Bleeding Duodenal Ulcer Successfully Managed with an Over-the-Scope-Clip

Abstract

A 70 year-old woman was admitted for right upper quadrant pain with radiation to the back, anorexia and vomiting. Ultrasound abdomen was notable for a dilated CBD to 12mm, thickened gallbladder wall with sludge but no stones and her liver chemistries were normal. HIDA scan and MRCP were also unremarkable. On further inquiry the patient reported 7-month history of abdominal pain and had never previously had an upper endoscopy. The EGD was notable for antral erosions and a pre-pyloric 5mm clean-based ulcer in the stomach. The duodenal bulb was notable for a large 2cm posterior ulcer with large adherent clot with active bleeding (Fig. 1A). The distal duodenum demonstrated no bleeding. The endoscope was removed from the patient and an over-the-scope-clip (OTSC) or “bear claw” was applied to its distal end and the endoscope was reintroduced into the patient's abdomen. Submucosal injection of epinephrine 1:10,000 was made around the lesion with effective mucosal blanching. Then a combination of irrigation and the clear cap was used to remove most of the clot. Then the 12-3 gc OTSC was placed revealing a visible vessel centered within the bear claw (Fig. 1B), effective hemostasis was achieved. A second look EGD three days later and repeat procedure at 4 weeks demonstrated healing of the ulcer (Fig 1C,D). At the last visit an EUS was performed revealing a 10mm CBD with smooth taper to the ampulla, without choledocholithiasis and a 5mm gallbladder polyp. Gastric biopsies for helicobacter pylori were negative. The patient's pain had resolved by that time. The OTSC was designed to ensnare a large amount of tissue to facilitate closure of perforations, fistulas and anastomotic leaks. However, the nitinol made clip has seen its use expand to hemostasis and stent fixation. Posterior duodenal bulb ulcers can present a challenge for the endoscopist. The position may not provide adequate access for management with endoscopic clips or the heater probe. Clips may fall off, injuring the culprit vessel and thereby initiating a cascade of further GI bleeding. In this case, the OTSC easily achieved hemostasis. In addition to acid suppression therapy the OTSC provided adequate ulcer healing in a few days with complete resolution of the duodenal ulcer at 4 weeks. This case demonstrates the expanding role of OTSCs in the gastroenterologist's management of bleeding ulcers.Figure 1