Studies addressing the role of endoscopy in post-bariatric patients with early GI bleeding are limited [6, 25, 30–33]. In a review of 89 patients with acute perioperative bleeding after laparoscopic RYGB, 77% of the patients could be treated without the need for endoscopic, radiological, or surgical intervention. Diagnostic and therapeutic endoscopy were used in only 6 (6.7%) and 5 (5.6%) of these patients, respectively [25]. In contrast, Jamil et al. proceeded with upper endoscopy in 27 of 30 patients (90%) with postoperative bleeding after laparoscopic RYGB, and the source of bleeding was from the gastrojejunal anastomosis in all patients [6]. Most patients (20/27; 74%) underwent endoscopy in an operating room and were endotracheally intubated (19/27; 70%). Bleeding stigmata at the gastrojejunostomy included active oozing (48%), visible vessel (26%), and adherent clot (26%). Endoscopic therapy was performed in 85% of patients and included epinephrine injection in 3 (13%), heater probe coagulation in 4 (17%), ­combination epinephrine injection and thermal ­coagulation in 14 (61%), and hemoclip placement in 2 (9%) patients. Initial hemostasis was achieved in all patients, but 5 (17%) patients required repeat endoscopy with therapy for rebleeding. None of the patients required surgery to control hemorrhage, but two complications occurred (pulmonary aspiration and perforation) [6].

In patients in whom endoscopic therapy is entertained, the use of endoclips is preferred when technically feasible. Unlike sclerosant injection and thermal coagulation, endoscopic clips do not extend tissue injury and can be used to manage concomitant anastomotic leaks and iatrogenic perforations [31]. Insufflation should be minimized and use of CO₂ considered.

Angiography and intraoperative endoscopy are considered when standard endoscopy fails to detect, reach, or secure the bleeding site. However, angiographic embolization can potentially devascularize fresh staple lines [25].