The Long Life of a Clip

Abstract

Hemoclips are a very common and effective intervention used during colonoscopies to stop immediate bleeding. A recent survey of VA gastroenterologists reported that when hemostatic treatment was applied, 76% of physicians preferred a hemoclip.1 Although hemoclips are very common, there are no clear established guidelines for their use. Hemoclips typically fall off on their own within 1-2 weeks. However, there have been an increased number of cases where clips have been found as long as 2 years later.6,7 Here we describe a case of retained hemoclip for over one year and discuss the possible implications of such clips<./p> A 67 year old African American man with a history of multiple GI bleeds, iron deficiency anemia, CAD, paroxysmal Afib, and CVAs presented to the GI endoscopy suite for colonoscopy to evaluate iron deficiency anemia. One 10mm TA was removed by cold snare polypectomy in the cecum. Two TA in the ascending colon were also removed. No hemoclips were placed. Several days later, patient had significant GI bleed while on dual antiplatelet therapy after recent NSTEMI. EGD was normal. On colonoscopy, post-polypectomy sites seen in the cecum and ascending colon showed evidence of bleeding stigmata. 3 hemoclips were placed in the cecum and 1 was placed in ascending colon achieving hemostasis. Numerous hyperplastic polyps were also seen in the rectosigmoid colon with the plan to remove them in one year once off anti-platelets. On repeat colonoscopy 1 year later, 3 flat hyperplastic polyps were removed. Interestingly, a clip was also seen in the cecum at the site of the prior post polypectomy bleed. The case presented here is another example of hemoclips staying in place much longer than expected. While hemoclips can be excellent tools to achieve hemostasis, they are not completely benign. They are contraindications to MRI, and two years after endoscopy hemoclips would likely not have been considered. Abdominal radiographs have been suggested as a possible way to screen for retained clips prior to MRI.7 There has also been a case report of a GI bleed resulting from focal ulceration at the base of a retained clip, therefore these retained clips may pose as a risk factor for future bleeding.8 In scenarios where large polyps are removed, persistence of clips could interfere with detecting and treating any residual polyps<.sup>9 Therefore, it is important for physicians to consider these possible complications prior to placing hemoclips<./p>2933_A Figure 1. Hemoclip placed in cecum to achieve hemostatis after GI bleed.2933_B Figure 2. Retained hemoclip on colonoscopy over one year later.