526 mortality is unknown. In a Cochrane meta-analysis the effects of red blood cell transfusions in adults with UGIB were assessed [7]. A total of three randomized or quasi- randomized trials comparing red blood cell transfusion and standard care without red blood cell transfusion included 126 patients. Red blood cell transfusion was, in these studies, associated with more deaths (5% vs. 0%; 2 studies) and more rebleeds (38% vs. 4%; 1 study). However, the included trials were heterogeneous in treatment regimens and outcome parameters and had several methodological deficiencies, which implied that the results of the meta-analysis can only be used as a stimulus for further studies, but not for firm clinical guidelines. In a large recent UK study, data on 4441 patients with acute UGIB were collected. Patients who received transfusion within 12 h of presentation had a twofold increased rate of rebleeding (OR 2.26; 95% CI 1.76–2.90) and a 28% increase in mortality (OR 1.28; 95% CI 0.94–1.74) compared to those not early transfused. These results persisted after correction for the severity of the bleed using Rockall scores and haemoglobin concentrations at presentation, the results may have been biased by persistent differences in case mix between early transfused and non- transfused patients [8]. Prospective studies with a strict defined transfusion protocol are needed. In the meantime, the risks and benefits of red blood cell transfusion must be carefully weighted individually. Pharmacotherapy Prior to Endoscopy Intravenous administration of high dose proton pump inhibitors (PPIs) prior to endoscopy neutralizes pH and leads to stabilization of blood clots. Investigators from Hong Kong studied the effect of preemptive infusion of omeprazole administered as an 80-mg intravenous bolus followed by an 8-mg infusion per hour before endoscopy in 638 patients with UGIB. They found a significant reduction in the need for endoscopic therapy (19% vs. 28%, P= 0.007) with fewer active bleeds during endoscopy (6% vs. 15%, P= 0.01) and more ulcers with clean base (64% vs. 47%, P=0.001) in the omeprazole-treated patients [9]. No effect was found on other major outcome parameters as the need for transfusion, rebleeding and mortality. Therefore, international guidelines remark that pre-endoscopic PPI therapy may be considered to downstage the bleeding site and decrease the need for endoscopic intervention, but that this should not delay endoscopy [10 ]. Risk Assessment Early risk assessment is crucial to determine the optimal timing of endoscopy, to define patients at highest risk of rebleeding, and to predict the need for other measures as administration of IV fluids, blood transfusion, and intensive Curr Gastroenterol Rep (2011) 13:525–531 care admission. For this purpose, several risk classification systems have been developed. Two frequently used scoring systems are the Blatchford score and the Rockall score [11, 12]. The latter contains a pre-endoscopic part, as well as a post-endoscopic component including the results of endos- copy. Both the Blatchford and Rockall scoring systems consider vital signs at presentation and comorbidity. The Blatchford score is more focused on symptoms (melena and/or syncope) and laboratory results (hemoglobin and urea) compared to the Rockall score, but does not consider age. A recent prospective cohort study comparing the validity and usefulness of these scoring systems concluded that the Blatchford score, but not the pre-endoscopic Rockall score, is useful for predicting low-risk patients who do not need therapeutic endoscopy and who may be suitable for outpatient management [13]. Disappointingly, the positive predictive value of both scores for the need for endoscopic intervention was low. This supports initiatives to adapt existing scorings systems or develop new, aiming for more precise risk stratification. Time to Endoscopy International consensus guidelines recommend early endosco- py within 24 h of presentation for patients with acute upper gastrointestinal bleeding [10 ]. Data from a nationwide UK survey of 6750 patients seen in 208 hospitals with UGIB show that this recommendation is not widely followed. Of patients deemed at high risk, only 55% received endoscopy within 24 h [4 ]. A main reason for delayed endoscopy was the absence in half of the hospitals of a formal out of hours endoscopy rota or service with a consultant available on call. Early endoscopy is safe and effective for all risk groups, allows timely diagnosis and treatment, reduces use of resources and length of hospital stay, and decreases the need for surgery [10 ]. So far, no additional benefit from very early or urgent (<12 h) endoscopy was found compared with early endoscopy (<24 h) with respect to rebleeding, surgery or mortality [14, 15]. However, emergen- cy endoscopy should be performed as soon as possible after hemodynamic stabilization in selective patients who are hemodynamically unstable or have massive hematemeses. Endoscopic Therapy Endoscopic Features and the Need for Therapy The endoscopic appearance of peptic ulcers provides impor- tant prognostic information and can identify ulcers as those with high versus low risk of rebleeding. Ulcers with signs of active spurting (Fig. 1) or oozing hemorrhage (resp. Forrest Ia and Ib) and ulcers with a visible vessel (Forrest IIa) are at