Despite significant advancements in endoscopy and supportive care, bleeding remains a prevalent, complex, and frequently life-threatening emergency for physicians. The overall mortality rate from bleeding still stands at approximately 10%, with the potential to rise to 35% for the elderly and hospitalized patients with severe comorbidities [20]. While tissue adhesive has demonstrated efficacy in controlling varicose vein bleeding and is included in several guidelines, its role in GITB remains uncertain. Our study, based on a retrospective analysis of 30 cases, confirmed that ETA exhibited outstanding immediate hemostatic success rate (100.0%) and a low re-bleeding rate (10.0% and 17.0% on days 7 and 30, respectively). To the best of our knowledge, this study represents one of the largest investigations conducted on the use of ETA to treat GITB.

Since its introduction in 1984, the widespread use of Histoacryl® has demonstrated its efficacy in managing bleeding from gastric varices [21]. A recent review of compiled case studies involving patients treated with Histoacryl® has indicated that the adhesive is relatively safe and effective. Despite this, complications like systemic embolism, end-organ infarction, visceral fistula, and microbiemia had occurred [22, 23]. Several retrospective studies have further revealed that Histoacryl® has an initial hemostasis rate ranging from 88 to 98%, with 1% experiencing severe complications, like systemic embolism. The re-bleeding rate was from 10 to 29% [24, 25]. Studies from China and South Korea have reported successful hemostasis rates of 95% to 100% in treated patients [26, 27]. To date, there are a lack of studies determining the outcomes are of Histoacryl® treatment in patients with GITB. According to our study, ETA with Histoacryl® treatment exhibited a 100% immediate hemostatic success rate, a low re-bleeding rate and was identified as a safe hemostatic method.

It has been reported that approximately four-fifths of upper gastrointestinal bleeding will resolve spontaneously, while the remaining one-fifth will persist or recur, leading to further bleeding [28, 29]. The occurrence of re-bleeding may not only increase the morbidity and mortality, but also escalates the medical cost for patients [10]. Therefore, the timely identification and active management of high-risk patients with persistent or recurrent bleeding have become the primary focus of upper gastrointestinal bleeding treatment. Some researchers advocate for surgery or selective transarterial embolization as the preferred method of controlling re-bleeding [30]. However, in our opinion, ETA should be utilized prior to surgery due to its cost-effective, lower complications rates, and high efficacy. In our study, the overall re-bleeding rates at 7, 30, and 60 day post-hemostasis were 10.0%, 17%, and 20.0%, respectively. Moreover, of the 4 patients who experienced re-bleeding, 3 were re-treated with ETA, resulting in successful cessation of bleeding in 2 cases. This outcome aligns with previously reported efficacy of endoscopic secondary treatment and is deemed to be a safer alternative to surgery [31].

Fatal systemic embolism is a significant complication associated with endoscopy [32, 33]. Fortunately, our study did not observe any instances of severe systemic embolism. In one case of embolization complication within our study, there were no apparent clinical symptoms or signs, and no re-bleeding occurred within a 60-day period post-hemostasis. Furthermore, our study population did not experience any fatal outcomes related to systemic embolization, such as organ infarction or abscess formation. Based on these findings, it can be concluded that ETA is an effective and safe treatment for GITB.

The present study design has certain limitations that may impact the generalizability of our findings. Primarily, the retrospective nature of the study and the lack of a control cohort were constraints that should be acknowledged. However, numerous reports have highlighted the efficacy of traditional endoscopic hemostasis in managing tumor bleeding, suggesting that the outcomes of this study can be considered sufficiently effective. Additionally, the absence of complications may be attributed in part to our extensive experience with this product in treating varicose bleeding, a practice well documented in the field of digestive endoscopy. Secondly, the identification of potential factors contributing to re-bleeding following immediate hemostasis remains challenging. Moreover, it is crucial to acknowledge that this study was conducted solely at a single center, introducing the possibility of selection bias influencing the outcomes. Lastly, the limited sample size of the present investigation may have compromised its capacity to detect genuine associations. Consequently, larger-scale studies are imperative to validate and substantiate our observations.

To the best of our knowledge, this clinical cohort represents the first incidence of GITB treated with ETA, demonstrating the effectiveness of ETA in managing potentially life-threatening GITB.