Refractory Bleeding Research Articles

Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents.

To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality. Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008-2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors. The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22-0.99; p =.047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13-50.14; p =.024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01-40.52; p =.047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10-10.74; p =.006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5min vs. 35.5 ± 23.4min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786). Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding. • Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding.

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

The Use of Prothrombin Complex Concentrates: Results of a Nationwide Survey of Critical Care Pharmacists

Background Prothrombin complex concentrates (PCCs) are frequently used. Objective To elucidate practices and perceptions of proprietary and nonproprietary PCCs use. Methods An electronic pretested cross-sectional survey e-mailed thrice to 1 critical care pharmacist at 1170 US institutions. Questions addressed hospital and pharmacy characteristics, use of PCCs, and perceptions of effectiveness and safety. Results 429 (39.5%) of 1086 eligible institutions completed the questionnaire. PCCs were used several times per month to several times per week (62.6%). An order set was routinely or always used to direct PCCs usage at 66.4% of institutions. Four-factor PCCs were preferred by 93% of institutions. The most common perceived indications for 4-factor PCCs were hemorrhage related to warfarin (92.1%) or oral Xa inhibitors (81.8%), intracranial hemorrhage (78.4%), trauma hemorrhage (66.2%), surgical hemorrhage (61.1%), and refractory hemorrhage (57.3%). The most common perceived contraindications were heparin-induced thrombocytopenia (42%), disseminated intravascular coagulopathy (39.2%), and active thromboembolism (38.9%). Most institutions considered patient weight (78.8%), indication (77.6%), and International Normalized Ratio (76.9%) when dosing PCCs. Only 43.8% of institutions used fixed dose, only 19.6% compounded PCCs at the bedside, and only 11.9% administered PCCs by rapid infusion. Compared to standard blood products, respondents believed PCCs acted more rapidly, were less likely to cause volume issues, and were more expensive. Respondents were neutral about PCCs acting longer, being more effective at preventing or treating hemorrhage, or causing thromboembolism. Conclusions Off-label use of PCCs is common. Differing perceptions surrounding indications, contraindications, and comparisons to blood products/procoagulants likely contribute to variable practices.

Transfusion management of abdominal delivery in pregnant women at high risk of bleeding with hemostasis control

Objective of the study . Optimization of transfusion support of abdominal delivery in pregnant women at risk of obstetric haemorrhage using monitored management of haemostasis disorders. Study materials. The study group consisted of 24 women of 23-47 years old with abnormal placental invasion (API) and bleeding during caesarean section at a gestational age of 32-36 weeks. Group 1 consisted of 14 patients, who were injected with tranexamic acid as part of combined therapy; Group 2 consisted of 10 women, who were injected with aminomethylbenzoic acid as part of combined therapy. Results. All patients received instrumental autoerythrocyte reinfusion. Three patients of Group 1 (21.4%) with refractory bleeding received recombinant coagulation factor VIIa (Coagil, Russia) at a dose of 60 pg/kg body weight (average dose 6.6 ± 1.4 mg), a decrease in bleeding was observed, the operative treatment was completed in the form of metroplasty. In the early stages of bleeding, eight patients were injected with a prothrombin complex concentrate of 600-1,200 IU before administration of fresh-frozen plasma (FFP), which allowed to reduce the volume of donor FFP in these patients. The study of hemostasis showed a very high inverse relationship between extent of blood loss and fibrinogen level in the groups of patients. Conclusion. The use of factor VIIa in refractory major obstetric haemorrhage (MOH) in patients with API allows to reduce the blood loss, perform metroplasty, and preserve the woman’s fertility. Patient blood management (PCM) in pregnant women with API makes it possible to conduct organ-preserving treatment in 91.7% of women.

S2107 Successful Management of Refractory Esophageal Variceal Bleeding Secondary to Chronic Portal Vein Thrombosis by Transsplenic Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt

INTRODUCTION: Trans-jugular intrahepatic portosystemic shunt (TIPS) becomes challenging in the presence of portal vein thrombus (PVT). We describe a case of successful management of refractory esophageal variceal bleeding secondary to chronic PVT and splenic vein thrombosis (SVT) by portal vein recanalization – TIPS through transsplenic and transhepatic approach. CASE DESCRIPTION/METHODS: A 29-year-old male with a history of homozygous methylenetetrahydrofolate reductase mutation with normal homocysteine levels on warfarin presented with acute hematemesis. He underwent emergent endoscopic band ligation of esophageal and GOV1 gastric varices. He had a history of chronic PVT with prior mechanical thrombectomy and thrombolysis two years ago, and received band ligation for bleeding esophageal varices in the last year, but did not follow up for surveillance. MRI of abdomen and pelvis revealed chronic PVT with cavernous transformation (Fig A) and chronic SVT. No further bleeding was reported after endoscopy. Liver biopsy one year ago showed benign liver tissue with focal mild congestion and sinusoidal dilation. There was a normal hepatic venous pressure gradient. Given concerns about his compliance and risk of re-bleeding, multidisciplinary team discussion led to consideration of a high-risk TIPS with splenic vein recanalization and stenting. Under ultrasound and fluoroscopic guidance, TIPS was placed using two snare targets. One snare was placed in the occluded portal vein via splenic vein access, and another was placed in the middle hepatic vein via internal jugular vein access. Using the gun-sight technique, a 21-gauge Chiba needle was advanced transhepatically through both the loop snares and then a guidewire was advanced until it could be captured by both the above snares (Fig B). With this newly obtained access, TIPS and splenic stents were successfully deployed (Fig C). Pressure gradient across TIPS was lowered to 6 mm Hg from 16 mm Hg. As varices did not fill on post TIPS portogram, embolization was not performed. He was started on aspirin in addition to his warfarin. Repeat CTA at 3 months demonstrated patent TIPS and splenic stent, and no further episodes of hematemesis were reported. DISCUSSION: In our patient, the gunsight TIPS approach helped decompress portal hypertension and prevent recurrent variceal bleeding when other alternatives including Sugiura surgery carried high morbidity and were not amenable. Post TIPS re-stenosis is a known complication, and may be prevented by aspirin and warfarin use.Figure 1.: Magnetic resonance imaging (MRI) of the abdomen and pelvis showing chronic portal vein thrombosis with cavernous transformation.Figure 2.: Fluoroscopic image showing gun-sight technique: Guide-wire is captured by the first snare in the presumed right portal vein and second snare in the middle hepatic vein.Figure 3.: Fluoroscopic image showing successful deployment of TIPS.

S2218 Management of Refractory Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia With Bevacizumab

S2218 Management of Refractory Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia With Bevacizumab

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

S1401 Malignant Mesenteric Venous Obstruction From Pancreatic Cancer, an Under-Recognized Condition Associated With Significant Morbidity, Can Be Treated With Venous Stenting

INTRODUCTION: Portal vein (PV) and superior mesenteric vein (SMV) stenosis can result from various pathologic processes including pancreatic cancer. Their clinical manifestations include portal hypertension (PH) with life-threatening variceal bleeding, refractory ascites, and mesenteric ischemia. In this abstract, 4 cases who underwent stenting are presented. CASE DESCRIPTION/METHODS: Case 1 is a 58-year-old woman with a history of pancreatic cancer status post Whipple resection, presented with worsening diarrhea, ascites, and malnutrition. Stool testing, colonoscopy with biopsies were negative. Ascitic fluid analysis was consistent with PH with no evidence of cirrhosis. Abdominal imaging showed ill-defined pancreatic body infiltrative mass with significant narrowing of the PV with resultant small bowel and colonic thickening. She underwent SMV/PV stenting which resulted in the resolution of diarrhea and bowel thickening. She went off total parenteral nutrition with 22 kg weight gain and was able to receive systemic anticancer therapy (SAT) and survived for 18 months afterward.Three other cases with similar preservations and varying degrees of refractory ascites, diarrhea, malnutrition, and bowel wall thickening on imaging. They all underwent PV or SMV stenting. Case 2 is a 68-year-old woman who experienced relief of symptoms but elected hospice care and passed away a month later, after developing SMV stent thrombosis despite oral anticoagulation. Case 3 is a 58-year-old woman who had PV and SMV stenoses. She developed refractory bleeding immediately after stenting and consequently died. Case 4 is a 66-year-old man who achieved symptoms resolution. His symptoms recurred due to stent thrombosis 6 weeks later. After thrombectomy, he improved and was alive at 4 months, on aspirin, enoxaparin, and SAT, with no recurrence of symptoms. DISCUSSION: PV and SMV stenosis caused by pancreatic cancer can result in varying degrees of bowel ischemia, malnutrition, refractory ascites and often leads to death. It is often unrecognized and clinical findings are attributed to the cancer itself. PV/SMV stenting is possible and can reverse PH, ascites, bowel ischemia, and malnutrition. Anticoagulation can decrease the risk of venous thrombosis associated with stenting but coexistent PH presents a challenge to anticoagulation. Further studies are needed to determine the targeted population that will benefit from stenting and when to start anticoagulation or antiplatelet therapy.Figure 1.: A) Abdominal CT scan showing PV stenosis B) PV stent placement process. Contrast failed to pass through the narrowed area.Figure 2.: C) Stent is successfully placed. D) Abdominal CT scan status post PV stent placement.

S3490 Post-ERCP Papillotomy Bleed - An Endoscopist's Worst Nightmare

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a common therapeutic procedure to remove bile duct stones. Pancreatitis is a complication while bleeding is rare. We present a case of severe and refractory post ERCP bleed following standard papillotomy. CASE DESCRIPTION/METHODS: A 64 year old male with alcoholism presented with confusion. Vitals were normal. He had slurred speech. He was not on anticoagulation, antiplatelet agents or liver toxic drugs. Labs revealed sodium 114, INR 1.1, ALP 289, bilirubin 2.3, AST 136, ALT 98. His speech improved with sodium correction. Liver enzymes worsened, bilirubin 11.1, prompting further evaluation. HIDA showed tracer in bile duct concerning for obstruction. He did not have tenderness or fever. MRCP without obvious stones. EUS showed foci in distal CBD suggestive of small stones/sludge. During ERCP, major papilla was stenotic. Standard papillotomy performed using ERBE. Using balloon, stones removed from bile duct and plastic stent placed. The next day, Hg fell and there was melena requiring transfusion. EGD revealed post papillotomy bleed controlled with epinephrine, clips and hemospray. Patient did well for 24 hours however, Hg dropped requiring more transfusions concerning for recurrent arterial bleed. Repeat ERCP showed bleed at papillotomy site. Plastic stent removed and covered metal stent placed into bile duct to tamponade. However, there was persistent ooze of blood treated with epinephrine, clips and hemospray. Patient did well for two days and again Hg dropped with melena. Hepatobiliary surgery and IR were consulted. Patient underwent embolization of branch of GDA and hemostasis secured. Repeat endoscopy revealed no further bleed, stent removed, patient discharged home. DISCUSSION: Post-ERCP bleeding is clinically significant or insignificant. Patient risk factors are coagulopathy, high bilirubin, cirrhosis, or papillary stenosis. Technique factors are rapid cutting, papillotomy length, or papillectomy. Operator factors are inexperienced endoscopist. Bleeding often stops spontaneously, rarely life threatening and managed with endoscopic therapy. Our patient had papillary stenosis and bilirubin >10. He underwent standard papillotomy by an experienced endoscopist. He had a clinically significant and refractory bleed uncontrolled by endoscopic therapy requiring GDA embolization. Endoscopists should be vigilant about recurrent bleeding despite endoscopic intervention and be open to angiogram and if required hepatobiliary surgery consultation.

S2192 Over-the-Scope Clip as Rescue Treatment for Bleeding Gastric Varices

INTRODUCTION: We present a case of gastrointestinal bleeding in a patient with pancreatitis-induced splenic vein thrombus. This case highlights an important etiology of gastric varices, a known complication of treating them, as well as a method for treating refractory bleeding. CASE DESCRIPTION/METHODS: An 18-year-old male with ALL s/p post allogeneic HSCT, chronic pancreatitis, bowel perforations s/p ileostomy presented with gastrointestinal bleeding. The patient had hospitalizations at other institutions with intermittent melena and occasional hematemesis. After multiple upper endoscopies that did not identify the etiology of bleeding, he was referred to our hospital for double balloon enteroscopy. His hemoglobin was down to 5.9 g/dL (baseline 9-10 g/dL). EGD was performed with plan for double balloon enteroscopy, but a large blood clot was seen in the stomach. A nodular area in the fundus was actively bleeding. Given concern for an isolated gastric varix (IGV-1), EUS-guidance was used to inject coils and N-butyl-2-cyanoacrylate into the gastric varices with adequate hemostasis. Follow-up imaging noted extensive portal and splenic vein embolization from the glue. The patient developed recurrent melena and an emergent TIPS placement with coronary vein coil embolization was performed. Recurrent gastrointestinal bleeding was again noted. CT angiography was obtained and revealed a splenic vein thrombus. The patient underwent a balloon-occluded antegrade transvenous obliteration with glue/coil embolization of a smaller vessel feeding the gastric varix. However, GI bleeding was again noted. A repeat endoscopy was subsequently performed with placement of three over the scope clips (OTSC) on the varix for successful hemostasis. DISCUSSION: Gastric varices are often associated with cirrhosis but can occur in patients with non-cirrhotic portal hypertension (i.e., splenic vein thrombosis). Cyanoacrylate glue injection is recommended for acute bleeding from IGV. A known complication of glue injection is the risk of embolization (approximately 1–2%). Endoscopic ultrasound guided coil deployment can act as a scaffold at the time of glue injection to reduce this risk. OTSC have been used successfully in esophageal variceal bleeding. We report the first successful use of OTSC for gastric varices which should be considered as salvage therapy.Figure 1.: Gastric varices with hemostasis after endoscopic ultrasound-guided coil and glue injection.Figure 2.: Portal vein embolization after endoscopic ultrasound-guided coil and N-butyl-2-cyanoacrylate injection.Figure 3.: Recurrent gastric variceal bleeding with hemostasis after successful over the scope clip deployment.

Quantitative CT Predictors of Portal Venous Intervention in Uncontrolled Variceal Bleeding

OBJECTIVE. The purpose of this study was to quantify abdominal CT predictors of endoscopically refractory, uncontrolled variceal hemorrhage requiring portal venous intervention. MATERIALS AND METHODS. From 2009 to 2018, 64 patients with endoscopically refractory variceal hemorrhage requiring portal venous intervention (variceal hemorrhage group) and 67 patients without hemorrhage but with symptomatic, pressure gradient-proven portal hypertension (control group) underwent CT. CT scans were retrospectively reviewed for the following: varix size, variceal intraluminal protrusion, liver and spleen volumes, and portal vein diameter. RESULTS. Gastric variceal protrusion was found to be a strong CT parameter associated with refractory hemorrhage (mean depth, 0.75 mm in variceal hemorrhage group vs -2.91 mm in control group; p = 0.001). Gastric varix size was also associated with variceal hemorrhage (mean diameter, 8.03 vs 6.51 mm; p = 0.001). However, this trend was not observed in the sizes of the esophageal varices (mean diameter, 6.28 vs 6.43 mm; p = 0.370). Larger spleen volume (mean, 1312 vs 1152 cm3; p = 0.029) and liver volume (mean, 1514 vs 1143 cm3; p = 0.004) were also found to be predictors of variceal hemorrhage. Significant CT threshold findings included gastric variceal protrusion depth more than 0 mm (odds ratio [OR], 6.44), gastric varix size more than 6 mm (OR, 3.89), spleen volume more than 1000 cm3 (OR, 2.63), and liver volume more than 1000 cm3 (OR, 2.82). CONCLUSION. Quantitative imaging parameters on abdominal CT, such as intraluminal protrusion of gastric varices, gastric varix size, and larger spleen and liver volumes, were predictive of portal venous intervention, whereas esophageal varix size was not.

The inferior mesoiliacal shunt: A novel shunt for refractory rectal variceal bleeding due to splanchnic thrombosis.

Surgical shunt therapy may be required when pharmacologic, endoscopic, and radiologic treatment of chronic splanchnic vein thrombosis have failed. In this case report, we present a new interposition shunt for the treatment of refractory rectal variceal bleeding: the inferior mesoiliacal shunt between the inferior mesenteric vein and the left common iliac vein using a cryopreserved iliac venous graft. The postoperative course was complicated by shunt thrombosis at day 2, probably owing to inadvertent interruption of anticoagulation and a decrease in the shunt flow rate. Surgical thrombectomy was performed successfully. The patient presented no relapse of rectal bleeding and was asymptomatic and well at the 12-month follow-up.

Angiomiolipoma hemorrágico espontáneo asociado a esclerosis tuberosa que conduce a nefrectomía urgente – Reporte de un caso y revisión de la literatura

Descripción: Acudió una mujer de 34 años a urgencias con dolor abdominal moderado en hipocondrio derecho (duración 3h), acompañado de hematuria y distensión abdominal progresiva y dolorosa. La tomografía reveló una tumoración sólida heterogénea de 14 cm, en riñón derecho, con hemorragia en su interior. Por datos de bajo gasto hemodinámico se transfundieron hemoderivados y mantuvo en vigilancia, persistiendo con descenso de hemoglobina hasta 7.2 gr/dl, por lo que se sometió a angioembolización selectiva urgente, tras lo cual remitió temporalmente el sangrado, recurriendo con hematuria y choque hipovolémico, que derivó en tratamiento quirúrgico definitivo mediante nefrectomía total. Su recuperación transcurrió sin incidentes. El examen histopatológico reveló un angiomiolipoma renal con hemorragia extensa.
 Relevancia: El síndrome de Wünderlich (Angiomiolipoma hemorrágico espontáneo) es una entidad rara cuya complicación más grave e indeseable es la hemorragia refractaria, que puede ser mortal.
 Implicaciones clínicas: Es importante la intervención temprana en pacientes con angiomiolipoma hemorrágico para prevenir potenciales complicaciones como hemorragia masiva y poner en riesgo la vida del paciente.
 Conclusiones: En caso de angiomiolipoma con hemorragia intratumoral y síntomas del síndrome de Wünderlich, la nefrectomía total resulta buena opción para preservar la vida del paciente, después del manejo conservador y/o angioembolización selectiva.

Thalidomide for refractory gastrointestinal bleeding from vascular malformations in patients with significant comorbidities.

BACKGROUNDRefractory gastrointestinal bleeding (GIB) secondary to gastrointestinal vascular malformations (GIVM) such as gastrointestinal angiodysplasia (GIAD) and gastric antral vascular ectasia (GAVE) remains challenging to treat when endoscopic therapy fails. Recently thalidomide has been suggested as a treatment option for refractory GIB.AIMTo determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.METHODSIRB approved, single center, retrospective review of electronic medical records from January 2012 to November 2018. Patients age > 18 years old, who had > 3 episodes of GIB refractory to medical or endoscopic therapy, and who had been treated with thalidomide for at least 3 mo were included. The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.RESULTSFifteen patients were included in the study, all with significant cardiac, hepatic, or renal comorbidities. The cause of GIB was GIAD in 10 patients and GAVE in 5 patients. Two patients were lost to follow up. Of the 13 patients followed, 38.5% (n = 5) had no recurrent GIB or transfusion requirement after treatment with thalidomide. Furthermore, 84.6% (n = 11) of patients had a reduction in transfusion requirements and hospitalizations for GIB. Thalidomide was discontinued in 2 patients due to cost (n = 1) and medication interaction (n = 1). Reported adverse reactions included fatigue (n = 3), neuropathy (n = 2), dizziness (n = 1), and constipation (n = 1). Six patients died during follow up due to unknown cause (n = 4) and sepsis (n = 2).CONCLUSIONThalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

Combination of meld and lactates predicts early death in patients treated by salvage tips for refractory variceal bleeding

Combination of meld and lactates predicts early death in patients treated by salvage tips for refractory variceal bleeding

Endoscopic ultrasound-guided injection of coils for the treatment of refractory post-ERCP bleeding

Endoscopic ultrasound-guided injection of coils for the treatment of refractory post-ERCP bleeding

Guidewire-assisted over-the-scope clip delivery method into the distal intestine: a case series

Background The Over-the-scope clip (OTSC) has been recently introduced for multiple purposes, including refractory bleeding, perforation, fistula, and anastomotic dehiscence of the gastrointestinal tract. However, no easy access techniques for delivering OTSCs to distant sites have been described. Therefore, we have developed a simple and safe guidewire-assisted OTSC delivery (GOD) method for use on the distal intestine. This study aimed to investigate the technical feasibility and safety of the method. Material and methods Between June 2018 and April 2019, all eight patients who underwent the GOD method were retrospectively examined. The primary outcome was the successful rate of OTSC delivery to the lesion without complications. The secondary outcomes were GOD procedure time, total procedure time, technical and clinical OTSC success rates, and GOD- and OTSC-associated complications. Results The rate of successful OTSC delivery was 100%. The median procedure time of GOD was 21 min (range 8–29). The median total procedure time was 38.5 min (range 26–41). The technical and clinical success rates of OTSC were 100% and 75% (6/8), respectively. No GOD- or OTSC-associated complications occurred. Conclusions The GOD method is a feasible and safe technique for delivering OTSC toward the small and proximal large intestine.

Every trick in the book: EUS angiotherapy for management of refractory bleeding secondary to a complicated duodenal ulcer in a patient with Roux-en-Y gastric bypass.

Every trick in the book: EUS angiotherapy for management of refractory bleeding secondary to a complicated duodenal ulcer in a patient with Roux-en-Y gastric bypass.

Endoscopic band ligation and over-the-scope clip placement for refractory bleeding of Dieulafoy ulcer in the jejunum.

Endoscopic band ligation and over-the-scope clip placement for refractory bleeding of Dieulafoy ulcer in the jejunum.

Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes.

The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.