Ankaferd blood stopper application in gastrointestinal bleeding: An updated narrative review

Abstract

Gastrointestinal bleeding is a common and potentially life-threatening condition that requires prompt and effective management. Ankaferd blood stopper (ABS) is a plant-derived topical hemostatic agent that has recently attracted attention as a potential adjunctive tool in endoscopic hemostasis. This narrative review summarizes the available evidence regarding its mechanisms of action and clinical applications in gastrointestinal bleeding. Current data suggest that ABS may provide immediate bleeding control, particularly in refractory bleeding where conventional methods are insufficient or challenging. Reported clinical use indicates variceal and nonvariceal bleeding, malignancy-related hemorrhage, radiation-induced injury, and post-procedural bleeding. However, the available evidence is largely derived from case reports and small observational studies, limiting definitive conclusions regarding efficacy and safety. Overall, ABS appears to be a promising adjunctive or rescue option in selected clinical scenarios. Further well-designed prospective and comparative studies are required to better define its role within current endoscopic hemostatic strategies.

Key Words: Ankaferd blood stopper; Gastrointestinal bleeding; Ankaferd hemostat; Hemostasis; Refractory bleeding; Adjunctive therapy; Topical hemostatic agents; Rescue therapy

Core Tip: Ankaferd blood stopper (ABS) represents a novel non-coagulation-dependent hemostatic approach that may expand the therapeutic options for gastrointestinal bleeding. Unlike conventional endoscopic methods, ABS acts rapidly and can be applied easily, making it particularly attractive in challenging or inaccessible bleeding sites. Its potential role as a bridging or rescue therapy in refractory bleeding highlights its clinical relevance. Although current evidence is limited, ABS may offer a practical adjunct in selected cases, warranting further investigation in well-designed prospective studies.

INTRODUCTION

Gastrointestinal (GI) bleeding remains a clinical challenge despite development of novel techniques and devices. Ankaferd blood stopper^® (ABS) is a standardized herbal extract comprising Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica[1,2]. Initially approved for superficial and surgical bleeding, ABS has demonstrated hemostatic efficacy and safety in various settings[2]. Its formulation and multi-form availability (e.g., ampoule, spray, tampon) supports its emerging use in GI bleeding management[2].

The hemostatic effect of ABS relies on the rapid (< 1 second) induction of a protein-based scaffold composed of blood proteins, particularly fibrinogen gamma, which triggers platelet and erythrocyte aggregation[2]. This aggregation supports the normal clotting process without disproportionately affecting any single coagulation factor[2]. Preclinical and clinical studies have demonstrated that ABS effectively controls bleeding in diverse settings, including intractable deep leg ulcers in Behçet’s disease[3], hemophilia A patients on inhibitors[4], and experimental full-thickness wound models[5]. Beyond its coagulation-enhancing role, ABS exhibits broader “pleiotropic” actions, including antimicrobial, anti-neoplastic, anti-mutagenic, antioxidant, and tissue-healing properties[1]. While its procoagulant function is well established, the underlying mechanisms remain under investigation[1]. ABS is also being increasingly used in intractable GI bleeding, with accumulating data supporting its efficacy and safety. Current European Society of GI Endoscopy guidelines suggest the use of topical hemostatic agents in cases of refractory GI bleeding. However, there are no specific guideline recommendation for ABS, and the available evidence remains largely observational[6].

GI bleeding remains an active and evolving field of research, with a growing body of literature spanning multiple disciplines[7]. Recent trends indicate an increasing focus on endoscopic hemostasis and the development of novel and adjunctive therapeutic modalities. In this context, updated evaluations of emerging hemostatic agents such as ABS are of particular clinical interest.

This study is designed as a narrative review aimed at summarizing the available mechanistic and clinical evidence regarding the use of ABS in GI bleeding. Although several previous reviews have addressed topical hemostatic agents, including ABS, the literature has expanded in recent years to include additional case reports and observational studies. Given the heterogeneity and predominantly low level of available evidence, a formal systematic review was not feasible. Instead, the aim of this narrative review is to provide an updated narrative synthesis, focusing on clinical applications, patterns of use, and potential mechanisms relevant to endoscopic hemostasis, and to summarize the current evidence of its utility across various cases of GI bleeding.

MECHANISM AND PLEIOTROPIC EFFECTS OF ABS

ABS has been successfully employed as a topical hemostatic agent across a wide range of clinical settings, including GI bleeding, as well as selected surgical and non-GI bleeding conditions such as endobronchial, dental, and operative bleeding[7-25]. These reports highlight its broad hemostatic potential; however, this review focuses primarily on its hemostatic role in GI endoscopic practice.

ABS has also been reported to promote tissue repair and wound healing across various tissues, including GI and extra-GI settings[1,5,18,23,26-37]. However, the direct relevance of these effects to GI bleeding remains limited. A study by Şensoy et al[38] demonstrated that the application of ABS does not cause any lesions or histopathological alterations in the stomach and small intestine tissues of rats, and these findings support that ABS is a safe hemostatic agent option for the GI system that preserves structural integrity. Its antimicrobial spectrum appears linked to localized oxygen enhancement via erythrocyte aggregation[1,37,39], showing activity against Candida albicans, Methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella, Acinetobacter baumannii, and Mycobacterium tuberculosis[37,39,40].

ABS has demonstrated also antineoplastic effects, by inhibiting cell proliferation, promoting apoptosis, and preventing blast cell transformation in B-cell chronic lymphocytic leukemia[41-43]. Additional investigations have revealed cytotoxicity against multiple myeloma and plasmacytoma cells - reducing M-protein production both in vitro and in vivo[42,43] - and preliminary data suggest activity against sarcoma and colon cancer cells[1]. It also exerts anti-inflammatory effects by reducing oxidative damage and modulating cytokines[28,29,34], thereby enhancing tissue repair[20,21,26,27,35]. Early evidence indicates possible synergy between ABS and standard surgical or pharmacological hemostatic approaches, potentially reducing the blood-transfusion needs in specific patient populations[22].

It shows promise for osteoporotic bone healing[30] and improved osseous graft outcomes[23]. Studies suggest no major alteration of key hepatic drug-metabolizing enzymes[33], implying minimal risk of drug interactions. Importantly, topical use remains crucial, as intravascular application into intact vasculature is contraindicated[44].

ABS^® is a unique plant-derived agent that rapidly promotes coagulation through the formation of a localized protein-cell scaffold. Unlike traditional hemostatic agents that typically target a single component of the coagulation cascade, such as thrombin or fibrinogen, ABS initiates a multifactorial process that creates a rapid and stable physiological plug. Accumulating studies underscore its antimicrobial, anti-inflammatory, antioxidant, anti-mutagenic, anti-neoplastic, and tissue-healing roles. Despite its initial use for external hemorrhage, increasing clinical data highlights the role of ABS in GI bleeding, including both variceal and non-variceal etiologies. Beyond its hemostatic effect, the anti-inflammatory and antiangiogenic properties of ABS may contribute to bleeding control by reducing mucosal inflammation and tumor-related vascularity; however, the clinical relevance of these effects in GI bleeding remains limited and not fully established. These investigations, involving case reports and small observational trials, suggest that ABS can immediately mitigate bleeding when used alone or alongside conventional techniques such as epinephrine injection, band ligation, heater probe coagulation or cyanoacrylate therapy.

MANAGEMENT OF GI BLEEDING

Gastric and esophageal varices

Available evidence on ABS in variceal bleeding is limited to case reports and small case series. Across these reports, ABS has primarily been used as a rescue or bridging therapy, particularly in situations where conventional treatments such as cyanoacrylate injection or endoscopic band ligation were unsuccessful, unavailable or challenging.

Beyazit et al[45] treated a 60-year-old woman with splenic vein thrombosis, who had medium-sized isolated gastric fundal varices that continued to ooze despite cyanoacrylate injection. Topical ABS application through a washing pipe led to immediate hemostasis. Control upper endoscopy on day 3 revealed clean varices and no signs of rebleeding.

Topical application of ABS has been reported to achieve immediate hemostasis within seconds to minutes in most cases. However, this effect appears to be predominantly temporary, as several patients subsequently required definitive interventions such as cyanoacrylate injection or transjugular intrahepatic portosystemic shunt. In another study, Karaman et al[46] found that ABS application stopped bleeding in 4 out of 5 variceal cases (3 esophageal, 2 gastric varices) where standard therapies could not be applied, and it was concluded that salvage could be used as a treatment. In 1 patient, bleeding could not be stopped, and Sangstaken-Blakemore tube insertion was performed.

Tuncer et al[8] described a 70-year-old man with cirrhosis secondary to chronic hepatitis B infection. Application of ABS into the varices through the catheter controlled the bleeding within seconds, allowing definitive cyanoacrylate injection. No further bleeding was observed during the 7-day inpatient stay or in subsequent outpatient follow-ups.

In a more recent study, Baş et al[47] reported 64 patients with various etiologies of upper and lower GI bleeding, all of which were treated with ABS alone or in combination with other hemostatic modalities. The cases included successful application of ABS onto five esophageal variceal bleeding cases. In 3 patients, variceal bleeding cases were managed only by ABS because of advanced sclerosis of the mucosa by former multiple band ligations. In the remaining two, the lumen was not visible due to massive bleeding. Control esophagogastroduodenoscopy after the first day showed no bleeding residue, and no mortality or re-bleeding was reported in the 1-month follow-up period.

Overall, these findings suggest that ABS may serve as a useful adjunctive or temporizing agent rather than a definitive therapy in variceal bleeding.

Ulcers

ABS has been applied in ulcer-related bleeding, including cases associated with underlying hematologic disorders or systemic diseases. Across reported cases, ABS has often been used after failure of conventional modalities, such as epinephrine injection or endoclipping, indicating its role as a rescue therapy.

Beyazit et al[48] presented a case of severe bleeding from an antral ulcer in a patient with diffuse gastroduodenal amyloidosis. The bleeding had not responded to hypertonic Na-epinephrine injections, but application of 15 mL ABS achieved hemostasis. Although the patient ultimately died of duodenal necrosis and perforation attributed to amyloid infiltration, no further GI bleeding occurred before death.

The pediatric experience with ABS further highlights its safety and efficacy. A 1-year-old infant with primary hemophagocytic syndrome and a duodenal ulcer was successfully treated with 1 mL ABS, illustrating the agent's potency and stability in pediatric gastroenterology[49].

Some reports describe the achievement of hemostasis, even in challenging clinical contexts, such as coagulopathy or immunosuppression. However, given the limited number of cases and lack of comparative studies, it remains unclear whether ABS provides additional benefit over established endoscopic therapies. Hacıoğlu et al[50] reported a 29-year-old woman with Glanzmann thrombasthenia who experienced refractory GI bleeding following non-steroidal anti-inflammatory drug use. Bleeding was unresponsive to multiple therapies, and the bleeding source could not identified. Oral ABS was administered, and complete resolution of bleeding by day 10. These observations suggest a potential role for ABS as an adjunctive hemostatic agent, particularly in refractory ulcer bleeding.

Malignancies

Neoplastic bleeding is often chronic, diffuse and associated with poor outcomes due to the underlying advanced stage of the disease. Traditional hemostatic methods that rely on local thermal procedure or mechanical compression are frequently insufficient for tumor-related bleedings. ABS has been reported to achieve effective control of oozing-type hemorrhage, especially following biopsy-related bleeding or in friable tumor surfaces. ABS appears to be particularly useful due to its ability to cover large bleeding areas.

Across small retrospective series, topical application of ABS has been associated with high rates of initial hemostasis, with bleeding control achieved in most reported cases[51,52]. However, in some patients, complete hemostasis was not achieved after the first application, requiring repeat dosing to obtain full bleeding control[51]. Early rebleeding appears to be uncommon, although clinical outcomes may be influenced by the underlying malignancy rather than bleeding itself[51].

Overall, these findings suggest that ABS may be an effective option for achieving rapid initial control of tumor-related bleeding, particularly in oozing lesions, while its role remains largely adjunctive in the absence of higher-level evidence.

Turhan et al[9] provided insight into the antiangiogenic effect of ABS by measuring tumor micro-vessel density in two patients, one with polypoid rectal cancer and the other with an ulcerated vegetative pylorus cancer, both before and after topical ABS application. Micro-vessel density in the superficial layers directly exposed to ABS was significantly lower than in deeper layers, suggesting a reduction in neovascularization. However, these findings remain preliminary in nature.

Despite encouraging reports, the available data are limited to small retrospective series and case reports. Therefore, ABS should be considered a supportive option, particularly in cases where conventional techniques are difficult to apply or are insufficient.

Radiation

Radiation-induced damage to the GI tract often results in chronic and recurrent bleeding, as well as significant inflammatory changes that impair quality of life. ABS has shown promising results in some studies in both the acute stabilization and long-term management of these injuries.

Experimental esophageal injury: Akbal et al[53] demonstrated that ABS alleviated inflammation, scarring, weight loss, and mortality in a caustic esophageal injury animal model, with no significant changes in laboratory data aside from albumin and creatinine levels.

Radiation proctopathy: In radiation-induced GI bleeding, ABS has been primarily used as an adjunctive or bridging therapy, particularly in cases refractory to standard treatments. In acute or focal radiation-related lesions, ABS has been associated with immediate hemostasis, even after failure of modalities like argon plasma coagulation, and may facilitate subsequent definitive treatment without early rebleeding[54,55].

ABS appears effective in alleviating radiation-induced GI damage; yet, in chronic radiation proctopathy, its benefits may be short-lived and often require complementary interventions.

Non-variceal upper and lower GI bleeding

The use of ABS in non-variceal GI bleeding (NVUGIB) has been reported across a range of clinical scenarios, including focal lesions (e.g., diverticular bleeding) and diffuse or active bleeding settings. Across these reports, ABS has been applied as a primary, adjunctive or rescue therapy depending on clinical context.

In diverticular bleeding, ABS has been associated with rapid hemostasis, particularly in cases where conventional endoscopic methods were insufficient or only partially effective[56]. These findings suggest that ABS may be useful in achieving prompt bleeding control in selected cases. However, evidence in these indications remains limited to case reports, and therefore its role cannot be clearly defined. As a result, ABS may be less effective in high-pressure arterial bleeding where mechanical or thermal modalities remain necessary for definitive control.

In a prospective trial by Gungor et al[57], 27 patients with active NVUGIB were initially treated with 8-10 mL saline followed by 8 mL ABS via a spray catheter. Immediate hemostasis was achieved in 19 (70.4%) patients. For the remaining 7 patients, standard measures (epinephrine, hemoclips, polidocanol) were subsequently used. Ultimately, all 27 achieved stable hemostasis, though those who failed initial ABS alone tended to have coagulopathy or be on antiplatelet/anticoagulant therapy. The rebleeding rate was 15.8% in the ABS-only group vs 33.3% where ABS was combined with conventional methods.

Another retrospective cohort[58] included 202 urgent NVUGIB patients (Glasgow-Blatchford score ≥ 6) treated by endoscopists with < 3 years’ experience. Ninety-six received ABS (alone or in combination), while 106 did not. Despite more severe presentations (e.g., hypotension, metastatic disease) in the ABS group, immediate hemostasis was 100%, compared with four failures in the non-ABS group. The ABS group also had fewer ICU admissions (5 vs 7) and lower rebleeding rates (3 vs 8) within 1 month. Notably, subsequent ABS use rescued the four failed cases in the non-ABS group, and all 19 cancer-related bleeds managed with ABS remained stable without rebleeding.

Evidence suggests that ABS can be successfully used in a range of non-variceal upper and lower GI bleeding cases, especially when standard endoscopic methods fail or are insufficient; however, further trials are needed to confirm its efficacy in severe bleeding.

Post-procedural bleeding

ABS was also tested on polypectomy-related bleeding. Karaman et al[59] reported 7 patients treated with ABS in endoscopic polypectomy-related bleeding. Five patients had gastric polypectomy and 2 patients had colonic polypectomy. Among all patients, 5-6 mL ABS was sprayed through the washing pipe as primary treatment in 5 and as adjunctive treatment after other failed modalities in 2. In all patients, hemostasis was achieved. There were no reports of re-bleeding through the 3-day follow-up period, and no adverse reactions were reported.

Kurt et al[55] reported that 10 patients with post-polypectomy bleeding were treated with ABS, alone or in combination with other techniques. On average, 10 mL ABS was sprayed through the washing channel, achieving prompt hemostasis in every case. Karaman et al[46] described two cases where hemorrhage developed after an endoscopic sphincterotomy. Bleeding persisted despite electrocoagulation, but 10 mL ABS allowed for complete hemorrhage control, with no local or systemic complications noted.

ABS has proven to be an effective and safe topical agent for managing post-procedural bleeding, including both polypectomy and sphincterotomy-related hemorrhages, even when conventional methods fall insufficient.

An overview of the published studies and their main characteristics are summarized in Table 1.

Table 1 Overview of the current data on the use of Ankaferd blood stopper in different gastrointestinal bleeding settings.

Ref.	Type of article, evidence value2	Bleeding etiology	ABS application	ABS volume and application route	Hemostasis3 achieved	Complication	Routinely used drugs of patients
Gungor et al[57], 2012	Prospective study	Gastric ulcer (n = 3)	Adjunct	8 mL, MediGlobe spray catheter	2/3	Absent	N/A
		Duodenal ulcer (n = 12)	Adjunct	8 mL, MediGlobe spray catheter	9/12	Absent	N/A
		Ulcer1 (n = 2)	Adjunct	8 mL, MediGlobe spray catheter	0/2	Absent	N/A
		Esophagitis (n = 2)	Adjunct	8 mL, MediGlobe spray catheter	2/2	Absent	N/A
		Ulcer at anastomosis site1 (n = 2)	Adjunct	8 mL, MediGlobe spray catheter	2/2	Absent	N/A
		Dieulafoy lesion1 (n = 2)	Adjunct	8 mL, MediGlobe spray catheter	1/2	Absent	N/A
		Polypectomy1 (n = 2)	Adjunct	8 mL, MediGlobe spray catheter	2/2	Absent	N/A
		Malignancy1 (n = 1)	Adjunct	8 mL, MediGlobe spray catheter	1/1	Absent	N/A
Turhan et al[9], 2009	Retrospective observational	Rectum malignancy (n = 3)	Alone	3 mL, not reported	Yes	Not reported	N/A
		Gastric malignancy (n = 7)	Alone	3 mL, not reported	Yes	Not reported	N/A
Baş et al[47], 2021	Retrospective observational	Duodenal ulcer (n = 22)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Gastric malignancy (n = 8)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Rebleeding in 1 month in 1 patient	N/A
		Gastric ulcer (n = 10)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Mallory-Weiss tear1 (n = 2)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Esophageal variceal bleeding (n = 5)	Alone	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Sphincterotomy (n = 2)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		GAVE (n = 1)	Adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Colonic malignancy (n = 8)	Alone	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Colonic polypectomy (n = 2)	Alone	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		ESD (n = 1)	Alone	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Rectal ulcer (n = 2)	1 alone, 1 adjunct	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
		Hemorrhoid (n = 1)	Alone	5-10 mL, sclerotherapy needle	Yes	Absent	N/A
Ozaslan et al[51], 2010	Retrospective observational	Gastric malignancy (n = 5)	Alone	9.5 mL on average (sclerotherapy needle/heater probe); 1 pt had 15 mL via NGT	4/5 patients yes, 1/5 patient yes in second application	Absent	N/A
		Periampullary malignancy (n = 1)	Alone	10 mL, sclerotherapy needle/heater probe	Yes	Absent	N/A
Baş et al[58], 2024	Retrospective observational	Duodenal ulcer (n = 43)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
		Gastric malignancy (n = 19)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
		Mallory-Weiss tear (n = 12)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
		GAVE (n = 6)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
		Gastric ulcer (n = 15)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
		Dieulafoy lesion1 (n = 1)	Adjunct	10 mL, sclerotherapy needle	Yes	Absent	N/A
Karaman et al[59], 2010	Retrospective observational	Gastric polypectomy (n = 2)	Adjunct	5-6 mL, washing pipe	Yes	Absent	N/A
		Colonic polypectomy (n = 5)	Adjunct	5-6 mL, washing pipe	Yes	Absent	N/A
Kurt et al[55], 2010	Retrospective observational	Polypectomy1 (n = 11)	Adjunct	Average 10.4 mL, washing pipe	Yes	Absent	N/A
		Gastric lesion biopsy (n = 4)	Alone	Average 10 mL, washing pipe	Yes	Absent	N/A
		Mallory-Weiss tear (n = 1)	Adjunct	7 mL, washing pipe	Yes	Absent	Warfarin
		Dieulafoy lesion1 (n = 2)	Adjunct	Average 47 mL, washing pipe	1/2 yes	Absent	N/A
		Radiation colitis (n = 3)	Adjunct	Average 24 mL, washing pipe	Yes	Absent	N/A
		GAVE (n = 3)	Adjunct	Average 15 mL, washing pipe	Yes	Absent	N/A
		Congestive gastropathy (n = 1)	Alone	10 mL, washing pipe	Yes	Absent	ASA, warfarin
		Esophageal lesion (n = 1)	Alone	40 mL, washing pipe	Yes	Absent	N/A
		Rectal lesion, post-submucosal dissection (n = 1)	Adjunct	40 mL, washing pipe	Yes	Absent	N/A
Tuncer et al[8], 2010	Case report	Gastric variceal bleeding (n = 4)	Alone	6 mL, washing pipe	Yes	Absent	N/A
Aslan et al[56], 2013	Case report	Colon diverticular bleeding	Alone	2 mL, sclerotherapy needle	Yes	Absent	Warfarin
		Colonic diverticula	Alone	4 mL, sclerotherapy needle	Yes	Absent	N/A
Beyazit et al[45], 2012	Case report	Gastric variceal bleeding	Adjunct	20 mL, washing pipe	Yes	Absent	N/A
Beyazit et al[48], 2013	Case report	Gastric ulcer	Adjunct	15 mL, washing pipe	Yes	Absent	N/A
Yarali et al[49], 2010	Case report	Duodenal ulcer	Alone	1 mL, not reported	Yes	Absent	N/A
Beyazit et al[52], 2011	Case report	Colonic mass	Alone	5 mL, washing pipe	Yes	Absent	N/A
Shorbagi and Sivri[54], 2010	Case report	Rectal telangiectasia (post-radiation)	Adjunct	20 mL, washing pipe	Yes	Absent	N/A
Hacıoğlu et al[50], 2015	Case report	Unidentified (refractory GI bleeding)	Adjunct	3 mL × 4 mL oral, 10 days	Not reported	Absent	N/A
Karaman et al[46], 2012	Case report	Post-sphincterotomy bleeding (n = 2)	Adjunct	10 mL, via duodenoscope channel	Yes	Absent	N/A

¹Organ location unspecified.

²Referance values are determined as 1: Prospective studies, > 2: Retrospective studies > 3: Case reports.

³Hemostasis was defined as cessation of bleeding during the procedure.

ABS: Ankaferd blood stopper; NGT: Nasogastric tube; ASA: Acetylsalicylic acid; GAVE: Gastric antral vascular ectasia; ESD: Endoscopic submucosal dissection; N/A: Not applicable.

ORAL ADMINISTRATION

Although ABS is one of the few hemostatic agents that can be administered via luminal (oral or rectal) routes, the current evidence regarding systemic use remains extremely limited.

Experimental data suggest that oral administration does not result in short-term toxicity in animal models[60]. In addition, a small number of case reports have described its use in situations where the bleeding source could not be identified or controlled endoscopically. In these reports, oral administration of ABS was associated with stabilization of bleeding and improvement in hemoglobin levels[50,60,61].

However, these observations are based on case reports without controlled clinical studies. The mechanisms, pharmacokinetics and long-term safety of systemic ABS use in humans remain unclear. Therefore, oral administration of ABS should be considered experimental, and no definitive conclusions regarding its efficacy or safety can be drawn at this stage.

Further prospective studies are required before this approach can be recommended in routine clinical practice.

COMPARISON WITH CONVENTIONAL ENDOSCOPIC THERAPIES

Endoscopic management of GI bleeding relies on well-established modalities, including injection therapy (e.g., epinephrine), mechanical methods (hemoclips), thermal coagulation, cyanoacrylate injection, and hemostatic powders such as TC-325 (Hemospray).

Compared with these modalities, ABS may offer practical advantages. Its topical application enables rapid coverage of bleeding surfaces, making it particularly suitable for diffuse oozing hemorrhage where precise targeting is challenging. In addition, ABS can be delivered through standard endoscopic accessories without requiring specialized devices or advanced technical expertise.

However, unlike established therapies, ABS lacks robust evidence from randomized controlled trials. Hemostatic powders such as TC-325 have demonstrated efficacy in larger studies[62], while clips and thermal modalities remain the standard of care for focal bleeding lesions. Furthermore, ABS may be less effective in high-pressure arterial bleeding, where mechanical or thermal methods provide more definitive control.

In many reported cases, ABS has been used in combination with conventional therapies, suggesting a complementary rather than replacement role. Therefore, ABS should be considered a potential adjunctive or rescue therapy, particularly in diffuse or refractory bleeding, while direct comparative studies are needed to better define its position within current treatment algorithms.

RECOMMENDATIONS FOR FUTURE RESEARCH

The transition of ABS from a specialized rescue agent to a first-line therapy requires continued scientific investigation.

Large-scale multicenter randomized controlled trials

There is a critical need for prospective trials directly comparing ABS with mineral-based powders (TC-325) and synthetic peptides (PuraStat) across specific etiologies, particularly peptic ulcers and malignancy-related bleeding.

Pharmacokinetic and systemic studies

While animal safety data is robust, further human studies are needed to fully map the systemic distribution and metabolic pathways following high-dose oral administration.

Combination therapy optimization

Research should investigate the synergistic effects of ABS when used in conjunction with proton pump inhibitors, somatostatin analogues, and other endoscopic modalities to develop optimized clinical algorithms.

CONCLUSION

This article summarized the current evidence on the efficacy, safety and potential mechanisms of ABS in the management of GI bleeding across various etiologies; including variceal, non-variceal, malignant, radiation-induced, and post-procedural bleeding. The accumulated literature, derived primarily from case reports and observational studies, demonstrate that ABS achieves hemostasis in the majority of reported cases, often within seconds to minutes of application, with safe re-bleeding rates.

ABS is characterized by rapid onset of action, ease of topical application through standard endoscopic accessories, and an acceptable safety profile, even in patients with coagulopathies or those receiving anticoagulant therapy. Compared with other endoscopic hemostatic methods, such as epinephrine injection, hemoclips, thermal devices, or topical agents like Hemospray, ABS has a multifactorial mechanism involving erythrocyte and fibrinogen gamma aggregation, though direct head-to-head comparative data remain limited.

Beyond GI use, ABS has shown promise in various surgical and mucosal bleeding settings, including urology, otolaryngology, dentistry, and dermatology. Its broad antimicrobial, anti-inflammatory, and wound-healing properties add further clinical appeal, particularly in patients at risk of infection or delayed healing. However, as topical use remains the mainstay, care must be taken to avoid intravascular application or use in non-accessible bleeding sites.

This article has several limitations that should be acknowledged. First, it is designed as a narrative review, with no formal systematic methodology or risk-of-bias assessment. Second, the available evidence is largely derived from case reports and small observational studies, which are inherently subject to publication bias, selective reporting, and heterogeneity in clinical outcomes. Its place in the therapeutic algorithm will only be clarified through randomized controlled trials evaluating its efficacy, safety, and cost-effectiveness compared with standard modalities. Additionally, pharmacokinetic studies and long-term outcome data are necessary to address remaining questions regarding systemic effects and recurrence risk. Establishing guidelines on dosage, indications, and combination strategies will be essential for integrating ABS into routine endoscopic practice.