Misinterpretation or Underestimation of the Appearance, Location, or Size of Non-bleeding Visible Vessels (Forrest Class IIa) as a Cause of Hemostasis Failure

Abstract

(1) Background: Endoscopy has become the primary diagnostic and treatment technique for non-variceal upper gastrointestinal bleeding. Despite advancements in therapeutic methods and instrumentation, endoscopic hemostatic failure occurs in 10% of patients. This study aimed to analyze endoscopic findings in patients with failed hemostasis and to elucidate strategies for endoscopists and gastroenterologists to facilitate improved treatment outcomes. (2) Methods: A total of 128 patients received hemostatic treatment for non-variceal upper gastrointestinal bleeding. Endoscopic findings in three patients in whom hemostasis could not be achieved after the initial and secondary endoscopies were analyzed. (3) Results: Hemostasis failure occurred in three cases (2.3%). All three cases involved patients with gastric ulcer and belonged to the Forrest class IIa category presenting with a non-bleeding visible vessel in endoscopic findings. Misinterpretation or underestimation of the appearance, location, or size of the vessel resulted in hemostasis failure. (4) Conclusions: Our findings demonstrate that identification of a non-bleeding visible vessel and assessment of the risk of re-bleeding in such vessels is often difficult. Detailed observation of the ulcer floor with awareness of the possibility of a non-bleeding visible vessel will lead to improved hemostatic treatment. The decision regarding hemostatic treatment of a visible vessel with a diameter larger than 2 mm should be made cautiously, and treatment should be followed by an appropriate fasting period under confirmatory endoscopy.