Devices For Endoscopic Hemostasis of Nonvariceal GI Bleeding (With Videos)

TECHNOLOGY ASSESSMENT
Devices for endoscopic hemostasis of nonvariceal GI bleeding

(with videos)
Prepared by: ASGE TECHNOLOGY COMMITTEE
Mansour A. Parsi, MD, MPH, FASGE,1 Allison R. Schulman, MD, MPH,2 Harry R. Aslanian, MD, FASGE,3
Manoop S. Bhutani, MD, FASGE,4 Kuman Krishnan, MD,5 David R. Lichtenstein, MD, FASGE,6
Joshua Melson, MD, FASGE,7 Udayakumar Navaneethan, MD,8 Rahul Pannala, MD, MPH, FASGE,9
Amrita Sethi, MD, FASGE,10 Guru Trikudanathan, MD,11 Arvind J. Trindade, MD,12
Rabindra R. Watson, MD,13 John T. Maple, DO, FASGE,14 ASGE Technology Committee Chair
This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal
Endoscopy (ASGE).
Background: Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although
some of the devices and techniques used for this purpose have been well studied, others are relatively new,
with few available outcomes data.
Methods: In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI
bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use.
Results: Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles),
thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofre-
quency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and
topical devices (hemostatic sprays).
Conclusions: Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal
upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract.
Other than injection therapy, which should not be used as monotherapy, there are few compelling data that
strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend
on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the
device. (VideoGIE 2019;4:285-99.)
INTRODUCTION for Devices and Radiological Health) database search to

identify the reported adverse events of a given technology.
The American Society for Gastrointestinal Endoscopy Both are supplemented by accessing the “related articles”
(ASGE) Technology Committee provides reviews of exist- feature of PubMed and by scrutinizing pertinent references
ing, new, or emerging endoscopic technologies that have cited by the identified studies. Controlled clinical trials are
an impact on the practice of GI endoscopy. Evidence- emphasized, but in many cases, data from randomized
based methodology is used, with a MEDLINE literature controlled trials (RCTs) are lacking. In such cases, large
search to identify pertinent clinical studies on the topic case series, preliminary clinical studies, and expert opin-
and a MAUDE (U.S. Food and Drug Administration Center ions are used. Technical data are gathered from traditional
and Web-based publications, proprietary publications, and
informal communications with pertinent vendors. Technol-
Copyright ª 2019 by the American Society for Gastrointestinal Endoscopy. ogy Status Evaluation Reports are drafted by 1 or 2 mem-
Published by Elsevier, Inc. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
bers of the ASGE Technology Committee, reviewed and
edited by the committee as a whole, and approved by
https://doi.org/10.1016/j.vgie.2019.02.004 the Governing Board of the ASGE. When financial
www.VideoGIE.org Volume 4, No. 7 : 2019 GASTROINTESTINAL ENDOSCOPY 285
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Devices for endoscopic hemostasis
guidance is indicated, the most recent coding data and list vasoconstriction, and indirect activation of the coagulation
prices at the time of publication are provided. For this re- cascade.3 Tissue coagulation by heat requires a
view, the MEDLINE database was searched through temperature of approximately 70 C.3 Thermal devices
September 2017 for articles related to endoscopic hemo- used for endoscopic hemostasis in the GI tract have
stasis devices by using relevant keywords such as “gastroin- traditionally been divided into contact (bipolar/multipolar
testinal bleeding,” “GI bleeding,” “nonvariceal bleeding,” electrocautery, heater probe, and hemostatic forceps)
“endoscopic hemostasis,” and “endoscopic treatment,” and noncontact devices (argon plasma coagulation)
among others. Technology Status Evaluation Reports are (Tables 2 and 3).
scientific reviews provided solely for educational and infor- Bipolar/multipolar electrocoagulation probes.
mational purposes. Technology Status Evaluation Reports Hemostasis using electric current passing through a probe
are not rules and should not be construed as establishing to generate heat can be performed using either a monop-
a legal standard of care or as encouraging, advocating, olar or a multipolar electrocoagulation (MPEC) device.4
requiring, or discouraging any particular treatment or pay- With monopolar devices, the current passes through the
ment for such treatment. patient and back to the unit via a return pad, whereas
with MPEC devices, the electric current is confined to
the tissue between the electrodes within the instrument
BACKGROUND
tip, obviating the need for a return pad.4,5
The MPEC probe can be used tangentially to, or perpen-
Endoscopic intervention is often the first line of therapy
dicularly to, the bleeding source. Pressure is applied to
for upper- and lower-GI nonvariceal bleeding. Devices
compress and seal the walls of the bleeding vessel (“coap-
used for endoscopic hemostasis in the GI tract can be clas-
tive coagulation”).6 MPEC probes are available in 7F and
sified into injection devices (needles), thermal devices
10F diameters with an irrigation port at the tip; the 10F
(multipolar/bipolar probes, hemostatic forceps, heater
probe requires the use of an endoscope with a 3.2 mm
probe, argon plasma coagulation, radiofrequency ablation
diameter instrument channel. Probe size, wattage,
and cryotherapy), mechanical devices (clips, suturing de-
contact pressure and duration, and number of
vices, banding devices, stents), and topical devices (hemo-
applications will vary depending on the lesion being
static sprays). This document describes technologies used
treated.
for endoscopic hemostasis. Cryotherapy and radiofre-
Heater probe. The heater probe comprises a PTFE–
quency ablation were described in detail in separate recent
coated hollow aluminum cylinder with an inner heating
ASGE Technology assessments and are not reviewed in this
coil and an irrigation port at the tip of a 230- to 300-cm
document.1,2
7F to 10F catheter.3 The probes are reusable and are
compatible with the HPU-20 (Olympus America, Center
TECHNOLOGY UNDER REVIEW Valley, Pa, USA) power source. The probe transfers heat
from its end or sides, causing tissue coagulation. The
Injection needles PTFE coating reduces adherence of the probe to tissue.7
Injection needles consist of an outer sheath made of The probe is placed directly at the site of the bleeding
plastic, polytetrafluoroethylene (PTFE, Teflon), or stainless vessel, either perpendicularly or tangentially, with
steel, an inner hollow-core needle (19-25 gauge), and a pressure applied for coaptive coagulation. A foot pedal
handle. The handle is used to manipulate the needle in controls heat activation and irrigation. Once the pulse
or out of the outer sheath. The handle includes a Luer has been initiated, the duration of activation is
lock connector for a syringe attachment. The needle is predetermined and will deliver the entire amount of
kept within the sheath for safe advancement through the preselected energy.3 A power setting of 25 J to 30 J per
working channel of the endoscope. When the target is pulse, using 4 to 5 pulses (total of 100-150 J) per station
reached, the outer sheath is advanced beyond the endo- (before the probe position is changed) has been
scope tip, and the needle is extended to a preset distance. recommended for peptic ulcer bleeding.7 Of note, sales
A syringe is then attached to the handle to inject liquid of the HPU-20 in the United States were discontinued in
agents into the target tissue.3 Injection of various 2011, and the manufacturer has communicated its inten-
solutions achieves hemostasis by mechanical tamponade tion to discontinue sales of the compatible probes in
and/or cytochemical mechanisms. Injection needles of 2019 (personal communication).
various lengths and diameters have been developed for Hemostatic forceps. Hemostatic forceps are devices
endoscopic hemostasis in the GI tract (Table 1). that were developed initially for treatment and prevention
of bleeding during endoscopic resection (Fig. 1). The
Thermal devices bleeding tissue is grasped within the jaws of the forceps,
Endoscopic hemostasis can be achieved by the applica- and electrocoagulation is used to coagulate the bleeding
tion of heat or cold at the site of bleeding. Heat causes he- source; retraction of the tissue will limit the depth of
mostasis by inducing edema, protein coagulation, coagulation injury. Hemostatic forceps are available from
286 GASTROINTESTINAL ENDOSCOPY Volume 4, No. 7 : 2019 www.VideoGIE.org
TABLE 1. Injection needles
Sheath Sheath Needle

diameter length Needle length Special
Manufacturer Device name (French) (cm) gauge (mm) List price features
Boston Scientific (Natick, Inject sclerotherapy needle 7 200, 240 23, 25 4, 6 $70 each
Mass, USA)
Medtronic Endoscopic Click-tip injection needle 7 180, 230 19, 4, 6 $743.88/
Technologies box of 10
(Chelmsford, 180, 230 22, 25 4, 6 $704.64/
Mass, USA) box of 10
FlexiTip disposable 7 160, 230 25 4, 5, 6 $294.6/
sclerotherapy needle - standard box of 5
FlexiTip disposable sclerotherapy 7 160, 230 25 4, 5, 6 $362.5/ Visible in
needle - optic yellow tip box of 5 bloody field
Cook Medical AcuJect variable 7 220 23, 25 Variable $51 each
(Winston-Salem, injection needle
NC, USA) Disposable varices 7 200-320 23, 25 Variable $62-86 each
injector 7 220 23, 25 Variable $61 each Flush port
Halyard Health Injection needle 7 160, 200, 240 23, 25 4, 6 $318.94/
(Roswell, Ga, USA) catheter box of 10
Olympus America (Center Injector Force Max 7 165-230 21, 23, 25 4, 5, 6, 8 $433.50 (21G)/
Valley, Pa, USA) injection needle box of 5
US Endoscopy (Mentor, Articulator Injection needle 7 160, 230, 350 25 4, 5 $53/box of 5
Ohio, USA) Carr-Locke injection needle 7 230 25 5 $63/box of 5
iSnare 10 230 23, 25 5 $139/box of 5 2.5- 4-cm
integrated snare
multiple manufacturers: Olympus Coagrasper, Fujifilm Variables of system setup include power (watts), gas-
Clutch Cutter (Fujifilm Medical Systems USA, Inc, flow rate, and mode of energy delivery.4 Increased power
Stamford, Conn, USA), Sumitomo Bakelite SB Knife results in more rapid devitalization of tissue and deeper
(Sumitomo Bakelite Co, Ltd, Tokyo, Japan) and vary in penetration. Gas flow should be set at the lowest
features including jaw shape, opening width, rotatability, possible rate for desired tissue effect to reduce the risk
and working length. Use of electrosurgical current of gas embolization and argon-related pneumoperito-
waveforms in which the peak voltage is held below 200 neum.4 The mode of current delivery can be set to either
volts, such as Soft Coag mode with the Erbe Vio 300 unit forced or pulsed. Forced mode entails continuous
(Erbe USA, Inc, Marietta, Ga, USA) or TouchSoft mode delivery of energy, resulting in more rapid tissue
with the gi4000 unit (US Endoscopy, Mentor, Ohio, USA) devitalization and hemostasis. By contrast, pulsed mode
has been described when using hemostatic forceps.8-10 He- sends intermittent bursts of energy to the tissue,
mostatic forceps that have been cleared by the U.S. Food resulting in a more superficial effect.4 APC is particularly
and Drug Administration (FDA) are monopolar devices; bi- well suited for superficial treatments because the
polar devices have been developed but are not currently penetration depth of the coagulation is limited to only a
available in the United States.11,12 few millimeters.13 APC probes are available in a variety of
Argon plasma coagulation. Argon plasma coagula- lengths and diameters with forward, side, or
tion (APC) is a noncontact thermal method of hemostasis. circumferential ports allowing forward, tangential, or
An APC delivery system consists of an argon gas cylinder, a circumferential applications, respectively.3
computer-controlled, high-frequency electrosurgical
generator with a gas flow-controlling valve, and an endo-
scopic probe.4 Inert argon gas is converted to ionized Mechanical devices
argon gas (plasma) by a monopolar electrode at the tip Clips. Clips are metallic devices that effect hemostasis
of the probe. The probe tip is placed close to the by mechanical approximation of tissue and subsequent
bleeding lesion, with the optimal distance ranging from 2 tamponade. Two broad categories of clips are currently
to 8 mm.3 High-frequency monopolar current is then con- available for endoscopic hemostasis in the GI tract:
ducted through the gas, resulting in tissue coagulation. through-the-scope (TTS) clips and cap-mounted clips.
TABLE 2. Contact thermal devices
Sheath Sheath
diameter length
Manufacturer Device name (French) (cm) List price Special features
Multipolar electrocautery probes

Boston Scientific (Natick, Mass, USA) Gold probe 7, 10 300, 350 $359
Injector gold probe 7, 10 210 $519 Integrated 25-gauge
injection needle
Medtronic Endoscopic Technologies Bicap superconductor, 5, 7, 10 200, 300, 350 $396.48
(Chelmsford, Mass, USA) multielectrode bipolar 7. 10 300 $240
probe
Cook Medical (Winston-Salem, Quicksilver bipolar 7, 10 350 $328
NC, USA) probe
Olympus America (Center Valley, BiCOAG bipolar 7, 10 350 $370.30 Bipolar coagulation provides
Pa, USA) probe 7, 10 350 coagulation at any angle
US Endoscopy (Mentor, Bipolar hemostasis 7, 10 350 $300

Ohio, USA) probe
Heater probes
Olympus America (Center Valley, HeatProbe 7, 10 230, 300 $812 Reusable
Pa, USA)
Hemostatic grasper
Olympus America (Center Valley, Coagrasper (upper/gastric) 7 165 $278 Opening width 5 or
Pa, USA) 6.5 mm
Rotatable
Coagrasper (lower) 7 230 $320 Opening width
4 mm
Rotatable
SB Knife (Jr, Short, Standard) 7 230, 195, 180 $1695 JR: opening width
4.5 mm; scissor-like jaw
Short: opening width
6 mm, angled tip design
Standard: opening width
8 mm, angled tip design
Rotatable
Fujifilm Medical Systems ClutchCutter 7 180 $670 Serrated, rotatable jaws
(Wayne, NJ, USA)
TABLE 3. Noncontact thermal devices
Sheath Sheath
diameter length
Manufacturer Device name (French) (cm) Fire direction List price Special features
Canady (Hampton, Va, USA) Canady plasma 5, 7 230, 340 Straight, side $1650/box of 10
GI probe $165/probe
Medtronic Endoscopic Technologies Beamer argon 5, 7, 10 160, 230, 320 Straight, fire $3202.80/box of 10
(Chelmsford, Mass, USA) probe
Beamer argon 7 160, 230 Straight, fire $2241.60/box of 5 Combination APC
snare probe probe and snare
ERBE USA, Inc. (Marietta, Ga, USA) APC probe 5, 7, 10 150, 220, 300 Straight, side, $2139.50 to
circumferential 2459.50/box of 10*
FiAPC probe 5, 7, 10 150, 220, 300 Straight, side, $2139.50 to Integrated filter
circumferential 2459.50/box of 10y
*Endoscopy size.
yEndoscope cap depth.
Figure 1. Colonic (left) and gastric (right) Coagrasper hemostatic forceps. (Image used with permission from Gastrointest Endosc 2015;81:1311-25.)
TTS clips were specifically developed for endoscopic he- a (atraumatic), type t (traumatic), and type gc (gastric fis-
mostasis in the GI tract and have been in use for many tula closure).14 The type a clip is marketed for
years (Video 1, available online at www.VideoGIE.org). hemostasis applications. The clips are available in 3 sizes,
They are composed of 3 main components: a metallic with the variation corresponding to different diameters of
double-pronged clip, a delivery catheter, and a handle the application cap, which is necessary for compatibility
used to operate and deploy the clip.3 The orientation of with a range of endoscope outer diameters (8.5 mm to
some clips can be adjusted by rotating the handle itself 14.5 mm). Two proprietary devices are available to
or a component of the handle. Some clips can be further retract tissue into the cap if needed: a dual-arm for-
reopened after initial closure before deployment. TTS ceps (“OTSC Twin Grasper”) and a tissue anchoring tripod
clips of various sizes and lengths are commercially (“OTSC Anchor”).16
available (Table 4). The Padlock system consists of an application cap with a
Cap-mounted clips were developed for endoscopic preloaded nitinol clip that is mounted onto the distal tip of
closure of GI perforations and fistulae, but they also have util- an endoscope and is attached to a releasing mechanism
ity in hemostasis. Compared with TTS clips, cap-mounted installed on the handle of the scope by a linking cable.
clips are able to compress a larger amount of tissue.14 As opposed to the OTSC system, the linking cable runs
Currently, 2 cap-mounted clip systems are commercially outside the scope, not within the instrument channel.15
available; the over-the-scope clip system (OTSC, Ovesco This design theoretically may allow for more efficient
Endoscopy AG, Tübingen, Germany) and the Padlock system suction of tissue into the cap.15 The Padlock system is
(US Endoscopy) (Fig. 2). Both systems are cleared by the available in 2 options: “Padlock Clip” for endoscopes
FDA for hemostatic indications.15 between 9.5 mm and 11 mm in outer diameter, and
The OTSC system comprises an application cap with a “Padlock Clip Pro-Select” for endoscopes between
preloaded nitinol clip that is mounted onto the distal tip 11.5 mm and 14 mm in outer diameter.17
of an endoscope. The mounted clip is attached to a Endoscopic suturing devices. An endoscopic sutur-
rotating wheel installed on the handle of the scope by a ing device (OverStitch, Apollo Endosurgery, Austin, Tex,
string that runs through the instrument channel of the USA) is currently available for clinical use. The primary ap-
endoscope. Rotating the wheel on the handle releases plications of this device are perforation closure and bariat-
the clip from the cap. The setup and deployment of these ric treatment.15 It is FDA cleared for soft tissue
clips is similar to band ligators used to treat esophageal approximation.15 Use of this device for attaining
varices. Three variants of the clip are available, with hemostasis in bleeding gastric and anastomotic ulcers has
differing configurations of the tissue-grasping teeth: type been described.18,19
TABLE 4. Mechanical hemostatic devices
Sheath Sheath
diameter length Jaw opening
Manufacturer Device name (French) (cm) width (mm) List price Special features
Boston Scientific Resolution Clip 7 155, 235 11 $330/each Open/close jaw
(Natick, Mass, USA) up to 5 times
MR conditional up
to 3 Tesla
Resolution 360 Clip 7 155, 235 11 $370/each Open/close jaw
up to 5 times
MR conditional
up to 3 Tesla
Controlled rotation in
tortuous anatomy
Can be rotated by
technician or endoscopist
Olympus America QuickClip2 7 165, 230 9 $713/box of 5
(Center Valley, Pa, USA) QuickClip2 long 7 165, 230 11 $2726/box of 20
QuickClip Pro 7 165, 230 11 $3714/box of 10 Precise rotation

MR conditional
up to 3 Tesla
Cook Medical (Winston- Instinct 7 207 16 $2621/box of 10 Open/close jaw
Salem, NC, USA) up to 5 times
MR conditional
up to 3 Tesla
ConMed (Utica, NY, USA) Dura Clip 7 165, 235 11 $3000/box of 10 Shorter clip design,
closer proximity to
tissue defect
Unlimited open/close
before deployment
MR conditional
up to 3 Tesla
Micro-Tech Endoscopy SureClip 7 165, 235 11 $1250/box of 10 Shorter clip design
USA (Ann Arbor, SureClip plus 7 235 16 Unlimited open/close
Mich, USA) before deployment
MR conditional
up to 3 Tesla
Ovesco Endoscopy USA Over-the-scope- 8.5 to 11 mm* 165 3, 6y $438 Blunt or pointed teeth
Inc (Carey, NC, USA) clip (OTSC) 10.5 to 12 mm* 165, 220 3, 6y $543 (3 mm) Blunt or pointed teeth
$589 (6 mm) Blunt or pointed teeth
11.5 to 14 mm* 220 3, 6y $610

US endoscopy (Mentor, Padlock Clip 9.5 to 11 mm* 165 10z $599
Ohio, USA) Padlock Clip 11.5 to 14 mm* 165 4 to 14z $599
Pro-Select
*Endoscopy size.
yEndoscope cap depth.
zTissue chamber depth.
The OverStitch device requires a double-channel endo- but it also has utility in the treatment of nonvariceal
scope (compatible only with Olympus scopes GIF-2T160 bleeding.23 Endoscopic banding devices consist of a
or GIF-2T180; Olympus Corporation, Tokyo, Japan) and transparent cap, a connecting wire or string, and a
consists of a suture anchor with a detachable needle tip handle. The cap is mounted on the distal end of the
carrying absorbable (2-0 or 3-0 polydioxanone) or nonab- endoscope and carries 4 to 10 preloaded bands.24 The
sorbable (2-0 or 3-0 polypropylene) sutures.15,20,21 This de- cap is connected to the handle by a connecting wire or
vice is described in detail in an ASGE technology string that runs through the instrument channel of the
assessment titled Endoscopic Closure Devices.22 endoscope. Once the bleeding lesion is suctioned into
Banding Devices. Endoscopic band ligation (EBL) is a the cap, rotation of the handle pulls the connecting wire,
well-established therapy for bleeding esophageal varices, leading to deployment of a band.25 Placement of a band
has historically been used as a hemostatic agent in Turkish

traditional medicine.32 It is in liquid form and is delivered
to the site of bleeding by a catheter, which is advanced
through the instrument channel of an endoscope.32
Various catheters can be used for this purpose. The
mechanism of action is not well understood, but it may
involve formation of an encapsulated protein mesh that
acts as an anchor for rapid erythrocyte aggregation.31,33,34
It may also influence angiogenesis and cellular
Figure 2. Over-the-scope (left) and Padlock (right) clips in deployed
proliferation.31
configuration. (Image used with permission form Gastrointest Endosc
2017;85:1087-92.) EndoClot
EndoClot (EndoClot Plus Inc, Santa Clara, Calif, USA) is an
absorbable hemostatic polysaccharide powder derived from
at the base of the bleeding tissue causes mechanical
plant starch.35 It is delivered to the site of bleeding with an
compression that leads to hemostasis and subsequent
applicator system, which includes a delivery catheter and a
thrombosis, necrosis, and sloughing.23
specially designed powder/air mixing chamber that is
Covered self-expandable metallic stents. Covered
connected to the powder container and an air compressor.
self-expandable metallic stents (CSEMSs) have been used for
The delivery catheter is inserted into the instrument
the treatment of biliary and esophageal strictures for many
channel of the endoscope and positioned toward the
years.26 The use of CSEMSs as a salvage technique for hemo-
bleeding lesion. Pressure from the air compressor propels
stasis has been described.15 CSEMSs induce hemostasis by
the powder through the catheter directly onto the
mechanical tamponade of the bleeding vessel/lesion.
bleeding area.36 The mechanism of action is thought to
relate to formation of a gelled matrix that adheres to and
Topical hemostatic agents seals the bleeding tissue, along with absorption of water
Topical hemostatic agents are sprayed on the bleeding from the blood, causing an increased concentration of
site to achieve hemostasis. Three different topical hemo- platelets, red blood cells, and coagulation proteins at the
static agents are commercially available, but only Hemos- bleeding site, with subsequent acceleration of the
pray (also known as TC-325; Cook Medical, Winston- physiologic clotting cascade.35
Salem, NC, USA) is currently FDA cleared for use in the
United States. Endoscopic Doppler probe
Hemospray. Hemospray is an inorganic hemostatic Endoscopic Doppler probe (EDP) does not directly pro-
powder that was used by the military for bleeding control vide hemostasis, but it may assist the endoscopist in assess-
before its introduction as an endoscopic hemostatic agent ing the success or failure of endoscopic therapy.37 It may
for use in the GI tract.15,27 The Hemospray system consists also guide treatment and help predict the risk of
of a cartridge with an integrated handle connected to a de- recurrent bleeding.38 EDP systems consist of a control
livery catheter. The handle houses the hemostatic powder, unit and a through-the-scope probe.39 Two EDP systems
a CO2 cartridge, a knob to activate the CO2 cartridge, a are currently available for use in GI endoscopy: VTI
valve to control the flow of the powder, and a trigger but- Endoscopic Doppler system (Vascular Technology Inc,
ton. The powder is sprayed toward the source of bleeding Lowell, Mass, USA), and the Endo-DOP system (DWL
through a 7F or 10F dedicated catheter, which is advanced GmbH, Singen, Germany).15 The VTI system uses a
through the instrument channel of the endoscope.28 The disposable 20-MHz probe with a diameter of 1.5 mm and
CO2 cartridge in the handle of the device is activated by lengths of 209 cm or 335 cm.40 The Endo-Dop system
turning the activation knob. After a valve on the device is uses a reusable 16-MHz probe with a diameter of 1.8 mm
opened, the trigger button allows the pressure generated and a length of 250 cm.41
from the CO2 cartridge to propel the powder through The probe is advanced through the instrument channel
the catheter and onto the desired surface.29 Hemospray of the endoscope and applied to the bleeding site with
is thought to cause hemostasis by sealing injured blood light-to-moderate pressure at multiple points, including
vessels and activating platelets and the intrinsic those immediately adjacent to any stigmata of bleeding.39
coagulation pathway.28,30,31 Use of the Hemospray device The auditory Doppler signal helps identify the presence
is demonstrated in Video 2 (available online at www. and course of bleeding vessels, which may not be visible.
VideoGIE.org). Disappearance of the Doppler signal after treatment
indicates successful treatment of the bleeding lesion.
Ankaferd blood stopper Bleeding lesions that remain Doppler positive after
Ankaferd blood stopper (ABS) (Ankaferd Health Prod- treatment may be at increased risk of recurrent
ucts Ltd, Istanbul, Turkey) is a medical plant extract that hemorrhage.39,42
EUS-guided hemostasis recurrent bleeding, length of hospital stay, units of blood

EUS-guided hemostasis is an emerging modality for con- transfused, surgery rates, and mortality were not different
trol of bleeding lesions that are not readily accessible or are between the 2 groups.51
refractory to standard endoscopic or interventional radio- In the lower-GI tract, a randomized study of 30 patients
logic techniques.43 In those settings, EUS has been used with bleeding radiation proctopathy compared the effec-
to inject various substances, deliver embolization coils, or tiveness of MPEC (n Z 15) with APC (n Z 15).52
mark the location of the bleeding vessel.44 Most studies Although both modalities were equally effective for
assessing EUS for bleeding control in the GI tract involve treatment of the bleeding, the overall adverse event rate
gastric variceal bleeding.15,44 Studies assessing the utility including stenosis and pain was higher in the MPEC
of EUS for nonvariceal bleeding control are limited to small group.52
case series and case reports. Heater probe. Two RCTs have compared treatment
with heater probe to clip placement for nonvariceal
UGIB, with somewhat conflicting results.53,54 In 1 study,
OUTCOMES DATA 113 patients were randomly assigned to receive treatment
with either heater probe (n Z 57) or clip (n Z 56) appli-
Injection therapy cation.53 Initial hemostasis, 30-day mortality, and
Diluted epinephrine is the most commonly studied in- emergency surgery rates were similar for both groups.
jectate for endoscopic treatment of nonvariceal GI However, recurrent bleeding was significantly higher in
bleeding.45 Epinephrine injection therapy promotes the heater probe group (21% vs 1.8%; P < .05). Length
initial hemostasis, but this effect attenuates over time, of hospital stay and transfusion requirements were
with subsequent risk of recurrent bleeding.46 In a meta- significantly lower in the clip group.53 In the other RCT,
analysis of 19 RCTs in which epinephrine alone was 80 patients with peptic ulcer bleeding were randomized
compared with combination therapy for control of to treatment with either heater probe (n Z 40) or clip
upper-GI bleeding (11 studies used a second injected placement (n Z 40).54 The rate of initial hemostasis was
agent, 5 used clips, and 3 used a thermal method), the significantly higher in the heater probe group than in the
risk of recurrent bleeding was significantly lower in the clip group (100% vs 85%; P Z .01), whereas recurrent
combination therapy groups than in the epinephrine- bleeding rates were similar between the 2 groups.54
alone group, regardless of which second modality was In a study of 93 patients with peptic ulcer bleeding, par-
applied (relative risk 0.53, 95% confidence interval 0.35 ticipants were randomized to receive either endoscopic
to 0.81).47 Another meta-analysis of 16 studies reported clip placement (n Z 46) or heater probe thermocoagula-
similar findings.48 tion plus epinephrine injection (n Z 47).55 Five patients
In contrast to upper-GI bleeding (UGIB), randomized were excluded because of clip placement failure. Initial
comparative studies and meta-analyses evaluating injection hemostasis and recurrent bleeding rates were similar in
therapy in acute lower-GI bleeding (LGIB) are lacking.45 both groups.55 A meta-analysis of 15 RCTs (n Z 1156)
However, although data are limited, guidelines have found thermocoagulation with MPEC or heater probe to
discouraged epinephrine monotherapy in LGIB.45 be equally effective as clip placement for treatment of non-
Although epinephrine injection can be used to gain variceal UGIB.56
initial control of active bleeding and improve visualization Hemostatic forceps. In a retrospective study of 39 pa-
in nonvariceal upper- and lower-GI bleeding, it should be tients with peptic ulcer bleeding (29 gastric, 10 duodenal),
combined with another method to decrease the risk of initial hemostasis was achieved in 37 patients (95%) by use
recurrent bleeding.45,49 of a monopolar hemostatic forceps. Recurrent bleeding
requiring treatment occurred in 2 patients.11 In a
Thermal therapy prospective nonrandomized study, 50 patients with
Multipolar electrocoagulation probe. In an RCT, nonvariceal UGIB underwent treatment by a bipolar
patients with peptic ulcer bleeding were assigned to hemostatic forceps (27 patients) or clip placement (23
epinephrine injection followed by MPEC (n Z 58) or patients). Hemostasis was achieved in all patients who
MPEC alone (n Z 56).50 The rate of initial hemostasis underwent hemostatic forceps treatment, compared with
was significantly higher and the required units of blood 78% (18 of 23) of patients treated with clip placement
significantly lower in the combination therapy group.50 (P < .05).12 In a prospective noninferiority study,
There was no significant difference between the 2 patients with peptic ulcer bleeding were randomized to
treatment groups with respect to recurrent bleeding, receive either epinephrine injection plus APC (n Z 75)
need for surgical intervention, or length of hospital stay. or epinephrine injection plus soft coagulation with
In another RCT, patients with UGIB were randomized to monopolar hemostatic forceps (n Z 76).57 Hemostasis
combination therapy with epinephrine injection and was achieved in 96% of patients in both groups, and
MPEC (n Z 21), or monotherapy with clip placement there was no difference in the rate of recurrent bleeding
(n Z 26).51 Successful initial hemostasis, rate of at 30 days.57
Argon plasma coagulation. A meta-analysis of 2 RCTs patients with high-risk bleeding ulcers treated endoscopi-
(n Z 121) comparing monotherapy with either APC or other cally, no combination of treatments was superior to me-
endoscopic hemostatic interventions (heater probe, injection chanical therapy with hemostatic clips alone.76 Another
sclerotherapy) for treatment of peptic ulcer bleeding found meta-analysis of 15 RCTs (n Z 1156) suggested that suc-
no significant outcomes differences between the treatment cessful application of clips is superior to injection
modalities.58 In an RCT of 116 patients with peptic ulcer therapy but comparable with thermocoagulation in pro-
bleeding, patients were randomized to combined therapy ducing definitive hemostasis in patients with nonvariceal
with distilled water injection plus APC (n Z 58) or distilled UGIB.56
water injection alone (n Z 58).59 Although initial Although no randomized studies have assessed the use
hemostasis rates were similar (97% vs 95%), the recurrent of TTS clips in LGIB, case series and reports have sug-
bleeding rate was significantly lower in the combination gested the effectiveness of clips for this purpose.45,77 For
therapy group (3.6% vs 16%, P Z .03).59 diverticular bleeding, endoscopic clips have been recom-
Three RCTs of comparable size (n Z 151 to n Z 185) mended to reduce the theoretic risk of transmural colonic
have evaluated the effectiveness of APC plus epinephrine injury associated with contact thermal therapy.77 An RCT
versus other modalities (heater probe, clip, hemostatic for- (n Z 1499) did not find prophylactic clipping to affect
ceps) plus epinephrine for treatment of peptic ulcer the rate of postpolypectomy bleeding for polyps <2 cm
bleeding.57,60,61 In all 3 trials, there were no significant dif- in diameter.78 A recent meta-analysis confirmed these re-
ferences between the 2 groups in terms of initial hemosta- sults and suggested that the use of prophylactic clip place-
sis (>95% in all treatment arms), recurrent bleeding, or ment after polypectomy should not be a routine practice.79
other relevant clinical outcomes. However, prophylactic clip placement in certain high-risk
Serial APC treatments in patients with bleeding gastric patients (eg, requiring anticoagulation, large and/or right-
antral vascular ectasia (GAVE) have been associated with sided lesions) may be beneficial, and this decision should
reduced transfusion requirements and improved hemoglo- be individualized.80
bin levels.62-64 In an RCT of 88 cirrhotic patients with Cap-mounted clips. In a retrospective study of 93 pa-
GAVE, participants were randomized to endoscopic treat- tients with 100 episodes of severe upper- (n Z 69) and
ment with either EBL (n Z 44) or APC (n Z 44).65 The lower- (n Z 31) GI bleeding treated with the OTSC system,
number of sessions required for complete obliteration of immediate hemostasis and absence of in-hospital recurrent
the lesions was lower with EBL therapy (2.98 sessions vs bleeding were achieved in 88 of 100 (88%) and 78 of 100
3.48 sessions; P < .05). The EBL group also required (78%) patients, respectively.81 Other smaller studies have
significantly fewer blood transfusions. There were no shown similar results.82-85 Successful use of the Padlock
significant differences in adverse event rates between the system to achieve hemostasis has been reported in 2
2 groups.65 APC has shown effectiveness for treatment of case series totaling 5 patients (1 bleeding rectal ulcer, 3
other types of UGIB including angioectasias, Dieulafoy postpolypectomy bleeds, and 1 duodenal Dieulafoy
lesions, portal hypertensive gastropathy, and tumor lesion).86,87
bleeding in small case series.66-69 In a Korean retrospective Endoscopic suturing. Outcomes data on the use of
series of 66 patients with obscure GI bleeding who under- the Overstitch device for hemostasis in the GI tract are
went balloon enteroscopy and were found to have small- limited to a small case series of 3 patients with gastric ulcer
bowel angioectasias, 45 patients underwent endoscopic bleeding and a case report of bleeding anastomotic ulcer
treatment (APC in 87%), and 21 did not receive any endo- after gastric bypass surgery.18,19 In all patients, bleeding
scopic treatment.70 During a mean follow-up time of 24.5 was controlled with the suturing device.
months, the recurrent bleeding rates in the endoscopic- Banding devices. In a study of 88 cirrhotic patients
treatment arm and no-treatment arm were 15.6% and with GAVE who were randomized to EBL or APC, the num-
38.2% (P Z .059). ber of sessions required for complete obliteration of the le-
Multiple small studies and case series have reported a sions and the number of required blood transfusions were
reduction in rectal bleeding and transfusion requirements significantly lower with EBL therapy.65 In a retrospective
and improvement in hemoglobin levels after serial treat- analysis of a prospectively maintained endoscopic
ments with APC for radiation proctopathy.71-74 One RCT database, outcomes from 24 patients with bleeding
(n Z 30) found APC to be equally effective as MPEC, duodenal Dieulafoy lesions were evaluated.88 After
with fewer adverse events for control of rectal bleeding treatment with EBL (n Z 11) or endoscopic clip
associated with radiation proctopathy.52 APC has also placement (n Z 13), primary hemostasis was achieved in
been reported to be an effective treatment for bleeding all patients. Recurrent bleeding was observed in 1 patient
colonic angioectasias.75 (9.1%) from the EBL group and in 5 patients (38.5%)
from the clip group (P Z .166). There were no
Mechanical therapy differences in secondary outcomes between the 2
Through-the-scope clips. In a subgroup analysis groups, including number of endoscopic sessions
from a large meta-analysis (20 studies, n Z 2472) of required, need for angiographic embolization or
emergent surgery, transfusion requirements, or length of endoscopic hemostasis (n Z 76) or hemostasis-assisted

hospital stay.88 In a Japanese series of 53 patients with by Doppler monitoring of blood flow (n Z 72).39 The
colonic diverticular bleeding, EBL provided effective primary outcome (recurrent bleeding within 30 days of
hemostasis in 26 of 27 (96%) patients with active endoscopic hemostasis) occurred more frequently in the
hemorrhage or a nonbleeding visible vessel.89 control group (26.3%) than in the Doppler group (11.1%;
Covered self-expandable metallic stents. The use P Z .021).39 Other nonrandomized studies have also
of CSEMSs for hemostasis in the GI tract has been studied suggested that Doppler probes can be of use for risk
in a randomized controlled fashion only in the setting of stratification of patients with UGIB, inasmuch as lack of a
esophageal variceal bleeding.90 In the biliary tract, Doppler signal after hemostasis indicates a reduced risk
successful use of CSEMSs for hemostasis has been of recurrent bleeding, whereas a persistently positive
reported in cases of uncontrolled bleeding after signal is a marker for higher risk of recurrent
sphincterotomy, sphincteroplasty, intraductal biopsy, and bleeding.38,112 Similar findings in a study of 38 patients
anastomotic stricture dilatation in posttransplantation with diverticular bleeding suggest a potential risk stratifica-
patients.91-94 Successful use of CSEMSs for hemostasis in tion role for EDP in LGIB as well.113
the esophagus, duodenum, and colon has also been EUS-guided hemostasis. Use of EUS in the therapy of
described in small case series and case reports.95-99 nonvariceal GI bleeding is limited to small case series and
case reports. In a case series involving 17 patients with
Topical hemostatic agents nonvariceal GI bleeding of diverse causes, EUS was used
Hemospray. Hemospray treatment was evaluated in a for either injection (eg, cyanoacrylate, ethanol), coil embo-
French registry of 202 patients with UGIB of various causes lization, or tattooing the site of a subepithelial vessel for
across 20 centers.100 Immediate hemostasis was achieved subsequent EBL. In this series, EUS-directed therapy was
in 195 of 202 patients (96.5%), independently of whether successful in 15 of 17 (88%) patients, with no further
it was used as first-line therapy (91/94; 96.8%) or salvage bleeding over a median follow-up duration of 12 months.44
therapy (104/108; 96.3%). The type of lesion did not influ- Other case series and reports have described similar
ence immediate hemostasis, which was achieved in 72 of results.114-116
75 (96.0%) of ulcers, 58 of 61 (95.1%) of malignant lesions,
34 of 35 (97.1%) of postendoscopic bleeding, and 31 of 31
(100%) of bleeding from other causes.100 Recurrent EASE OF USE
bleeding was noted at day 8 and day 30 in 26.7% and
33.5%, respectively. Other smaller studies have shown Many hemostatic devices require an adequate view of
similar results.101, 102 Use of Hemospray for control of the bleeding source and precise, en face positioning of
LGIB, early postoperative anastomotic bleeding, and post- the endoscope to facilitate direct contact with the bleeding
sphincterotomy bleeding has shown promise in case series lesion. In many cases, these conditions may not be easily
and case reports.28,103-105 achievable. Noncontact hemostatic devices such as APC
Ankaferd blood stopper. In a retrospective case se- and topical hemostatic agents obviate the need for some
ries of 26 patients with upper- and lower-GI bleeding of of these conditions and are generally easier to use. Heater
various causes (including Mallory-Weiss tear, Dieulafoy probes and bipolar probes require adequate pressure on
lesion, GAVE, radiation proctopathy, and postpolypectomy the tissue and sufficient duration of treatment to induce
bleeding), application of ABS provided hemostasis in all pa- coaptive coagulation. Both excessive pressure and duration
tients.32 Other case series and case reports have indicated of treatment increase the risk of deep tissue injury and
the effectiveness of ABS in the treatment of variceal perforation, whereas inadequate pressure or treatment
bleeding, tumor bleeding, postsphincterotomy bleeding, duration can exacerbate bleeding by unroofing the
and diverticular bleeding.106-109 Large prospective studies bleeding vessel.117
are lacking. APC is a noncontact technique requiring an operative
EndoClot. In a prospective multicenter study of 70 pa- distance from the probe tip to the tissue that ranges
tients, hemostasis was achieved in 30 of 47 (64%) patients from 2 to 8 mm.3 Longer distances hamper ignition of
with UGIB treated with EndoClot as a first-line therapy, 11 the plasma, whereas probe contact with the tissue may
of 11 (100%) patients with UGIB treated with EndoClot as a potentially cause flow of argon gas into the submucosa,
salvage therapy, and 10 of 12 (83%) patients with LGIB.110 leading to pneumatosis and rarely extraintestinal gas.118
In another study, LGIB after EMR was successfully Any liquid (eg, blood) between the probe tip and
controlled with EndoClot in 18 of 20 (90%) lesions, with bleeding tissue can induce the development of a
no procedure-related adverse events.111 coagulation film that can prevent adequate treatment of
Endoscopic Doppler probe. In an RCT for the assess- the bleeding source.118
ment of hemostasis in UGIB, 148 patients (125 with peptic Deployment of TTS clips may be challenging through
ulcers, 19 with Dieulafoy lesions, and 4 with Mallory Weiss an angulated endoscope or over a duodenoscope
tears) were assigned to either standard (visually guided) elevator.3 TTS clips also may be difficult to place on
bleeding vessels within a large fibrotic ulcer base because FINANCIAL CONSIDERATIONS
there may be inadequate tissue to anchor the clip.3
Rotatable clips may permit easier alignment of the open List prices of commonly used hemostatic devices in the
jaws with the bleeding vessel. Differences in the jaw United States are shown in Tables 1 through 4. Device
opening and the length of the tail of the clip may affect costs for most clinical enterprises will be lower than list
performance in different anatomic locations. Potential prices owing to purchasing agreements. Current
disadvantages of the cap-mounted clips include require- Procedural Terminology (CPT) codes for endoscopic
ment for scope withdrawal to load the device, difficulty hemostasis, any method, include the following: 43227
in traversing the cricopharyngeus or luminal stenoses (esophagoscopy), 43255 (EGD), 44366 (enteroscopy not
with the mounted cap, and challenge in accessing certain including ileum), 44378 (enteroscopy including ileum),
areas of the GI tract.21 In addition, cap-mounted clips are 44391 (colonoscopy through stoma), 45334 (flexible
difficult to remove. Limitations of endoscopic suturing de- sigmoidoscopy), and 45382 (colonoscopy). When CPT
vices are lack of widespread availability, need for a codes are used for nonvariceal bleeding, additional codes
double-channel endoscope, technical complexity, and for injection or EBL are not concomitantly reported.
restricted maneuverability, hindering access to some
areas of the GI tract.21
Advantages of topical hemostatic agents include ease AREAS FOR FUTURE RESEARCH
of application in a variety of locations and the potential
utility for treatment of many different bleeding le- Topical hemostatic agents such as Hemospray are
sions.30,119 Disadvantages of these agents include a tran- promising treatments for GI bleeding. Comparative studies
sient reduction in endoscopic visualization and possible between these agents and other conventional modalities
interference with other treatment modalities if hemosta- would be useful to better define their clinical role. Cap-
sis should fail.30,119 mounted clips may be particularly useful in refractory
bleeding because they allow ligation of larger vessels and
may be less hindered by fibrotic tissue than TTS clips.
Further clinical experience will serve to better define the
SAFETY bleeding lesions and the anatomic locations that are best
served by cap-mounted clips. The presently available
Adverse events of injection therapy are usually related endoscopic suturing system is restricted to use with a
to the substance injected rather than to the needle itself.3 double-channel endoscope, but a suturing platform is in
Rare adverse events include tissue necrosis, ulceration, development for use with standard endoscopes and thus
and perforation, and also hypertension and cardiac may potentially have broader applicability. Although hemo-
arrhythmia with epinephrine injection.120,121 Serious static forceps have been used primarily for the prevention
adverse events of endoscopic thermal hemostasis and treatment of bleeding during endoscopic resection,
include uncontrollable bleeding and perforation.122 their use as therapy for noniatrogenic GI bleeding should
Pooled data from prospective controlled trials of bipolar be further evaluated.
electrocoagulation and heater-probe therapy for peptic
ulcer hemostasis reported bleeding that required urgent SUMMARY
surgery in 5 of 1684 cases (0.3%) and perforation in 8 of
1684 cases (0.5%) .123 The risk of perforation may be Endoscopic evaluation and treatment remain a corner-
increased with retreatment after initial thermal stone in the management of nonvariceal upper- and
therapy.124 A meta-analysis of RCTs reported similar re- lower-GI bleeding. A variety of devices are available for he-
sults.125 Adverse events from APC are rare and include mostasis of bleeding lesions in the GI tract. Other than in-
distention of the GI tract with argon gas, submucosal jection therapy, which should not be used as
emphysema, pneumomediastinum, pneumoperitoneum, monotherapy, there are few compelling data that strongly
and perforation.3 Intracolonic gas explosion with favor any one device over another. For endoscopists, the
inadequate colonic cleansing has been described; as choice of a hemostatic device should depend on the
such, complete colonic cleansing is recommended before type and location of the bleeding lesion, the availability
use of APC in the colon.118 Clip deployment failure has of equipment and expertise, and the cost of the device.
been described at certain locations in the GI tract,
particularly the posterior wall of the duodenal bulb.56
Perforation from clip placement has been reported but is DISCLOSURES
exceedingly rare.126 The reported adverse events
associated with topical hemostatic agents are primarily The following authors disclosed financial relationships
technical in nature, including occlusion of the spray relevant to this publication: J. Melson: Independent inves-
catheter or instrument channel.126 tigator grant support from Boston Scientific Corporation;
Medical Advisory Board for Clinical Genomics. H. Asla- 15. Weilert F, Binmoeller KF. New endoscopic technologies and proce-
nian: Consultant for Boston Scientific and Olympus. dural advances for endoscopic hemostasis. Clin Gastroenterol Hepa-
tol 2016;14:1234-44.
M. Bhutani: Advisory Board for Medi-Globe. D. Lichten- 16. OTSC System. Over the scope clipping system for flexible endoscopy.
stein: Consultant for Olympus. U. Navaneethan: Consul- Available at: http://www.ovesco.com/uploads/tx_sbdownloader/
tant for Takeda, AbbVie, and Janssen. R. Pannala: OTSC_System_Broschure_eng_Rev09_2017-01-30_hp.pdf. Accessed
Consultant for Boston Scientific Corp.; research support September 5, 2017.
from Apollo Endosurgery. M. Parsi: Consultant for and 17. Padlock Clip Defect Closure System. Available at: http://www.
usendoscopy.com/Products/Padlock-Clip-defect-closure-system.aspx.
honoraria from Boston Scientific. A. Sethi: Consultant Accessed September 5, 2017.
for Boston Scientific Corporation and Olympus. G. Triku- 18. Barola S, Magnuson T, Schweitzer M, et al. Endoscopic suturing for
danathan: Advisory Board for AbbVie. All other authors massively bleeding marginal ulcer 10 days post Roux-en-Y gastric
disclosed no financial relationships relevant to this bypass. Obes Surg 2017;27:1394-6.
publication. 19. Chiu PW, Chan FK, Lau JY. Endoscopic suturing for ulcer exclusion in
patients with massively bleeding large gastric ulcer. Gastroenterology
2015;149:29-30.
Abbreviations: ABS, Ankaferd blood stopper; APC, argon plasma 20. Appolo Endosurgery. OverStitch endoscopic suturing system. Avail-
coagulation; ASGE, American Society for Gastrointestinal Endoscopy; able at: http://apolloendo.com/overstitch/. Accessed July 28, 2017.
CSEMS, covered self-expandable metallic stent; CPT, Current 21. Fujii-Lau LL, Wong Kee Song LM, Levy MJ. New technologies and ap-
Procedural Terminology; EBL, endoscopic band ligation; EDP, proaches to endoscopic control of gastrointestinal bleeding. Gastro-
endoscopic Doppler probe; U.S. FDA, United States Food and Drug intest Endosc Clin N Am 2015;25:553-67.
Administration; GAVE, gastric antral vascular ectasia; HP, heater 22. ASGE Technology Committee; Banerjee S, Barth BA, Bhat YM, et al.
probe; LGIB, lower GI bleeding; MPEC, multipolar electrocoagulation; Endoscopic closure devices. Gastrointest Endosc 2012;76:244-51.
OTSC, over-the-scope clip; PTFE, polytetrafluoroethylene; RCT, 23. ASGE Technology Committee; Liu J, Petersen BT, Tierney WM, et al.
randomized controlled trial; TTS, through-the-scope; UGIB, upper GI Endoscopic banding devices. Gastrointest Endosc 2008;68:217-21.
bleeding. 24. Poza Cordon J, Froilan Torres C, Burgos Garcia A, et al. Endoscopic
management of esophageal varices. World J Gastrointest Endosc
2012;4:312-22.
25. Cardenas A. Management of acute variceal bleeding: emphasis on
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Current affiliations: Section for Gastroenterology & Hepatology, Tulane
University Health Sciences Center, New Orleans, LA (1), Division of Gastro- Reprint requests: John T. Maple, DO, FASGE, ASGE Technology Committee
enterology and Hepatology, University of Michigan, Ann Arbor, MI (2), Sec- Chair, 800 Stanton L Young Blvd, AAT 7400, Division of Digestive Diseases
tion of Digestive Diseases, Department of Internal Medicine, Yale and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma
University, New Haven, CT (3), Department of Gastroenterology, Hepatol- City, OK 73104, USA. E-mail: [email protected].
ogy and Nutrition, MD Anderson Cancer Center, The University of Texas,

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TECHNOLOGY ASSESSMENT

Devices for endoscopic hemostasis of nonvariceal GI bleeding

INTRODUCTION for Devices and Radiological Health) database search to

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TABLE 1. Injection needles

Sheath Sheath Needle

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TABLE 2. Contact thermal devices

Multipolar electrocautery probes

US Endoscopy (Mentor, Bipolar hemostasis 7, 10 350 $300

TABLE 3. Noncontact thermal devices

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TABLE 4. Mechanical hemostatic devices

QuickClip Pro 7 165, 230 11 $3714/box of 10 Precise rotation

11.5 to 14 mm* 220 3, 6y $610

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has historically been used as a hemostatic agent in Turkish

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EUS-guided hemostasis recurrent bleeding, length of hospital stay, units of blood

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emergent surgery, transfusion requirements, or length of endoscopic hemostasis (n Z 76) or hemostasis-assisted

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