When Control of Bleeding Causes Bleeding! Rescuing of Massive Upper Gastrointestinal Bleeding Using Over-the-Scope Clip Developed After Conventional Endoscopic Therapy

Abstract

Upper gastrointestinal bleed (GIB) is divided to varcial and nonvariceal causes. Endoscopic therapy can be achieved using combination of different conventional modalities. To achieve better outcomes, GIB has to be managed promptly and effectively. These conventional techniques can fail in approximately 5-12% of cases. This leads to significant morbidity and mortality. Over the scope clip (OTSC) is a tool designed for closure defect but recently has been used to achieve hemostasis when other conventional modalities fails. Here, we report a case of rescue therapy using OTSC of massive UGI developed while conventional therapy was utilized. A 62-year-old male smoker with history of hypertension presented with melena, fatigue and dizziness for the last 3 days. He denied any previous GI bleeding, but reported taking NSAIDS heavily for the 2 weeks prior to presentation for osteoarthritis flare. He was hypotensive with tachycardia in the emergency room. Laboratory workup revealed hemoglobin of 7.6 mg/dl with BUN of 41 mg/dl and creatinine of 0.92 mg/dl. He was volume resuscitated with intravenous fluids, blood transfusions and pantoprazole infusion. Once stabilized, patient underwent prompt upper endoscopy which revealed presence of multiple 2-3 cm sized clean based gastric ulcers, one of which had a visible vessel (figure 1). Endo therapy was performed using local injection of 1:10,000 epinephrine followed by Bipolar Hemostasis coagulation therapy, the visible vessel opened spurting in a continuous high speed jet (figure 2). Rescue Hemostasis was promptly achieved using OTSC (figure 3). After endoscopic therapy the patient was continued on pantoprazole therapy in intensive care unit. For 3 consecutive days post procedure, all his parameter including hemoglobin remained stable with no evidence of recurrent bleeding. OTSC has been increasing used for hemostasis. Its design permits compression of large surface area including bleeding exposed vessels. This feature is helpful if the source of UGIB is surrounded by fixed harder tissue. It is fast to assemble and can be deploy using easy band-like ligation technique. In many recent studies, OTSC was used as a rescue modality after failure of conventional endoscopic modalities. In those studies, hemostasis was achieved with very few rebleeding rates. In this case we highlight the utility of OTSC as a rescue tool to achieve successful hemostasis when control Of GIB using conventional modalities may result in a worse bleeding adversarial effect. Further studies are needed to define the optimal use of this emerging tool as a secondary tool.Figure: Endoscopic Image showing large ulcer in the body of stomach with vessel (arrow) underneath.Figure: Endoscopic Image showing a spurting vessel in gastric ulcer.Figure: Endoscopic Image showing over the scope clip placed on spurting vessel in gastric ulcer with successful hemostasis.