Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review

Table 3 Summary of the pros and cons of new emerging endoscopic treatment modalities for non-variceal gastrointestinal bleeding

Emerging endoscopic treatment	Pros	Cons
Over the scope clips	1 Simple to use	1 Difficult to close hard, chronic, and severely fibrotic lesions with OTSC
	2 Special endoscopic skills are not required to implant the clip	2 Time consuming especially in the emergency situations (after identifying the bleeding source, the scope must be removed to mount OTSC system on the scope and reintroduce to deploy clips
	3 Effective for the ulcers larger than 2 cm in diameter, or with bleeding vessel > 2 mm
Endoscopic suturing	1 Technically more feasible and efficacious for larger, deep, and fibrotic ulcers	1 Double channel endoscope and expert endoscopic skills are required to operate endoscopic suturing device
Endoscopic band ligation (EVL)	1 Associated with the reduction of treatment sessions, control of bleeding and need for transfusion	Few cases of Hyperplastic gastric polyps
	2 EVL is safe, technically straightforward, and highly effective in this patient with complete eradication of GAVE
Coagrasper	1 One of the safest and most efficacious hemostasis modalities due to large surface area of the forceps and anti-slip jaw design provides mechanical tamponade effect to the surrounding tissue	1 Coagulation may be incomplete because of electrical leakage if the lesion submerged in water or lesion with large tissue volume or surface area
	2 The risk of perforation is extremely low because coagrasper works at a lower voltage as compared to other thermal treatments coagulates tissues without any carbonization and does not extend to deeper tissue	2 Because the devices used for soft coagulation, including disposable hemostatic forceps, are relatively expensive, the method may be appropriate only for centers that perform ESD frequently
	3 The forceps can be used to treat multiple bleeding sites proving to be cost-effective	3 Few cases of aspiration pneumonia reported
Radiofrequency ablation	1 Feasible and safe in ablating GAVE lesions	1 Endoscopic skills are required to perform RFA
	2 Able to deliver high energy captive coagulation of superficial mucosa including blood vessels	2 Exact apposition of the gastric antral mucosa with electrode is required to allow effective delivery of the electric energy which means the endoscope may have to be removed, the electrode rotated, and reintroduced multiple times The newer through-the-scope internally rotatable ablating catheter may sidestep this disadvantage but has smaller surface area
	3 Wider surface area coverage of mucosa owing to the various electrode sizes
	4 Contact technique with uniform zone of energy distribution and penetration such that deeper ectatic submucosal vascular channels are coagulated
Endoscopic ultrasound guided angiotherapy	1 EUS-guided therapy of nonvariceal bleeding has been shown to be feasible and safe for peptic ulcer disease, Dieulafoy's lesions, bleeding tumors, and pseudoaneurysms due to the ability to directly visualize and target the bleeding vessel with a specific therapy and subsequently confirm hemostasis with real-time Doppler ultrasound are significant advantages of EUS-guided therapy	1 Endoscopic skills are required to perform endoscopic ultrasound
		2 EUS guided angiotherapy more resource intensive than other routine hemostasis endoscopic procedures
Topical therapies, i.e., Hemospray and Endoclot	Easy to use, safe and effective Cost effective. Can be used for malignant GI hemorrhage	1 Theoretically possible side effects of Hemospray include embolization, intestinal obstruction, and allergic reaction to the powder
		2 If hemostasis fails, there is the disadvantage that the powder attached to the mucous membrane may limit the use of other hemostatic modalities
		3 Hemospray works only on active bleeding

EVL: Endoscopic band ligation; GAVE: Gastric antral vascular ectasia; EUS: Endoscopic ultrasound; GI: Gastrointestinal; RFA: Radiofrequency ablation; ESD: Endoscopic submucosal dissection; OTSC: Over-The-Scope Clip.