1875 Acute Pancreatitis Due to Clipping of the Ampulla With Over-The-Scope Clip as a Complication of Bleeding Duodenal Ulcer Treatment

Abstract

INTRODUCTION: Over-the-scope clips (OTSC; Ovesco, Tübingen, Germany) are extensively used for management of gastrointestinal (GI) bleeding, stent anchoring, fistulas, and bowel perforations. Its mechanism of action includes mechanical compression and tissue approximation. Removal of OTSC is indicated when complications occur, which include ulceration, luminal obstruction or clip misplacement. ReMOVE system (Ovesco, Tübingen, Germany) is a safe and effective tool designed to remove the clip. CASE DESCRIPTION/METHODS: A 56-year-old male presented to our hospital with abdominal pain and rectal bleeding for 4 days. On examination, the patient had epigastric tenderness and rectal exam revealed melanotic stool with bright red streaking. Labs revealed Hgb of 10.4 g/dL. CT abdomen/pelvis revealed active bleeding in the 2nd and 3rd portion of the duodenum. The patient was started on pantoprazole and red blood cell infusion. EGD revealed a peptic ulcer with an exposed vessel in the 2nd portion of duodenum proximal to the ampulla (Figure 1). Hemostasis was achieved using epinephrine injection and placement of an Ovesco OTSC. Patients hemoglobin stabilized however he continued to experience excruciating abdominal pain. Serum lipase was checked and was elevated to 17,925 U/L. A repeat EGD showed OTSC deployed over the ampulla (Figure 2) and attempts to break the clip using a needle knife and APC were unsuccessful. Two days later, using the bipolar direct current (DC) cutter (remOVE system, Ovesco, Tübingen, Germany) (Figure 3) the clip was removed following which bile was seen to be draining freely. Repeat EGD 1 month later showed normal duodenum with healed ampulla and ulcer. DISCUSSION: Ovesco OTSC is an innovative clipping system intended for endoscopic treatment of GI bleeding and closure of acute or chronic wall lesions. The OTSC for flexible endoscopy is an elastic device that works by compression and approximation of tissue. The clip is composed of Nitinol, a biocompatible material that can remain in the body as a long-term implant. RemOVE system can be used for endoscopic OTSC clips removal from the GI tract. It includes DC Cutter which is a bipolar instrument that allows fragmentation by localized melting and cutting of OTSC when used with DC Impulse. The DC Cutter’s tip consists of three electrodes that are brought in contact with the thinnest parts of the nitinol clip which is the frame/hinge. The OTSC must be cut at two spots on opposite side of the row of teeth and the clip fragments can be extracted.