Endoscopic management of upper non-variceal and lower gastrointestinal bleeding: Where do we stand?

Abstract

Non-variceal upper gastrointestinal bleeding (GIB) remains a significant clinical challenge with a 30-day mortality of up to 11%. Peptic ulcers are the most common cause, followed by other conditions like Mallory-Weiss syndrome, Dieulafoy's lesions, and gastric neoplasms. Treatment strategies include acid-suppressive therapy, endoscopic interventions, and surgical or radiological procedures. Endoscopic techniques such as over-the-scope clips, coagulation graspers, and endoscopic ultrasound-guided treatments have significantly improved outcomes, reducing rebleeding rates and the need for surgery. Injectable therapies, mechanical hemostasis via clips, and thermal modalities (e.g., electrocoagulation, argon plasma coagulation) remain standard approaches for active bleeding. Newer hemostatic powders, such as TC-325, offer promising non-contact treatments, particularly in cases of refractory bleeding or malignancy. Doppler endoscopic probes aid in risk stratification by detecting residual arterial blood flow, improving the efficacy of endoscopic therapy and reducing rebleeding risks. For small bowel bleeding, endoscopic management with enteroscopy and thermal therapies remains key, though medical therapies are evolving. Lower GIB, which often involves conditions like diverticular disease and angioectasia, requires a comprehensive approach combining endoscopic, radiologic, and surgical interventions. Pharmacologic management focuses on balancing antithrombotic therapy with bleeding risks, with reversal agents playing a crucial role in life-threatening bleeding episodes. This review highlights advances in diagnostic tools and endoscopic therapies that have enhanced management outcomes for GIB across various etiologies.