Cancer care is often complicated by coagulopathy leading to thrombosis and bleeding. While venous thromboembolism (VTE) has been extensively studied, bleeding remains an underestimated threat. To address this knowledge gap, we leveraged the Epic Cosmos database to determine the impact of cancer-associated clinically relevant bleeding (CRB) in 2 455 332 individuals with incident cancer encounters from 215 US health systems between 2018 and 2024. In the 12 months leading up to the cancer diagnosis, the period prevalence of CRB was 5.3% in the overall cohort, highlighting CRB as a common early presentation preceding cancer diagnosis. In the 12-month window after cancer diagnosis, the cumulative incidence of CRB was 6.3% in the overall cohort, 7.0% in those receiving systemic antineoplastic therapy, and up to 15.0% among individuals on certain baseline anticoagulants. In addition to age, sex, and race, factors appreciably associated with CRB on multivariable analysis included cancer types, metastatic disease, systemic therapy, anticoagulant or antiplatelet use, higher comorbidity index, recent hospitalization, recent history of bleeding or VTE, and selective laboratory features (hemoglobin, platelets, albumin, eGFR). Furthermore, the onset of CRB as a time varying covariate was independently associated with mortality in multivariable adjusted analysis: intracranial hemorrhage (HR 4.17, 95% CI 4.11-4.24); gastrointestinal bleeding (HR 2.52, 95% CI 2.50-2.55); other bleeding (HR 2.46, 95% CI 2.44-2.49). Together, these findings reveal a substantial and overlooked risk of bleeding in cancer care and underscore a need for validated bleeding risk models that can be integrated alongside VTE prediction tools to guide personalized thromboprophylaxis decisions.

Small bowel bleeding is an uncommon cause of gastrointestinal hemorrhage and is often difficult to diagnose when upper and lower endoscopy fail to identify the bleeding source. Dynamic contrast-enhanced computed tomography (DCE-CT) has emerged as an important imaging modality for localizing lesions, estimating the underlying etiology, and guiding treatment strategies. We report two cases of small bowel bleeding with distinct etiologies: Arteriovenous malformation (AVM) and gastrointestinal stromal tumor (GIST). In the first case, DCECT demonstrated a mass-like lesion with intense arterial-phase enhancement comparable to adjacent arteries and early venous drainage, strongly suggesting a vascular lesion. Elective surgical resection was performed, and histopathological examination confirmed AVM. In the second case, CT revealed a well-defined mass with relatively persistent enhancement and contrast extravasation, indicating active bleeding from a neoplastic lesion. Due to hemodynamic deterioration, emergency surgical resection was required, and the lesion was diagnosed as GIST. These cases indicate that systematic evaluation of enhancement patterns and associated CT findings, including early venous drainage and contrast extravasation, can facilitate differentiation between vascular and neoplastic causes of small bowel bleeding and support appropriate treatment selection.

A 79-year-old woman with massive hematochezia after endoscopic hemostasis was diagnosed with a localized ileal arteriovenous malformation supplied by a single vasa recta from the ileal branch of the ileocolic artery, classified as Cho classification type IIIa. Superselective embolization using a triple coaxial technique and a 1:7 n-butyl cyanoacrylate-lipiodol mixture achieved complete occlusion of the feeding artery and nidus while preserving bowel perfusion. No ischemic complications or recurrent bleeding occurred during an 18-month follow-up period. This case suggests that superselective n-butyl-2 cyanoacrylate embolization is an effective, curative, and minimally invasive treatment for small bowel arteriovenous malformations, supported by a review of previously reported cases.

Lower gastrointestinal bleeding (LGIB) is a common emergency, defined nowadays as bleeding of colorectal origin. It predominantly affects elderly patients in whom it is associated with increased morbidity and mortality. The main causes include diverticulosis, anorectal disorders, angiodysplasias, ischemic colitis, post-endoscopic resection complications, and tumor-related bleeding. Clinically, lower gastrointestinal bleeding (LGIB) presents with episodes of hematochezia or melena, or sometimes as occult bleeding. Initial assessment of clinico-biological severity and risk of recurrence is essential to determine the need for hospitalization and the timing of diagnostic procedures. Colonoscopy is the reference diagnostic and therapeutic procedure, ideally performed within 24 hours with CT angiography reserved for cases of hemodynamic instability. In case of failure, therapeutic escalation includes repeat endoscopy, arterial embolization, and, as a last resort, surgery. Early multidisciplinary management helps reduce morbidity, mortality, and recurrence.

Suspected small bowel bleeding is defined as a gastrointestinal bleeding, overt or occult (iron-deficiency anemia), with unremarkable high-quality upper endoscopy and colonoscopy. The main causes are vascular lesions (angiodysplasia) and inflammatory lesions (Crohn's disease). Diagnosis is primarily based on capsule endoscopy, which has an optimal yield if performed within 48 hours on bleeding onset. Deep enteroscopy often allows targeted treatment, but its availability is limited. If the capsule endoscopy is not contributive as well, the bleeding is referred to as obscure gastrointestinal bleeding. Management is not consensual. Treatment of the anemia and surveillance may be an option. It is reasonable course of action to repeat endoscopies, optimizing them, particularly in the event of recurrence.

Non-portal hypertension-related upper gastrointestinal bleeding (UGIB) remains one of the most common emergencies in gastroenterology, accounting for the majority of UGIB cases in Western countries.Its incidence is estimated at 50-150 cases per 100.000 population per year, with a mortality rate that remains between 5% and 10% despite advances in diagnostic and therapeutic strategies. Clinical presentation is often abrupt, typically as hematemesis or melena, requiring prompt and structured management including initial resuscitation, diagnostic and therapeutic endoscopy, and secondary prevention.In recent years, the therapeutic armamentarium available to the endoscopist has expanded with the introduction of innovative devices such as over-the-scope clips, hemostatic powders, and gels. Several randomized trials have refined the optimal timing of endoscopy and compared the efficacy of various techniques.

Acute gastrointestinal bleeding is a medical emergency in which early management, including pre-hospital care, is crucial for prognosis. The patient's history and clinical examination should focus on identifying signs of severity requiring immediate medical intervention. The pharmalogical treatment of upper gastrointestinal bleeding depends on the suspected cause: proton pump inhibitors for peptic ulcers, splanchnic vasoconstrictors and antibiotics in cases of portal hypertension. Risk stratification using validated scoring systems helps identify low-risk patients eligible for outpatient management. A restrictive transfusion strategy (hemoglobin < 7 g/dL) is recommended. For upper gastrointestinal bleeding, endoscopy should be performed within 24 hours (within 12 hours in patients with portal hypertension). For lower gastrointestinal bleeding, computed tomography angiography is useful for locating active bleeding, while colonoscopy remains the gold standard procedure.

Gastrointestinal bleeding (GIB) is a frequent and potentially life-threatening emergency. It is defined as any bleeding originating from the digestive tract, either overt (hematemesis, hematochezia, melena) or occult. From a nosological perspective, GIB is classified into upper GIB (proximal to the Treitz ligament), lower GIB (colonic or anorectal origin), suspected small bowel bleeding (SSBB), mid-GIB (jejunal or ileal lesions), and obscure GIB (no source identified despite complete evaluation). Over the past 20 years, the incidence of upper GIB has declined by 30-50%, mainly due to Helicobacter pylori eradication, proton pump inhibitors use, and reduced tobacco consumption. Conversely, lower GIB is increasing, and in some countries has surpassed upper GIB in frequency. Hospital mortality has decreased from about 10% to 5-7% owing to advances in diagnostics, therapeutic endoscopy, and healthcare organization. Cirrhotic patients and the elderly remain at particularly high risk.

Acute variceal bleeding treatment in patients with portal hypertension combines vasoactive drugs, prophylactic antibiotics, hepatic encephalopathy prophylaxis and upper gastrointestinal endoscopy for variceal treatment (elastic band ligation and/or tissue adhesive injection), on top of non-specific measures. Failure to control bleeding must lead to salvage TIPS (Transjugular Intrahepatic Portosystemic Shunt) discussion, after esophageal tamponade (balloon or stent).Pre-emptive TIPS within 72h must systematically be considered in high-risk patients to reduce rebleeding and mortality. Pre-emptive TIPS must also be discussed in case of gastric variceal bleeding.Following the acute bleeding episode, secondary prophylaxis combines non-selective betablockers and recurrent endoscopic treatments (except after TIPS). Liver transplantation must be discussed in certain cases of refractory bleeding or early relapse after TIPS implantation.