2122 Novel Use of EndoRotor® Device to Clear Large Obscuring Clot in Patient With Upper Gastrointestinal Bleed

Abstract

INTRODUCTION: Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools and promotility agents are available to disrupt clots and increase visibility with varying degrees of success. The EndoRotor® device is a non-thermal, automated endoscopic resection system designed to remove benign mucosal tissue throughout the gastrointestinal tract. Here, we present a challenging case where standard endoscopic techniques failed to clear a large obscuring gastric clot and how novel application of the EndoRotor® allowed successful localization of the culprit lesion. CASE DESCRIPTION/METHODS: A 79 year old woman with a history of end stage renal disease and liver fibrosis presented with coffee ground emesis and melena. On admission, initial labs were notable for Hgb 9.7, Plts 129, INR 1.1. Patient was treated with IV pantoprazole and octreotide. EGD was notable for nonbleeding esophageal varices and a moderate size blood clot in the lesser curvature and fundus of stomach obscuring visualization and the procedure was terminated. Patient continued to pass melena with Hgb drop to 5.8 requiring 3 units pRBC and metoclopramide was added to her regimen to try to clear the large clot. Repeat EGD revealed an interval increase in size of blood clot. Despite irrigation and suction, area could not be cleared. Use of cold snare or Roth net removal were not feasible due to clot size and use of BioVac® was ineffective. A repeat EGD was performed the following day using the EndoRotor®. The combination of the EndoRotor device’s rotating cold blade and suctioning enabled the large clot to be liquefied. Fibrous tissue intermittently clogged the EndoRotor® suction channel but was easily cleared with flushing. After about 30 minutes, the large obstructing clot was completely cleared revealing a bezoar. The patient was kept NPO and continued on IV metoclopramide for 48 hours to clear the bezoar. An EGD was then repeated which revealed a 5 mm cratered ulcer in the posterior gastric wall with a nonbleeding visible vessel. Bipolar probe was applied successfully for hemostasis. DISCUSSION: Our case illustrates the challenges associated with a large clot obscuring visualization. Standard use of promotility agents with supportive care were not successful as the patient continued to intermittently bleed increasing the clot size . Our case is the first reported application of the EndoRotor® to safely to clear large blood clots in upper GI bleeding as an adjunct to our standard therapies.