Endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding - Strategies in difficult cases

Endoscopic hemoclipping using short clips is the first choice of therapy for nonvariceal upper gastrointestinal bleeding in our department. In cases where lesions exhibit massive bleeding, or bleeding from large visible vessels, or in cases where hemostasis by hemoclipping proves insufficient, combination therapy including endoscopic injection of hypertonic saline with epinephrine or diluted epinephrine is performed. A transparent hood is useful for lesions that are difficult to keep a good view or tangent lesions in which hemostasis is difficult. An endoscope with a water jet is also useful for the detection of bleeding points, thus enabling rapid hemostasis. Although the development of endoscopic procedures and instruments enables us to achieve endoscopic hemostasis in the majority of cases with peptic ulcer bleeding, there are a few difficult cases such as those of bleeding from larger arteries present in deep ulcers. When endoscopic hemostasis fails, endoscopists should closely coordinate with radiologists and surgeons from an early stage, and interventional radiology or surgery should be performed without any delay.