Endoscopic Treatment of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding remains an important gastrointestinal condition despite a decline in its incidence, the introduction of acid-suppressive therapy, and advances in endoscopic techniques. Based on etiology, it is classified as variceal or nonvariceal bleeding, with peptic ulcers constituting the majority of nonvariceal bleeding. Before endoscopy, it is essential to stabilize the patient by administering appropriate fluids, blood transfusions, proton pump inhibitors, vasoconstrictors, and antibiotics, followed by an early endoscopic examination and treatment whenever possible. Endoscopic management can be facilitated by accessories such as transparent caps, water-jet pumps, overtubes, and multi-bending endoscopes. Studies have reported emerging tools, including machine learning models for risk prediction, swallowable bleeding sensors, and hemostasis guided by endoscopic ultrasound or Doppler. Endoscopic hemostasis includes injections, mechanical therapy, electrocautery, and topical therapies. Once the bleeding source is identified, an appropriate endoscopic modality can be selected according to the lesion. For nonvariceal bleeding, injections, coagulation, and mechanical methods are used when endoscopic hemostasis is indicated. Band ligation is commonly used to treat esophageal variceal bleeding, whereas gastric variceal bleeding is typically treated with cyanoacrylate injections. If endoscopic therapy fails or rebleeding occurs, angiography with embolization or surgery may be required, and in acute variceal bleeding, a transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration can be considered. Second-look endoscopy may be performed selectively in patients at high risk of rebleeding or when repeat evaluation is needed. In peptic ulcer disease, early biopsy should be performed when malignancy is suspected, and Helicobacter pylori testing and eradication should be ensured.