Severe upper gastrointestinal bleeding remains a common medical emergency. In the last two decades endoscopy has become the cornerstone of diagnosis, risk stratification and treatment of peptic ulcer bleeding. Clinical assessment and endoscopic recognition of the stigmata of recent haemorrhage can allow the identification of patients with a high risk of rebleeding. Patients with active bleeding at the time of endoscopy and with non-bleeding visible vessels should receive endoscopic treatment. Studies comparing different treatment modalities are mostly single centre studies with relatively small groups of patients and therefore lack statistical power. Furthermore most of those trials were heterogeneous because of differences in the end points, differences in the risk factors for rebleeding and differences in the levels of experience of the endoscopists in both recognition and treatment of bleeding ulcers. Recently different treatment modalities have been studied. The injection of clot-inducing factors, a combination of injection and thermal therapies, repeat endoscopies and the use of mechanical devices such as clips and ligatures are promising new techniques. However, there are, at present, no convincing data to suggest that any one of these treatment modalities is superior when looking at the overall group of patients with bleeding peptic ulcer. Larger randomized controlled trials must focus on tailoring therapies and using the optimal therapy for different subgroups of patients.