2014 Over-the-Scope Clip as Salvage Therapy for Refractory Non-Variceal Upper Gastrointestinal Hemorrhage After Failed Conventional Management: A Case Series

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INTRODUCTION: Elderly patients with cardiovascular co-morbidities are of higher mortality risk from non-variceal upper gastrointestinal hemorrhage (NVUGIH). Traditional endoscopic interventions with through-the-scope-clips, electrocautery and epinephrine injections have a high failure rate at managing bleeding from large visible vessels, especially bleeding from posterior duodenal bulb ulcers. Over-the-scope-clips (OTSC) are preferred by endoscopists for their versatile role in repair of fistulas, bowel perforations and NVUGIH. We report two NVUGIH cases where traditional endoscopic and angiographic interventions failed and over the scope clip was used as salvage therapy. CASE DESCRIPTION/METHODS: 85-year-old female with Pulmonary Hypertension and Atrial Fibrillation was admitted for hypovolemic shock from hematemesis. Endoscopy revealed a large posterior duodenal bulb ulcer with adherent clot for which epinephrine injection was used. The ulcer’s size and location prompted angiography and coil embolization of the gastroduodenal artery (GDA). Patient was in hypovolemic shock again due to a massive bleed. She was high risk for surgical intervention due to pulmonary hypertension, and repeat endoscopy was performed for hemostasis. An 11/6 T-type OTSC clip was successfully deployed at a large vessel oozing blood, after removal of a large adherent clot by snare. No further intervention was needed afterward. 76-year-old male with extensive cardiac history was admitted with burns and inhalation injury from a house fire, requiring tracheostomy and gastrostomy placement. During hospitalization, patient had multiple episodes of melena and required blood transfusion. Endoscopy revealed two large anterior and posterior duodenal bulb ulcers, with a visible vessel, managed by electrocautery. Due to persistent bleeding, he underwent coil embolization of the GDA. Two days later, patient had recurrent bleeding. Repeat endoscopy with OTSC was used for successful hemostasis of a large visible vessel in the posterior duodenal bulb. DISCUSSION: Traditional endoscopic management carries a 20% re-bleeding risk and successful secondary hemostasis drops from 90% to 75%. Anatomic variation in blood supply to the duodenal bulb, either from branches of celiac axis or superior mesenteric artery may be the reason why our patients failed angiographic coil embolization of the GDA. To our knowledge, we report the first two cases where OTSC was used for successful salvage of NVUGIH that failed initial endoscopic and angiographic interventions.