S3449 OVESCO Clip Can Save Lives - A Success Story of Non-Variceal Upper GI Bleed From a Large Vessel

Abstract

INTRODUCTION: The most common causes of upper GI bleed are non-variceal. Despite major advances in medical and endoscopic therapies, mortality rate and cost of hospitalization from upper GI bleed are still significant. We report successful use of Over-the-scope clip (OVESCO) in an elderly patient with cardiovascular and other comorbidities presenting with hemodynamically significant upper GI bleed. CASE DESCRIPTION/METHODS: A 79-year-old man with past medical history of CAD s/p CABG, AFib on eliquis, HTN, DM type 2 and CKD stage 3, presented to the ER with black tarry stool for one day and dizziness for one week. Vitals on admission were significant for BP 50/30mmHg and HR 110/min. Abdominal exam was negative for tenderness or stigmata of chronic liver disease. Rectal exam showed black stool. Laboratory findings were significant for Hct 26.2%, Hb 7.4g/dL (baseline ∼ 10), BUN 83mg/dL (baseline ∼ 17), Cr 1.3mg/dL (baseline ∼0.5), platelets 183K and INR 2.5. Elevated INR was attributed to eliquis. Patient was admitted to ICU. Resuscitation was initiated with IV fluids and PRBC transfusions to maintain SBP > 100 and Hb > 8 respectively. Prothrombin complex concentrate was given to normalize INR. Urgent upper endoscopy was done after resuscitation within 24 hours. This showed 5-6mm gastric antral ulcer with a large non-bleeding vessel about 3mm and blood. It was controlled by epinephrine injection around the vessel and OVESCO clip application to completely occlude the vessel and ulcer. Repeat upper endoscopy within 72 hours revealed atrophy of the vessel and absence of rebleed. Patient was restarted on anticoagulant after 72 hours and was discharged home. DISCUSSION: Peptic ulcer disease is the most common cause of NVUGIB. The timing of endoscopy is guided by overall clinical status and type of intervention depends on endoscopic findings. Our patient had high Glasgow Blatchford Score which placed him at high risk for mortality. Urgent upper endoscopy showed a large vessel within an antral ulcer, most likely a branch of the left gastric artery. We thought conventional endoscopic therapy like thermal or standard clips would be insufficient to achieve complete hemostasis and would carry risk of rebleed. Patient was high risk for surgery, therefore epinephrine injection followed by OVESCO clip was chosen to control the bleeding and was successful. To conclude, OVESCO clip should be a part of GI bleed kits in every endoscopy unit. It can be life-saving and spare repeat interventions such as IR therapy or surgery.Figure 1.: Upper endoscopy within 24 hours showing gastric antral ulcer 5–6mm with a large non-bleeding vessel about 3mm and blood.Figure 2.: Upper endoscopy within 24 hours showing OVESCO clip application.Figure 3.: Repeat upper endoscopy within 72 hours showing atrophy of the vessel and absence of rebleed.