. S. & Friedel, D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med. Clin. North Am. 92, 511–550 (2008).

  15. 15

    Elta, G. H. Acute nonvariceal upper gastrointestinal hemorrhage. Curr. Treat. Options Gastroenterol. 5, 147–152 (2002).

  16. 16

    Jensen, D. M. & Machicado, G. A. Endoscopic hemostasis of ulcer hemorrhage with injection, thermal, and combination methods. Tech. Gastrointest. Endosc. 7, 124–131 (2005).

  17. 17

    Klein, H. G., Spahn, D. R. & Carson, J. L. Red blood cell transfusion in clinical practice. Lancet 370, 415–426 (2007).

  18. 18

    Hogue, C. W. Jr, Goodnough, L. T. & Monk, T. G. Preoperative myocardial ischemic episodes are related to hematocrit levels in patients undergoing radical prostatectomy. Transfusion 38, 924–931 (1998).

  19. 19

    Cappell, M. S. A study of the syndrome of simultaneous acute upper gastrointestinal bleeding and myocardial infarction in 36 patients. Am. J. Gastroenterol. 90, 1444–1449 (1995).

  20. 20

    Maltz, G. S., Siegel, J. E. & Carson, J. L. Hematologic management of gastrointestinal bleeding. Gastroenterol. Clin. North Am. 29, 169–187 (2000).

  21. 21

    Contreras, M. Final statement from the consensus conference on platelet transfusion. Transfusion 38, 796–797 (1998).

  22. 22

    McIntyre, L. A. et al. A survey of Canadian intensivists' resuscitation practices in early septic shock [abstract]. Crit. Care 11, R74 (2007).

  23. 23

    Coffin, B. et al. Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Gastrointest. Endosc. 56, 174–179 (2002).

  24. 24

    Winstead, N. S. & Wilcox, C. M. Erythromycin prior to endoscopy for acute upper gastrointestinal hemorrhage: a cost-effectiveness analysis. Aliment. Pharmacol. Ther. 26, 1371–1377 (2007).

  25. 25

    Leontiadis, G. I. et al. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol. Assess. 11, 1–164 (2007).

  26. 26

    Andriulli, A. et al. Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers: a series of meta-analyses. Am. J. Gastroenterol. 100, 207–219 (2005).

  27. 27

    Green, F. W. Jr, Kaplan, M. M., Curtis, L. E. & Levine, P. H. Effect of acid and pepsin on blood coagulation and platelet aggregation: a possible contributor to prolonged gastrodudoenal mucosal hemorrhage. Gastroenterology 74, 38–43 (1978).

  28. 28

    Lau, J. Y. et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N. Engl. J. Med. 356, 1631–1640 (2007).

  29. 29

    Triandaf, I., Stanciu, C., Solomon, M., Grauer, M. & Untu, A. Continuous electrocardiographic monitoring during upper gastrointestinal endoscopy. Med. Interne 16, 43–45 (1978).

  30. 30

    Dillon, K. A. Time out: an analysis. AORN J. 88, 437–442 (2008).

  31. 31

    Isaacs, K. L. in Handbook of Gastroenterologic Procedures 4th edn (eds Drossman, D. A., Grimm, I. S. & Shaheen, N. J.) 30–37 (Lippincott Williams & Wilkins, Philadelphia, 2005).

  32. 32

    Waring, J. P. et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest. Endosc. 58, 317–322 (2003).

  33. 33

    Enestvedt, B. K., Gralnek, I. M., Mattek, N., Lieberman, D. A. & Eisen, G. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest. Endosc. 67, 422–429 (2008).

  34. 34

    Jutabha, R. & Jensen, D. M. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med. Clin. North Am. 80, 1035–1068 (1996).

  35. 35

    Ciociola, A. A., McSorley, D. J., Turner, K., Sykes, D. & Palmer, J. B. Helicobacter pylori infection rates in duodenal ulcer patients in the United States may be lower than previously estimated. Am. J. Gastroenterol. 94, 1834–1840 (1999).

  36. 36

    Cappell, M. S. & Schein, J. R. Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity. Gastroenterol. Clin. North Am. 29, 97–124 (2000).

  37. 37

    Kupfer, I., Cappell, M. S. & Tessler, S. Acute gastrointestinal bleeding in the intensive care unit: the intensivist's perspective. Gastroenterol. Clin. North Am. 29, 275–307 (2000).

  38. 38

    Kovacs, T. O. & Jensen, D. M. Endoscopic treatment of ulcer bleeding. Curr. Treat. Options Gastroenterol. 10, 143–148 (2007).

  39. 39

    Freeman, M. L. Stigmata of hemorrhage in bleeding ulcers. Gastrointest. Endosc. Clin. N. Am. 7, 559–574 (1997).

  40. 40

    Chen, J. J., Changchien, C. S., Lin, C. C. & Chang, W. C. The visible vessel on the bleeding gastric ulcer: an endoscopic-pathological study. Endoscopy 29, 821–826 (1997).

  41. 41

    Beckly, D. E. & Casebow, M. P. Prediction of rebleeding from peptic ulcer experience with an endoscopic Doppler device. Gut 27, 96–99 (1986).

  42. 42

    Kohler, B., Maier, M., Benz, C. & Riemann, J. F. Acute ulcer bleeding: a prospective randomized trial to compare Doppler and Forrest classifications in endoscopic diagnosis and therapy. Dig. Dis. Sci. 42, 1370–1374 (1997).

  43. 43

    Wong, R. C. Endoscopic Doppler US probe for acute peptic ulcer hemorrhage. Gastrointest. Endosc. 60, 804–812 (2004).

  44. 44

    Laine, L. & Petersen, W. L. Bleeding peptic ulcer. N. Engl. J. Med. 331, 717–727 (1994).

  45. 45

    Leontiadis, G. I. & Howden, C. W. Pharmacologic treatment of peptic ulcer bleeding. Curr. Treat. Options Gastroenterol. 10, 134–142 (2007).

  46. 46

    Savides, T. J. & Jensen, D. M. Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol. Clin. North Am. 29, 465–487 (2000).

  47. 47

    Chung, S. C., Leung, J. W., Steele, R. J., Crofts, T. J. & Li, A. K. Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial. Br. Med. J. 296, 1631–1633 (1988).

  48. 48

    Chung, I. K. et al. Evaluation of endoscopic hemostasis in upper gastrointestinal bleeding related to Mallory-Weiss syndrome. Endoscopy 34, 474–479 (2002).

  49. 49

    Barnert, J. & Messmann, H. Management of lower gastrointestinal tract bleeding. Best Pract. Res. Clin. Gastroenterol. 22, 295–312 (2008).

  50. 50

    Jensen, D. M., Machicado, G. A., Jutabha, R. & Kovacs, T. O. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N. Engl. J. Med. 342, 78–82 (2000).

  51. 51

    Kahi, C. J. et al. Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis. Gastroenterology 129, 855–862 (2005).

  52. 52

    Cappell, M. S. The water jet deformation sign: a novel provocative maneuver to help diagnose an inverted diverticulum. South. Med. J. 102, 295–298 (2009).

  53. 53

    Bini, E. J. & Cohen, J. Endoscopic treatment compared with medical therapy for the prevention of recurrent ulcer hemorrhage in patients with adherent clots. Gastrointest. Endosc. 58, 707–714 (2003).

  54. 54

    Jensen, D. M., Kovacs, T. O., Jutabha, R. & Machicado, G. A. Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots. Gastroenterology 123, 407–413 (2002).

  55. 55

    Bleau, B. L. et al. Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy. Gastrointest. Endosc. 56, 1–6 (2002).

  56. 56

    Kubba, A. K. & Palmer, K. R. Role of endoscopic injection therapy in the treatment of bleeding peptic ulcer. Br. J. Surg. 83, 461–468 (1996).

  57. 57

    Chung, S. C., Leung, J. W. & Leung, F. W. Effect of submucosal epinephrine injection on local gastric blood flow: a study using laser Doppler flowmetry and reflectance spectrophotometry. Dig. Dis. Sci. 35, 1008–1011 (1990).

  58. 58

    Cappel, M. S. Gastrointestinal bleeding associated with myocardial infarction. Gastroenterol. Clin. North Am. 29, 423–444 (2000).

  59. 59

    Cappell, M. S. & Iacovone, F. M. Jr. Safety and efficacy of esophagogastroduodenoscopy after myocardial infarction. Am. J. Med. 106, 29–35 (1999).

  60. 60

    Gangarosa, L. M. in Handbook of Gastroenterologic Emergencies 4th edn (eds Drossman, D. A., Grimm, I. S. & Shaheen, N. J.) 87–92 (Lippincott Williams & Wilkins, Philadelphia, 2005).

  61. 61

    Calvet, X., Vergara, M., Brullet, E., Gisbert, J. P. & Campo, R. Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers. Gastroenterology 126, 441–450 (2004).

  62. 62

    Lin, H. J. et al. A prospective, randomized trial of large- versus small- volume endoscopic injection of epinephrine for peptic ulcer bleeding. Gastrointest. Endosc. 55, 615–619 (2002).

  63. 63

    Chung, S. C. et al. Epinephrine or epinephrine plus alcohol for injection of bleeding ulcer: a prospective randomized trial. Gastrointest. Endosc. 43, 591–595 (1996).

  64. 64

    Lopefrido, S., Patelli, G. & La Torre, L. Extensive necrosis of gastric mucosa following injection therapy of bleeding peptic ulcer. Endoscopy 22, 285–286 (1990).

  65. 65

    Monkewich, G. J. & Haber, G. B. in Advanced Therapy in Gastroenterology and Liver Disease 5th edn (eds Bayless, T. M. & Diehl, A. M.) 167–177 (BC Decker, Hamilton, Ontario, 2005).

  66. 66

    Liou, T. C., Chang, W. H., Wang, H. Y., Lin, S. C. & Shih, S. C. Large-volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding. J. Gastroenterol. Hepatol. 22, 996–1002 (2007).

  67. 67

    Benedetti, G., Sablich, R. & Lacchin, T. Endoscopic injection sclerotherapy in non-variceal upper gastrointestinal bleeding: a comparative study of polidocanol and thrombin. Surg. Endosc. 5, 28–30 (1991).

  68. 68

    Church, N. I. et al. A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer. Gastroenterology 125, 396–403 (2003).

  69. 69

    Przemiosio, R. T., McNair, A. & Williams, R. Thrombin is effective in arresting bleeding from gastric variceal hemorrhage. Dig. Dis. Sci. 44, 778–781 (1999).

  70. 70

    Lin, H. J. et al. Endoscopic injection with fibrin sealant versus epinephrine for arrest of peptic ulcer bleeding: a randomized, comparative trial. J. Clin. Gastroenterol. 35, 218–221 (2002).

  71. 71

    Pescatore, P. et al. Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial. Gastrointest. Endosc. 55, 348–353 (2002).

  72. 72

    Rutgeerts, P. et al. Randomized trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer. Lancet 350, 692–696 (1997).

  73. 73

    Song, S. Y., Chung, J. B., Moon, Y. M., Kang, J. K. & Parks, I. S. Comparison of the hemostatic effect of endoscopic injection with fibrin glue and hypertonic saline-epinephrine for peptic ulcer bleeding: a prospective randomized trial. Endoscopy 29, 827–833 (1997).

  74. 74

    Capellan, O. & Hollander, J. E. Management of lacerations in the emergency department. Emerg. Med. Clin. North Am. 21, 205–231 (2003).

  75. 75

    Aabakken, L. Current endoscopic and pharmacological therapy of peptic ulcer bleeding. Best Pract. Res. Clin. Gastroenterol. 22, 243–259 (2008).

  76. 76

    Lee, K. J., Kim, J. H., Hahm, K. B., Cho, S. W. & Park, Y. S. Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers. Endoscopy 32, 505–511 (2000).

  77. 77

    Fry, L. C., Neumann, H., Olano, C., Malfertheiner, P. & Mönkemüller, K. Efficacy, complications and clinical outcomes of endoscopic sclerotherapy with N-butyl-2-cyanoacrylate for bleeding gastric varices. Dig. Dis. 26, 300–303 (2008).

  78. 78

    Schmidt, B. et al. Pulmonary vein isolation with high-intensity focused ultrasound: HIFU 12F study. Europace 11, 1281–1288 (2009).

  79. 79

    Johnston, J. H., Jensen, D. M. & Auth, D. Experimental comparison of colonoscopic yttrium-aluminum-garnet laser, electrosurgery, and heater probe for canine gut arterial coagulation. Importance of vessel compression and avoidance of tissue erosion. Gastroenterology 92, 1101–1108 (1987).

  80. 80

    Jensen, D. M. & Machicado, G. A. Contact thermal devices, endoscopic hemoclips, and epinephrine injection for ulcer hemorrhage. UpToDate [online], (2009).

  81. 81

    Jaramillo, J. L., Carmona, C., Gálvez, C., de la Mata, M. & Miño, G. Efficacy of the heater probe in peptic ulcer with a non-bleeding visible vessel: a controlled, randomised study. Gut 34, 1502–1506 (1993).

  82. 82

    Fullarton, G. M., Birnie, G. G., Macdonald, A. & Murray, W. R. Controlled trial of heater probe treatment in bleeding peptic ulcers. Br. J. Surg. 76, 541–544 (1989).

  83. 83

    Laine, L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage: a prospective controlled trial. N. Engl. J. Med. 316, 1613–1617 (1987).

  84. 84

    Laine, L. Multipolar electrocoagulation in the treatment of peptic ulcers with nonbleeding visible vessels: a prospective, controlled trial. Ann. Intern. Med. 110, 510–514 (1989).

  85. 85

    Cohen, J. Argon plasma coagulation in the management of gastrointestinal hemorrhage. UpToDate [online], (2009).

  86. 86

    Skok, P., Krizman, I. & Skok, M. Argon plasma coagulation versus injection sclerotherapy in peptic ulcer hemorrhage: a prospective, controlled study. Hepatogastroenterology 51, 165–170 (2004).

  87. 87

    Cappell, M. S. in Textbook of Gastroenterology 5th edn (eds Yamada, T. et al.) 2785–2810 (Wiley-Blackwell, Oxford, 2009).

  88. 88

    Lecleire, S. et al. Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis. Gastrointest. Endosc. 67, 219–225 (2008).

  89. 89

    Karamanolis, G. et al. Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis. Endoscopy 41, 529–531 (2009).

  90. 90

    Kwan, V. et al. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am. J. Gastroenterol. 101, 58–63 (2006).

  91. 91

    Herrera, S. et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest. Endosc. 68, 440–446 (2008).

  92. 92

    Gostout, C. J., Bowyer, B. A., Ahlquist, D. A., Viggiano, T. R. & Balm, R. K. Mucosal vascular malformations of the gastrointestinal tract: clinical observations and results of endoscopic neodymium: yttrium-aluminum-garnet laser therapy. Mayo Clin. Proc. 63, 993–1003 (1988).

  93. 93

    Naveau, S., Aubert, A., Poynard, T. & Chaput, J. C. Long-term results of treatment of vascular malformations of the gastrointestinal tract by neodymium YAG laser photocoagulation. Dig. Dis. Sci. 35, 821–826 (1990).

  94. 94

    Schulze, S. & Lyng, K. M. Palliation of rectosigmoid neoplasms with Nd:YAG laser treatment. Dis. Colon Rectum 37, 882–884 (1994).

  95. 95

    Krejs, G. J. et al. Laser photocoagulation for the treatment of acute peptic-ulcer bleeding: a randomized controlled clinical trial. N. Engl. J. Med. 316, 1618–1621 (1987).

  96. 96

    Jensen, D. M., Machicado, G. A. & Hirabayashi, K. Hemoclipping (CLIP) of chronic ulcers: a randomized prospective study of initial success, CLIP retention rates, and ulcer healing [abstract]. Gastrointest. Endosc. 61, 174 (2005).

  97. 97

    Chen, C. Y. et al. Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study. Gastrointest. Endosc. 67, 35–39 (2008).

  98. 98

    Eriksson, L. G., Sundbom, M., Gustavsson, S. & Nyman, R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J. Vasc. Interv. Radiol. 17, 959–964 (2006).

  99. 99

    Ishiguro, T. & Nagawa, H. Inadvertent endoscopic application of a hemoclip to the splenic artery through a perforated gastric ulcer. Gastrointest. Endosc. 53, 378–379 (2001).

  100. 100

    Barbagallo, F. et al. Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device. World J. Gastroenterol. 13, 2889–2891 (2007).

  101. 101

    Cho, I., Gaslightwala, I., Jensen, D. M. & Cohen, J. Endoclip therapy in the gastrointestinal tract: bleeding lesions and beyond. UpToDate [online], (2009).

  102. 102

    Chuttani, R. et al. Endoscopic clip application devices. Gastrointest. Endosc. 63, 746–750 (2006).

  103. 103

    Shin, E. J. et al. Comparative study of endoscopic clips: duration of attachment at the site of clip application. Gastrointest. Endosc. 66, 757–761 (2007).

  104. 104

    Gill, K. R., Pooley, R. A. & Wallace, M. B. Magnetic resonance imaging compatibility of endoclips. Gastrointest. Endosc. 70, 532–536 (2009).

  105. 105

    Lin, H. J. et al. A prospective randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am. J. Gastroenterol. 97, 2250–2254 (2002).

  106. 106

    Sung, J. J., Tsoi, K. K., Lai, L. H., Wu, J. C. & Lau, J. Y. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 56, 1364–1373 (2007).

  107. 107

    The 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. 319, 983–989 (1988).

  108. 108

    Garcia-Tsao, G., Sanyal, A. J., Grace, N. D. & Carey, W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 46, 922–938 (2007).

  109. 109

    Beppu, K. et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest. Endosc. 27, 213–218 (1981).

  110. 110

    Merkel, C. et al. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am. J. Gastroenterol. 95, 2915–2920 (2000).

  111. 111

    Bajaj, J. S. & Franco, J. Endoscopic band ligation of esophageal varices in patients on anticoagulation. J. Clin. Gastroenterol. 42, 782–785 (2008).

  112. 112

    Baron, T. H. & Wong Kee Song, L. M. Endoscopic variceal band ligation. Am. J. Gastroenterol. 104, 1083–1085 (2009).

  113. 113

    Conway, J. D. & Shrestha, R. in Handbook of Gastroenterologic Procedures 4th edn (eds Drossman, D. A., Grimm, I. S. & Shahen, N. J.) 112–118 (Lippincott Williams & Wilkins, Philadelphia, 2005).

  114. 114

    Liu, J. et al. Endoscopic banding devices. Gastrointest. Endosc. 68, 217–221 (2008).

  115. 115

    Kravetz, D. Prevention of recurrent esophageal variceal hemorrhage: review and current recommendations. J. Clin. Gastroenterol. 41 (Suppl. 3), S318–S322 (2007).

  116. 116

    Misra, S. P. et al. Endoscopic band ligation as salvage therapy in patients with bleeding peptic ulcers not responding to injection therapy. Endoscopy 37, 626–629 (2005).

  117. 117

    Leclaire, S. et al. Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine. Aliment. Pharmacol. Ther. 30, 399–405 (2009).

  118. 118

    Alis, H. et al. Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion? Surg. Endosc. 23, 1465–1469 (2009).

  119. 119

    Di Giorgio, P. et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy 36, 860–863 (2004).

  120. 120

    Cappell, M. S. & Abdullah, M. Management of gastrointestinal bleeding induced by gastrointestinal endoscopy. Gastroenterol. Clin. North Am. 29, 125–167 (2000).

  121. 121

    Bourke, M. J. & Williams, S. J. in Colonoscopy: Principles and Practice 2nd edn (eds Waye, J. D., Rex, D. K. & Williams, C. B.) 318–327 (Wiley-Blackwell, Chichester, 2009).

  122. 122

    Abu-Hamda, E. M. & Baron, T. H. in Handbook of Gastroenterologic Emergencies 4th edn (eds Drossman, D. A., Grimm, I. S. & Shaheen, N. J.) 97–102 (Lippincott Williams & Wilkins, Philadelphia, 2005).

  123. 123

    Katsinelos, P. et al. Endoloop-assisted polypectomy for large pedunculated colorectal polyps. Surg. Endosc. 20, 1257–1261 (2006).

  124. 124

    Ljubicic, N. Endoscopic detachable mini-loop ligation for treatment of gastroduodenal angiodysplasia: case study of 11 patients with long-term follow-up. Gastrointest. Endosc. 59, 420–423 (2004).

  125. 125

    Sung, J. J. & Chung, S. C. The use of detachable mini-loop for the treatment of esophageal varices. Gastrointest. Endosc. 47, 178–181 (1998).

  126. 126

    Lo, C. C. et al. Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointest. Endosc. 63, 767–773 (2006).

  127. 127

    Chung, S. S. et al. Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. BMJ 314, 1307–1311 (1997).

  128. 128

    Canady, J., Wiley, K. & Ravo, B. Argon plasma coagulation and the future applications for dual-mode endoscopic probes. Rev. Gastroenterol. Disord. 6, 1–12 (2006).

  129. 129

    Lau, J. Y. et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N. Engl. J. Med. 340, 751–756 (1999).

  130. 130

    Jensen, D. M. Management of severe ulcer rebleeding. N. Engl. J. Med. 340, 799–801 (1999).

  131. 131

    Milward, S. F. ACR appropriateness criteria on treatment of acute nonvariceal gastrointestinal tract bleeding. J. Am. Coll. Radiol. 5, 550–554 (2008).

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Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Cappell, M. Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 7, 214–229 (2010).

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