Nonvariceal Upper Gastrointestinal Bleeding: When Endoscopic Therapy Fails-A Surgeon's Perspective

Endoscopic hemostasis of upper gastrointestinal bleeding has dramatically reduced the need for surgical management over the past two decades. Nevertheless, surgery still plays a pivotal role. Initial endoscopy stops bleeding in over 90% of cases and allows stratification of patients by their risk of rebleeding. Patients who are at high risk of rebleeding are the elderly with comorbidities; those presenting with shock or a large ulcer; and those who have active bleeding or a nonbleeding visible vessel. In cases of rebleeding after initial success at endoscopic hemostasis, a second endoscopic attempt is justified. Failure to control bleeding endoscopically is the indication for surgical intervention, thus a close cooperation between endoscopists and surgeons is essential. When indicated, surgery should not be delayed.