Management of Difficult Bleeders The management of patients exsanguinating from an upper GI source represents a major challenge. Such patients should be resuscitated with RBC transfusion and intubated before endoscopy. Coagulopathy should be corrected but should not delay endoscopy. History of aortic aneurysm or aortic intervention should alert the possibility of aortoenteric fistulation. Patients with liver cirrhosis should be given intravenous antibiotics and a vasoactive drug before endoscopy. Band ligation and histo-acryl glue injection are standard treatments for esophagogastric varices. The majority of bleeding lesions are along a lesser curve, angular and antrum of the stomach and duodenal bulb. The use of a dual-channel endoscope can facilitate suctioning of fluid and clots. We can also shift a pool of blood from the fundus into the distal stomach by a head-up and right lateral position. Predictors of major or recurrent bleeds are larger ulcers (size > 2 cm) in the posterior duodenal bulb or the lesser curve of the stomach. These often erode into arterial complex belong the gastroduodenal artery and the left gastric artery respectively. In observational studies and randomized controlled trials, Hemospray ™ and over-the-scope clips have both been shown to be efficacious as rescue therapies. In bleeding gastroduodenal tumours, Hemospray ™ is particularly useful. The literature on the use of both modalities will be discussed and illustrated with video case presentations. Increasingly, interventional radiology in the forms of TIPSS for variceal bleeding and embolization for bleeding peptic ulcers are used as adjuncts when endoscopic treatment has failed or in selected cases at a high risk of further bleeds.