Non-variceal upper gastrointestinal bleeding: advances and future directions in management

Numerous clinical guidelines have been developed for the management of non-variceal upper gastrointestinal bleeding (NVUGIB), yet significant variations exist among the recommendations. This review summarizes the most recent evidence on NVUGIB management, structured across four key stages: pre-endoscopic management, endoscopic treatment, post-endoscopic care, and the identification and management of refractory bleeding. In the pre-endoscopic phase, several risk-scoring systems have been developed to predict mortality. A restrictive transfusion strategy, with a threshold of 7 to 8 g/dL, is now recommended for most patients. Pre-endoscopic administration of intravenous erythromycin also improves visualization during endoscopy. A wide array of endoscopic hemostasis techniques is available, with the choice of method depending on the underlying cause of bleeding. When endoscopic hemostasis fails, transcatheter arterial embolization (TAE) is generally preferred over surgery as the second-line intervention. Once hemostasis is achieved, high-dose acid suppression is essential, and the risk of rebleeding should be assessed. For patients who experience rebleeding, repeat endoscopic therapy is recommended as the first-line approach. However, determining the optimal timing for TAE remains a challenge. Because of the heterogeneity of clinical presentations, NVUGIB management should be personalized. Further research is needed to establish evidence-based, individualized treatment strategies.