Four Endoscopic Hemostasis Techniques for Gastrointestinal Bleeding

This article will explain the four core hemostasis techniques under digestive endoscopy in an easy-to-understand manner.

Mechanical hemostasis can be described as an endoscopic "physical interception technique", whose core is to directly close blood vessels or ruptures by mechanical force.

Hemostasis with metallic clips (titanium clips) is one of the most commonly used mechanical methods. Like a tiny "vascular clip", after endoscopy identifies the bleeding site, the doctor releases the titanium clip through the working channel of the endoscope to directly clamp the bleeding vessel or tissue tear. This method is especially suitable for visible vascular stumps at the base of ulcers, bleeding after polypectomy, or small tissue lacerations, achieving immediate hemostasis.

Ligation hemostasis is mainly used for bleeding from ruptured esophageal varices. Similar to ligating objects with rubber bands, a ligator is attached to the front of the endoscope. When contacting the varicose vein, it is aspirated into the ligator and a rubber band is released to ligate the vein, causing ischemia, necrosis, and eventual fibrosis.

The greatest advantage of mechanical hemostasis is its intuitive and reliable effect, with little damage to surrounding tissues. Especially with titanium clips, after successfully clamping the vessel, the clip usually falls off spontaneously after days or weeks and is excreted with feces, without requiring a second operation for removal.

Thermal coagulation hemostasis can be regarded as a precise "tissue welding technique", which denatures and coagulates tissue proteins using heat to seal bleeding blood vessels.

High-frequency electrocoagulation is the most classic thermal method. It uses heat generated by high-frequency current through an electrode in contact with the bleeding lesion to coagulate and necrose tissue, forming a protective eschar for hemostasis. This method is particularly suitable for ulcer bleeding or post-polypectomy bleeding, but power must be precisely controlled to avoid deep tissue injury.

Argon plasma coagulation (APC) is a non-contact thermal coagulation technique. It transfers heat to the tissue surface via ionized argon gas, covering large bleeding areas evenly, especially for diffuse oozing or superficial bleeding. With a shallow effect depth, it is relatively safe.

Heat probe hemostasis combines mechanical compression and thermal coagulation. The probe directly compresses the bleeding point to temporarily block blood flow, then heats to coagulate tissue. This "compress first, heat later" mode provides excellent results for active ulcer bleeding.

In addition, microwave coagulation is another thermal technique that coagulates tissue proteins using microwave-generated heat. The doctor inserts an electrode into the submucosa around the bleeding lesion, adjusts appropriate power and duration until the mucosa turns white and bleeding stops.

Drug injection and spraying hemostasis are methods that achieve hemostasis by promoting vasoconstriction, accelerating blood coagulation, or forming a physical barrier through pharmacological effects.

Local drug spraying is one of the simplest hemostatic methods. The doctor inserts a spray catheter through the endoscope to apply hemostatic agents directly to the bleeding lesion. Common drugs include norepinephrine (vasoconstriction), thrombin (promotes coagulation), and Monsel's solution. It is easy to perform and suitable for diffuse oozing or small-vessel bleeding.

Drug injection hemostasis involves injecting drugs directly around the bleeding site. The most common is diluted epinephrine (usually 1:10,000), which helps stop bleeding through strong vasoconstriction. Sclerosing agents (such as lauromacrogol) or tissue adhesives (such as cyanoacrylate) can also be injected. Tissue adhesive solidifies rapidly after injection, sealing vascular ruptures like "super glue", especially for critical conditions such as bleeding from ruptured gastric fundal varices.

The advantage of drug hemostasis is its relative simplicity without complex equipment. However, excessive doses of some drugs (e.g., epinephrine) may cause cardiovascular side effects, so doctors must strictly control the dosage.

In clinical practice, doctors often combine multiple hemostatic techniques according to the patient’s specific condition to achieve better hemostatic effects.

Combined therapy shows obvious advantages for active bleeding or high-risk lesions. For example, for active ulcer bleeding, the doctor may first inject diluted epinephrine to constrict vessels and reduce bleeding, then use a heat probe or high-frequency electrocoagulation for reinforcement, and even add a titanium clip if necessary.

This "injection + thermal/mechanical hemostasis" combination often yields better results than a single method and significantly reduces the risk of rebleeding.

Combined therapy strategies require doctors to have comprehensive technical proficiency and rich clinical experience, formulating individualized hemostatic plans based on the cause, type, severity of bleeding, and available equipment.

Modern endoscopic hemostasis techniques are well-established. Based on the cause, location, and severity of bleeding, doctors select the most appropriate tools and methods like skilled craftsmen. Even if one method is unsatisfactory, combined therapy can usually control bleeding effectively.

Advances in these minimally invasive techniques have spared many patients from surgical trauma and significantly improved therapeutic outcomes.