Importance of risk assessment,endoscopic hemostasis,and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)is a common medical emergency in clinical practice.While the incidence has significantly reduced,the mortality rates have not undergone a similar reduction in the last few decades,thus presenting a significant challenge.This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis.Since ANUVGIB predominantly affects the elderly population,the impact of comorbidities may be responsible for the poor outcomes.A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly.Early risk stratification plays a crucial role in deciding the line of management and predicting mortality.Emerging scoring systems such as the ABC(age,blood tests,co-morbidities)score show promise in predicting mortality and guiding clinical decisions.While conventional endoscopic therapies remain cornerstone approaches,novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives,particularly in cases refractory to traditional modalities.By integrating validated scoring systems and leveraging novel therapeutic modalities,clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

White-light-induced synthesis of injectable alginate-based composite hydrogels for rapid hemostasis

Dear Editor,Timely and effective hemostasis is of great significance for reducing body damage and mortality of patients [1]. Alginate is generally considered to be an excellent hemostatic polymer-based biomaterial and has been approved by the Food and Drug Administration as Generally Recognized as Safe [2]. However, the violent crosslinking reaction and unstable structure at the wound site limit its clinical applications. Hence, we report a biocompatible and injectable composite hydrogel methacrylate alginate (Alg-AEMA)-based Eosin Y/N-phenylglycine (NPG)-initiated composite hydrogel (AEC) composed of photocrosslinkable alginate, viscosity modifiers and novel white light photoinitiator, namely Eosin Y/NPG system, for instant hemorrhage control.

Femoral Access with Ultrasound-Guided Puncture and Z-Stitch Hemostasis for Adults with Congenital Heart Diseases Undergoing Electrophysiological Procedures

Aims:Although the application of ultrasound-guided vascular puncture and Z-stitch hemostasis to manage femoral access has been widely utilized,there is limited data on this combined application in adult congenital heart disease(ACHD)patients undergoing electrophysiological(EP)procedures.We sought to evaluate the safety and efficacy of ultrasound-guided puncture and postprocedural Z-stitch hemostasis for ACHD patients under-going EP procedures.Methods and Results:The population of ACHD patients undergoing transfemoral EP pro-cedures at the University of Zurich Heart Center between January 2019 and December 2022 was observed and analyzed.During the study period,femoral access(left/right,arterial/venous)was performed under real-time ultrasound guidance.At the end of the procedure,a single Z-stitch was performed at the puncture site.We eval-uated the incidence of in-hospital complications associated with femoral access puncture in this population.Among 101 patients who had a total of 147 previous ipsilateral vascular punctures(mean 1.5 per person),100 patients underwent successful femoral vascular access for EP procedures.The median age of the patients was 47±15 years and 34(34%)were male.Z-stitches were performed after the procedure in 100 patients with 303 femoral vascular accesses(mean 3 punctures per person).No patient developed vascular puncture relevant inguinal hematoma,pseudo aneurysm,arteriovenousfistula,venous or arterial thrombosis.Conclusion:In ACHD patients undergoing EP procedures,optimal femoral access management can be achieved with ultra-sound-guided puncture and postprocedural Z-stitch hemostasis.

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal(GI)bleeding is a significant cause of morbidity and mortality.Traditionally,through-the-scope(TTS)clips,thermal therapy,and injection therapies are used to treat GI bleeding.In this review,we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis.Specifically,we discuss the efficacy and applicability of over-thescope clips,hemostatic agents,TTS doppler ultrasound,and endoscopic ultrasound,each of which offer an effective method of reducing rates of GI rebleeding.

Adverse events associated with the gold probe and the injection gold probe devices used for endoscopic hemostasis:A MAUDE database analysis

BACKGROUND Gastrointestinal(GI)bleeding accounts for over half a million admissions annually and is the most common GI diagnosis requiring hospitalization in the United States.Bipolar electrocoagulation devices are used for the management of gastrointestinal bleeding.There is no data on device-related adverse events for gold probe(GP)and injection gold probe(IGP).AIM To analyze this using the Food and Drug Administration(FDA’s)Manufacturer and User Facility Device Experience(MAUDE)database from 2013 to 2023.METHODS We examined post-marketing surveillance data on GP and IGP from the FDA MAUDE database to report devicerelated and patient-related adverse events between 2013-2023.The MAUDE database is a publicly available resource providing over 4 million records relating to medical device safety.Statistical analyses were performed using IBM SPSS Statistics V.27.0(IBM Corp.,Armonk,NY,United States).RESULTS Our search elicited 140 reports for GP and 202 reports for IGP,respec-tively,during the study period from January 2013 to August 2023.Malfunctions reportedly occurred in 130 cases for GP,and actual patient injury or event occurred in 10 patients.A total of 149 patients(74%)reported with Injection GP events suffered no significant consequences due to the device failure,but 53 patients(26%)were affected by an event.CONCLUSION GP and IGP are critical in managing gastrointestinal bleeding.This study of the FDA MAUDE database revealed the type,number,and trends of reported device-related adverse events.The endoscopist and support staff must be aware of these device-related events and be equipped to manage them if they occur.

口腔急诊出血患者的临床特征与危险因素

目的:分析口腔急诊出血患者的临床特征及危险因素。方法:对北京大学口腔医院急诊科2019年1月至2022年12月期间收治的口腔出血患者进行回顾性研究,分析止血方法、就诊次数与患者性别、年龄、全身状况和出血原因等因素的关联性。结果:共纳入口腔出血患者4764人次,其中男性2660人次(55.84%),女性2104人次(44.16%),平均年龄40.7岁。口腔出血最常见的原因是拔牙术后出血(3080例,64.65%),其次为牙龈出血(1386例,29.09%)、门诊手术术后出血(194例,4.07%)、颌面部肿物出血(33例,0.69%)、住院手术术后出血(24例,0.50%)、其他原因出血(47例,0.99%)。使用简单方法止血1867例(39.19%),使用复杂方法止血2897例(60.81%),其中碘条填塞及加压缝合是最常使用的止血方法。Logistic回归分析显示,男性患者较女性患者使用复杂止血方法的比例更高,牙龈出血通常使用简单方法止血,拔牙术后出血通常采用复杂方法止血。患有高血压、凝血功能障碍的人群更易因出血问题多次就诊,性别及年龄不影响患者的就诊次数。结论:急诊就诊的口腔出血常见原因是拔牙术后出血及牙龈出血,临床上大多数患者通过压迫止血、加压缝合和填塞碘条可有效止血,部分严重出血的患者需进一步处理;少数的出血患者可诱发全身并发症,临床医生应充分重视。

Optimizing care for gastric cancer with overt bleeding:Is systemic therapy a valid option?

Gastric cancer(GC)and gastroesophageal junction cancer(GEJC)represent a significant burden globally,with complications such as overt bleeding(OB)further exacerbating patient outcomes.A recent study by Yao et al evaluated the effectiveness and safety of systematic treatment in GC/GEJC patients presenting with OB.Using propensity score matching,the study balanced the comparison groups to investigate overall survival and treatment-related adverse events.The study's findings emphasize that systematic therapy can be safe and effective and contribute to the ongoing debate about the management of advanced GC/GEJC with OB,highlighting the complexities of treatment decisions in these high-risk patients.

Hyperbaric oxygen therapy in the treatment of severe gastric laceration with active bleeding: A case report

BACKGROUND Endoscopic therapy is the primary approach for treating Mallory-Weiss syndro-me,particularly under conditions of mucosal protection and gastric acid suppre-ssion.However,for a subset of patients who cannot undergo endoscopic interven-tion or for whom such treatment proves ineffective,alternative measures like arterial embolization or surgical intervention may be required.While hyperbaric oxygen therapy(HBOT)has been applied across a range of medical conditions,its application in managing hemorrhage due to gastric tears remains undocumented.CASE SUMMARY A 52-year-old patient was admitted with symptoms of hematemesis and melena,and an endoscopy revealed a gastric fundus tear approximately 4 cm×5 cm in size.The lesion was considered unsuitable for endoscopic repair by the attending endoscopist.Despite conservative measures,including fasting and acid sup-pression,the patient experienced persistent bleeding and a substantial decrease in hemoglobin levels relative to admission values.Following a multidisciplinary consultation,HBOT was initiated,resulting in the cessation of bleeding and rapid wound healing.CONCLUSION For patients with gastric tears presenting with active hemorrhage,HBOT might offer an effective alternative when conventional endoscopic therapies are not viable or have been unsuccessful.

缝合止血与电凝止血对腹腔镜卵巢囊肿剔除术患者卵巢储备功能的影响

目的:比较缝合止血与电凝止血对腹腔镜卵巢囊肿剔除术(LOCR)患者卵巢储备功能的影响。方法:选取2020年10月—2023年10月于醴陵泰安医院行LOCR治疗的患者共计124例,以随机数字表法分成电凝组(n=62)和缝合组(n=62),缝合组给予缝合止血,电凝组给予电凝止血,比较两组围手术期指标、卵巢储备功能、免疫功能及术后并发症。结果:电凝组手术时间较缝合组短,术后首次排气时间、首次下床时间均较缝合组早,术中出血量较缝合组少,差异均有统计学意义(P<0.05);两组术后1个月黄体生成素(LH)、卵泡刺激素(FSH)水平均升高,抑制素B(INHB)、抗苗勒管激素(AMH)水平均下降,但缝合组LH、FSH水平均较电凝组低,INHB、AMH水平均高,差异均有统计学意义(P<0.05);两组术后1个月CD3^(+)、CD4^(+)均下降,CD8^(+)均升高,但缝合组CD3^(+)、CD4^(+)均较电凝组高,CD8^(+)低,差异均有统计学意义(P<0.05);缝合组术后并发症发生率为3.23%(2/62),与电凝组的6.45%(4/62)比较差异无统计学意义(P>0.05)。结论:LOCR患者采用缝合止血与电凝止血均具有较高的安全性,但电凝止血术中出血量更少,手术时间更短,术后恢复更快,而缝合止血对卵巢储备功能及免疫功能的影响较小,临床需根据患者实际选择合适的止血方法,以提高手术效果。

Platelets in hemostasis and thrombosis:Novel mechanisms of fibrinogen-independent platelet aggregation and fibronectin-mediated protein wave of hemostasis

Platelets are small anucleate cells generated from megakaryocytes in the bone marrow. Although platelet genera- tion, maturation, and clearance are still not fully understood, significant progress has been made in the last 1-2 dec- ades. In blood circulation, platelets can quickly adhere and aggregate at sites of vascular injury, forming the platelet plug （i.e. the first wave of hemostasis）. Activated platelets can also provide negatively charged phosphatidylserine- rich membrane surface that enhances cell-based thrombin generation, which facilitates blood coagulation （i.e. the second wave of hemostasis）. Platelets therefore play central roles in hemostasis. However, the same process of hemostasis may also cause thrombosis and vessel occlusion, which are the most common mechanisms leading to heart attack and stroke following ruptured atherosclerotic lesions. In this review, we will introduce the classical mechanisms and newly discovered pathways of platelets in hemostasis and thrombosis, including fibrinogen-inde- pendent platelet aggregation and thrombosis, and the plasma fibronectin-mediated ＂protein wave＂ of hemostasis that precedes the classical first wave of hemostasis. Furthermore, we briefly discuss the roles of platelets in inflam- marion and atherosclerosis and the potential strategies to control atherothrombosis.

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustainedhemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category Ⅲ , Ⅳ and Ⅴ ), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.

Hemostasis in liver transplantation:Pathophysiology,monitoring,and treatment

Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. Similarly, the decreased platelet count may be counterbalanced by increased platelet aggregability caused by highly active von Willebrand multimeres. The coagulation system is therefor stated to be rebalanced. While under normal "unstressed" conditions diffuse bleeding is rarely observed, however both diffuse bleeding or thrombus formation may occur when compensation mechanisms are exhausted. While most patients presenting for liver transplantation have severe cirrhosis, liver function and thus production of pro- and anticoagulant factors can be preserved especially in cholestatic liver disease. During liver transplantation, profound changes in the hemostasis system can occur. Surgical bleeding can lead to diffuse bleeding as coagulation factors and platelets are already reduced. Ischemia and tissue trauma can lead to alterations of hemostasis comparable to trauma induced coagulopathy. A further common disturbance often starting with the reperfusion of the transplanted organ is hyperfibrinolysis which can eventually precipitate complete consumption of fibrinogen and an endogenous heparinization by glycocalyx shedding. Moreover, thrombotic events inliver transplantations are not uncommon and contribute to increased mortality. Besides conventional laboratory methods, bed-side monitoring of hemostasis(e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.

Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy(ES) bleeding.METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, comorbidities, endoscopic diagnosis, presence of periampullary diverticulum, occurrence of immediate postES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.RESULTS: A total of 35 patients(21.7%) had rebleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/d L, initial bleeding severity, and bleeding diathesis were significant predictors of rebleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/d L and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single(n = 23) or multiple(range, 2-7; n = 6) sessions in 29 of the 35 patients(82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/d L are predictors of re-bleeding.

Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review

Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.

Injectable Self‑Healing Adhesive pH‑Responsive Hydrogels Accelerate Gastric Hemostasis and Wound Healing

Endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)are well-established therapeutics for gastrointestinal neoplasias,but complications after EMR/ESD,including bleeding and perforation,result in additional treatment morbidity and even threaten the lives of patients.Thus,designing biomaterials to treat gastric bleeding and wound healing after endoscopic treatment is highly desired and remains a challenge.Herein,a series of injectable pH-responsive selfhealing adhesive hydrogels based on acryloyl-6-aminocaproic acid(AA)and AA-g-N-hydroxysuccinimide(AA-NHS)were developed,and their great potential as endoscopic sprayable bioadhesive materials to efficiently stop hemorrhage and promote the wound healing process was further demonstrated in a swine gastric hemorrhage/wound model.The hydrogels showed a suitable gelation time,an autonomous and efficient self-healing capacity,hemostatic properties,and good biocompatibility.With the introduction of AA-NHS as a micro-cross-linker,the hydrogels exhibited enhanced adhesive strength.A swine gastric hemorrhage in vivo model demonstrated that the hydrogels showed good hemostatic performance by stopping acute arterial bleeding and preventing delayed bleeding.A gastric wound model indicated that the hydrogels showed excellent treatment effects with significantly enhanced wound healing with type I collagen deposition,α-SMA expression,and blood vessel formation.These injectable self-healing adhesive hydrogels exhibited great potential to treat gastric wounds after endoscopic treatment.

Upper non-variceal gastrointestinal bleeding-review the effectiveness of endoscopic hemostasis methods

Upper non-variceal gastrointestinal bleeding is a conditionthat requires immediate medical intervention and has a high associated mortality rate(exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the firstline treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy(within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature.

Improved hemostasis with major hepatic resection in the current surgical era

Background: Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections. Methods: Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era. Results: A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era ( P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era ( P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001). Conclusions: The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

Hemostasis testing in patients with liver dysfunction: Advantages and caveats

Due to concomitant changes in pro-and anti-coagulant mechanisms,patients with liver dysfunction have a“rebalanced hemostasis”,which can easily be tipped toward either a hypo-or a hypercoagulable phenotype.Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities.Conventional coagulation screening tests,such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures.The introduction of global coagulation assays,such as viscoelastic testing(VET),has been an important step forward in the assessment of the overall hemostasis profile.A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings.The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.

Rapid hemostasis of the residual inguinal access sites during endovascular procedures:A case report

BACKGROUND In endovascular procedures including total percutaneous endovascular aneurysm repair(pEVAR),percutaneous access through the common femoral artery is most commonly performed.Access-site bleeding is a major concern in percutaneous techniques.Herein,we present a case of successful control of continuous oozing using a vascular closure device(VCD)and the application of Surgicel(Johnson&Johnson,United States)over the access tract.CASE SUMMARY An 82-year-old man presented with an unruptured abdominal aortic aneurysm measuring 83 mm×75 mm.The patient had a medical history of atrial fibrillation and was receiving rivaroxaban(15 mg/d).Routine pEVAR was performed using the preclose technique with ProGlide(Abbott,Santa Clara,CA,United States).Significant amount of bleeding was observed at the end of the procedure after the deployment of the closure device at the access site.A sheet of Surgicel was applied to the suture thread using a surgical needle.Surgicel was applied to the surface of the artery along the access tract using a pusher,and hemostasis was immediately attained.CONCLUSION This simple technique is an excellent adjunct to control residual bleeding from the access site following VCD use.

Accurate hemostasis with a new endoscopic overtube for emergency endoscopy

Endoscopic hemostasis performed in the emergency room is difficult due to the presence of blood clots and food residue that makes obtaining a clear view of the bleeding vessel difficult. We experienced the efficacy of a newly developed inverted overtube to shorten the hemostatic time and obtain a clear endoscopic view with upper gastrointestinal bleeding patient who were transferred by ambulance car and required emergency endoscopy. The technique improved the endoscopic views and enabled us to perform the hemostatic procedures from the conventional standing position while freely and easily changing the patient's position. The presence of blood clots and food residue in the gastric fornix or upper gastric body makes identifying a bleeding exposed vessel impossible. This set-up significantly shortened the procedure time. The inverted overtube helped us obtain a clear view in patients who were laid in the right lateral position. Rapid identification of ex-posed vessels resulted in success of hemostasis.