Over time, the role of endoscopy has expanded significantly in the management of various gastrointestinal diseases, and therapeutic endoscopy is becoming increasingly invasive and complex. Despite the high therapeutic success of endoscopy in the management of early gastrointestinal tumors and pancreaticobiliary diseases, bleeding remains one of the most commonly encountered adverse events that can interfere with the procedure and be associated with negative outcomes. Procedure-related bleeding can vary from mild, self-limiting oozing to severe, potentially life-threatening bleeding. Nevertheless, the vast majority of procedure-related bleeding can be managed effectively and safely using different endoscopic techniques. In this article, we will discuss the endoscopic management of intra-procedural bleeding (IPB) with a focus on bleeding related to endoscopic resection of benign gastrointestinal lesions or early malignancy.

Procedure-related bleeding can be either intra-procedural or delayed (post-procedure) and can occur several days to weeks post-procedure. It is important to recognize that bleeding is only considered an adverse event if it interferes with the procedure or is associated with important negative patient-related outcomes such as prolonging hospitalization, the requirement for surgical or radiological interventions, or blood transfusion. In fact, the American Association of Gastrointestinal Endoscopy (ASGE) published a lexicon that gives a very clear definition of bleeding as an adverse event and its severity [1]. Intra-procedurally, bleeding is only considered an adverse event if it causes the procedure to be aborted or alters the procedural management. Indeed, many of the IPB episodes are self-limited, resolve spontaneously without any specific intervention, and do not interfere with the completion of the procedure [2]. Hence, a large proportion of IPB episodes are not considered true adverse events. Nevertheless, appropriate management of such bleeding events is crucial to avoid negatively impacting the procedure- and patient-outcomes. Delayed bleeding is defined as overt signs of bleeding (e.g. hematemesis and/or melena) or a hemoglobin drop of more than 2g/dL which can occur at any time after the completion of the endoscopy (up to several weeks post-procedure) and can range in severity from a mild and self-limiting event to a severe episode that is associated with significant morbidity and rarely mortality [1]. In the upcoming section, we will focus on the IPB part of several endoscopic procedures, including polypectomy and mucosal resection of neoplastic gastrointestinal lesions, while the management of delayed bleeding is out of the scope of this review and will not be discussed any further. Nevertheless, many of the principles of the endoscopic management of IPB and delayed bleeding are the same and can be applied to both scenarios.