Hemoclip Placement Research Articles

A Retrospective Analysis of Cyanoacrylate Injection versus Hemoclip Placement for Bleeding Dieulafoy's Lesion in Duodenum.

Background Duodenal Dieulafoy's lesion (DL) is a rare disease that may lead to lethal hemorrhage in the upper gastrointestinal tract. The best technique for endoscopic intervention still remains unclear. In the present study, we performed a retrospective analysis of cyanoacrylate injection versus hemoclip placement for treating bleeding DLs. Materials and Methods We retrospectively analyzed eighteen patients from three medical centers between October 2008 and February 2016; six patients received cyanoacrylate injection, while hemoclips were placed in 12 patients during the upper gastrointestinal endoscopy. Results All patients received first endoscopic examination and/or endotherapy within 12 hours of admission to hospital. No difference was observed in the primary hemostasis rate or the recurrent hemorrhage rate between the cyanoacrylate injection (CI) group and the hemoclip placement (HP) group, except that in one patient from the HP group melena was found three days after the first endotherapy. This patient received cyanoacrylate injection once again. Conclusion Both cyanoacrylate injection and hemoclip placement are effective in treating duodenal DL, and neither of them causes significant side effects.

Solitary Rectal Ulcer Syndrome with a Visible Vessel: An Uncommon Cause of Lower GI Bleeding

Solitary Rectal Ulcer Syndrome with a Visible Vessel: an Uncommon Cause of Lower GI Bleeding Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare condition affecting both healthy and immunocompromised patients. Presenting symptoms are diverse but can include rectal bleeding in up to 25% of patients. Case: A 51 year old man with PMH including HIV on HAART, HCV cirrhosis, c.difficile colitis and solitary rectal ulcer syndrome (SRUS) presented to the emergency room with new onset hematochezia and clot passage for 3 days. He reported associated tenesmus and constant left lower quadrant abdominal pain. His medical history was notable for diverticulosis and left hemicolectomy with renanastamosis 15 years prior. He reported recent anal intercourse with 1 partner and had used an enema for constipation prior to symptom onset. On evaluation, the patient was tachcardic and hypotensive. Physical exam was significant for left lower quadrant tenderness without rebound, guarding, or masses. Rectal exam showed gross blood, with mild tenderness on inspection and no hemorrhoids or fissures. Lab work demonstrated hemoglobin of 7.7 g/dL, WBC count of 2.1K/mcL, platelets of 57K/mcL and INR of 1.5. He received IV fluid and blood products and was admitted for further workup. Colonoscopy revealed persistent sharp angular ulcerations in the rectum without erythema or colitis. A prominent visible vessel seen in an ulcer bed. A hemoclip was placed successfully. Ulcer histopathology demonstrated mucosal prolapse without architectural distortion. Stains were negative for viral pathogens. The patient's hemoglobin stabilized and he was advised to avoid rectal trauma.Figure 1Figure 2Discussion: Symptoms of SRUS can include bleeding, mucoid discharge, perineal and abdominal pain, feeling of incomplete defecation, constipation and overt rectal prolapse. The pathogenesis is poorly understood but may be related to trauma or shear forces during defecation in combination with mucosal ischemia. Treatment options include bulking agents, topical therapies, biofeedback, and surgery. Bleeding from SRUS has been reported, but visualization of a visible vessel is rare. Dieulafoy-like lesions have been described in the context of stercoral ulcers but to our knowledge, no case of a visible vessel has been reported in SRUS. Endoscopic hemoclip placement was successful for acute treatment in this patient with follow up colonoscopy showing ulcer improvement after 6 weeks.

Successful Endoscopic Clipping of Appendiceal Orifice Bleeding: A Technical Maneuver to Convert an Emergency to an Elective Procedure

Objective: We report a rare case of an elderly man with appendiceal bleeding successfully treated with endoscopic placement of hemoclips. Methods: We describe the patient’s clinical presentation, laboratory test results, imaging, and treatment. Results: An 89-year-old man presented with two episodes of bloody diarrhea that occurred two hours apart. Colonoscopy revealed active bleeding from the appen- diceal orifice. Hemostasis was achieved with epinephrine injections followed by placement of five hemoclips to effectively close the appendiceal orifice. An abdominal computed tomography (CT) showed an irregular thick- ening of the appendix wall, raising the possibility of an appendiceal mass. On hospital day 4, the patient underwent appendectomy and partial cecectomy. Pathology revealed focal ulceration of the mucosa without malig- nancy. The remainder of the patient’s hospital course was uneventful.Conclusion: The endoscopic methods used in our case proved effective in achieving hemostasis and allowed the patient to be stabilized prior to surgery. It is unclear whether longer monitoring would reveal any possible long-term complications after endoscopic closure of the appendix. It would be of interest to further investigate this approach to assess the long-term safety and efficacy of this procedure.

Clinical outcome of endoscopic management of duodenal Dieulafoy's lesions: endoscopic band ligation versus endoscopic hemoclip placement.

The most appropriate type of endoscopic hemostasis for bleeding due to duodenal Dieulafoy's lesions (DLs) is not yet established. The aim of this study was to assess the efficacy of mechanical endoscopic hemostasis for duodenal DLs and long-term outcome after successful hemostasis, as well as to compare the efficacy and safety of endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP). Patients admitted to the emergency unit with acute upper gastrointestinal bleeding from duodenal DLs were enrolled in this study. The data were collected prospectively, but data analysis was performed retrospectively. Twenty-four patients with duodenal DLs were treated with EBL (n=11) or EHP (n=13). There were no significant differences between groups with respect to clinical or endoscopic characteristics, apart from the number of epinephrine (three cases with EBL vs. 11 cases with EHP; p=0.011). Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient (9.1%) from the EBL group and in five patients (38.5%) from the EHP group (p=0.166). The recurrent bleeding in the patient from the EBL group was treated by EHP. In the EHP group, all five patients achieved successful secondary hemostasis by endoscopic treatment (EBL in two patients and EHP in three patients). There were no differences in secondary outcomes between the two groups, including the number of endoscopic sessions required, need for angiographic embolization or emergent surgery, transfusion requirements, or length of hospital stay. No complications occurred, and there was no recurrence of bleeding in either group during the follow-up period. Mechanical endoscopic treatments are effective and safe for the treatment of bleeding duodenal DLs. A large-scale, randomized, controlled study is required to confirm the efficacy and safety of EBL and EHP for the management of bleeding duodenal DLs.

Endoscopic Repair of Gastrogastric Fistulas After Roux-en-Y Gastric Bypass

Introduction: Gastrogastric fistulas are a rare complication of Roux en Y gastric bypass. Several options exist for repair. Our goal was to present our experience with the use of an over the scope clip system for endoscopic intervention. This is a retrospective review from a university hospital where three patients have undergone endoscopic repair of gastrogastric (GG) fistulas using an over the scope clip (OTSC) system developed by OVESCOTM. Case Presentations: Patient 1, a 58 yo female, presented with increased food intake. She was found to have a GG fistula 2 months post Roux en Y bypass (RNY). Her postoperative course was complicated by a left subphrenic abscess and left empyema which necessitated a VATS procedure. Two fistulas were found at EGD, one of which measured 14 mm and the other 5 mm in diameter. Two hemoclips and one OTSC (12/6 GC) were applied to the larger defect and one hemoclip was applied to the smaller defect. Repeat upper GI series one month post EGD showed failure of fistula closure. Patient 2, a 69 yo female, presented with epigastric abdominal pain and was found to have a 4 mm GG fistula 34 months post RNY. She had lost ˜118lbs since bypass. On initial repair attempt the fistulous tract appeared to have closed after APC and hemoclip placement x 2, however the fistula was again noted on repeat upper GI series 4 months later. A follow up EGD was performed with successful OTSC deployment (12/6 GC). Patient 3, a 44 yo female, presented with epigastric abdominal pain, nausea, emesis, and weight gain and was found to have a 5 mm GG fistula 66 months post RNY. She had lost ˜ 435 lbs since bypass. Successful OTSC deployment was performed (12/6 GC). The patient experienced symptom relief on follow up. Discussion: The success of gastrogastric fistula repair using an OTSC system appeared to be influenced by several factors including size, acuity, and post operative complications. Smaller fistulas were closed with greater success. The time interval between bypass and fistula development seems to have influenced success as well with fistula closure achieved in patients with a mean development interval of 50 months. Small superficial mucosal tears, with no evidence of bleeding or perforation, were noted in the proximal esophagus in both successful cases. The use of an OTSC system represents a safe, minimally invasive strategy for endoscopic closure of gastrogastric fistulas ≤5 mm.Figure 1Figure 2Figure 3

Pyogenic Granuloma: A Rare Cause of Obscure Gastrointestinal Bleeding

Pyogenic granuloma is a lobular capillary hemangioma that occurs mostly on the skin, and occasionally on the mucosal surface of the oral cavity, but very rarely in the gastrointestinal tract. We report a case of a 63-year-old man who suffered from iron deficiency anemia with multiple syncopal episodes and intermittent melenic stools for the past 1 year. Multiple studies at various centers including esophagogastroduodenoscopies (EGDs), push enteroscopies, colonoscopies, bleeding scintigraphies, and abdominal CT scans during this time period could not reveal the bleeding source. He had not received medical treatment except for oral iron. The patient was transferred to our University hospital for further assessment after he presented to an outside facility with presycope, moderate volume melena, and a hemoglobin of 4.0 g/dl. Initially, a colonoscopy was done which only showed a scant amount of dark blood in the terminal ileum. Next, a video capsule endoscopy revealed a bleeding focus in the jejunum without a distinct etiology. Afterwards, antegrade and retrograde single balloon enteroscopies were planned to locate the source. During retrograde single balloon enteroscopy, a 15 mm pedunculated polypoid mass, with active bleeding, was found in the small intestine 90 cm away from the ileocecal valve (Image 1 and Image 2). The bleeding was controlled with epinephrine injection and hemoclip placement. The following day, surgical resection of the small bowel segment was performed. The histological features revealed a capillary hemangioma with a pyogenic granuloma pattern (Image 3). Shortly after resection, the patient's anemia improved and he had no further bleeding episodes. The small bowel is the source of gastrointestinal bleeding in 2% to 10% of all bleeding episodes. Vascular tumors of the small bowel are very rare, accounting for only 7% to 10% of all benign tumors of the small bowel. Pyogenic granulomas of the small bowel are difficult to diagnose, as they are usually inaccessible via conventional endoscopic techniques. This patient underwent a total of 8 endoscopic and radiologic procedures prior to finally visualizing this rare source of bleeding. This case demonstrates the challenges in the diagnosis and management of obscure GI bleeding. One should be aware of the rare causes of obscure GI bleeding such as pyogenic granuloma and utilize the appropriate diagnostic modalities such as capsule endoscopy and balloon-assisted enteroscopy in finding the source.Figure 1Figure 2Figure 3

Colonic Dieulafoy Lesion

A 76 year old man with hepatitis C cirrhosis complicated by hepatocellular carcinoma treated with embolization and ablation, ESRD on dialysis, diabetes, hypertension, and MGUS is admitted with shortness of breath for one week and chronic abdominal pain progressively worsening for several months. On admission, the patient denied bright red blood per rectum but then had a bloody bowel movement during evaluation. The patient became hypotensive to systolic blood pressures of 70 mmHg and found to have anemia with a hemoglobin of 6.8 g/dL. He received blood products, octreotide, nexium, and neosynephrine drips and admitted to the MICU. Emergent upper endoscopy showed portal hypertensive gastropathy and two small antral erosions in the stomach with bleeding that were cauterized. Flexible sigmoidoscopy revealed blood and clots in rectum but no bleeding source was identified. He was started on ceftriaxone for SBP prophylaxis. The patient continued to have hematochezia and subsequent colonoscopy showed blood throughout the colon, sparing the terminal ileum. A single site of bleeding was located 50 cm from the rectum suggestive of colonic dieulafoy where argon plasma coagulation and two hemostatic clips were successfully used for hemostasis. Following colonoscopy, his hemoglobin downtrended slowly despite normal stools and negative CT scan. The patient was weaned off pressor support and required no further transfusions. He developed septic shock of unclear etiology and despite aggressive treatment the patient expired. The Dieulafoy lesion is described as a tortuous, large-calibre arteriole protruding through a small defect in the mucosa. It represents only 1-2% of all gastrointestinal bleeds, but can result in massive and recurrent bleeding. Typically Dieulafoy lesions are localized to the stomach in 71% of cases whereas only 2% are found in the colon. These lesions can then be managed by epinephrine injection, thermal anticoagulation, or hemostatic clipping. Hemostatic clipping is more successful in achieving permanent hemostasis when compared to epinephrine injection; however, if the anatomy does not allow for accurate placement of hemoclips it may result in continued hemorrhage. Thus, it is important for clinicians to not only assume hematochezia is from a diverticular source, and maintain a high index of suspicion for the presence of Dieulafoy lesions in lower gastrointestinal bleeds to reduce the mortality associated with it.

Su1496 Delayed Post-Polypectomy Bleeding Is Not Prevented by Prophylactic Hemoclips: Experience At a Tertiary Academic Medical Center

Post polypectomy bleeding occurs in 0.3% to 6.1% of cases. Risk factors for post polypectomy delayed bleeding include polyp size, NSAIDs, anticoagulation, antiplatelets, and right colon location. Despite lack of evidence and increased cost, prophylactic placement of hemoclips is increasingly used to prevent delayed bleeding.

Endoscopic management of mallory-weiss tearing.

Mallory-Weiss tearing (MWT) is a common cause of non-variceal upper gastrointestinal bleeding. Although the majority of patients with bleeding MWT require no intervention other than hemodynamic supports, spectrum of MWT is wide, and the condition sometimes results in a fatal outcome. Endoscopic management to stop the bleeding may be required during the index endoscopy, especially in those with active bleeding or stigmata of recurrent bleeding. Most commonly used endoscopic treatment for actively bleeding MWT is injection therapy, argon plasma coagulation, hemoclip placement, and band ligation. Selection of the optimal endoscopic hemostasis depends on the physician's ability and patient's clinical status.

Utility of double-balloon enteroscopy in patients with left ventricular assist devices and obscure overt gastrointestinal bleeding.

Obscure overt gastrointestinal bleeding (OGIB) is a challenge in patients with left ventricular assist devices (LVADs). We evaluated the utility and safety of double-balloon enteroscopy (DBE) in patients with LVADs in an observational consecutive-patient cohort from a single tertiary referral center. Ten patients with LVADs underwent thirteen DBEs for obscure OGIB. The first OGIB event necessitating DBE occurred after a mean of 512 ± 363 days of LVAD support. All patients underwent DBE, eleven anterograde and two retrograde, with a mean insertion depth 176 ± 85 cm. Diagnostic yield was 69 % with the primary bleeding lesion most frequently found in the mid-bowel. The most common lesions were arteriovenous malformations. Therapeutic yield with argon plasma coagulation (APC), epinephrine injection, and/or hemoclip placement was 89 %. There were no procedure-related complications. DBE in patients with LVADs has good diagnostic yield and high therapeutic yield for obscure OGIB and is safe and well tolerated.

Efficacy of the Over-The-Scope Clip Device in the Management of Acute Gastroduodenal Artery Territory Bleeding From Duodenal Ulcers: A Single-Center Experience

Introduction: The over-the-scope clip (OTSC’) is a novel device for the management of acute bleeding originating from the gastroduodenal artery (GDA) territory. The compression force and volume of tissue captured are greater with OTSC relative to standard hemoclips. We compared the outcomes between OTSC® and standard hemoclips in the management of acute duodenal ulcer bleeding. Methods: We reviewed the electronic medical records of all patients evaluated in our tertiary referral center for acute duodenal ulcer bleeding between January 2005 and May 2014. Data were abstracted for demographic, comorbid conditions, and important clinical parameters such as anticoagulation status, INR, medication history and information on bleeding disorders and platelet dysfunction, outcomes related to hemostasis, re-bleeding, and re-intervention rates, number of clips placed, procedural adverse events, and cost-effectiveness of the procedure. Means and proportions between the 2 groups were compared. Results: A total of 828 patients had endoscopically confirmed acute duodenal source of bleeding. Of these, 211 patients underwent mechanical hemostasis as the primary treatment modality. Since 2008, in 25 patients (17 men), the source of bleeding was in the gastro duodenal artery territory, and this was treated with OTSC®. We identified 45 (35 men) age, location, and comorbidity matched controls between 2005 and 2008 who were treated with hemoclips. The rate of presumed re-bleeding requiring repeat endoscopy in OTSC patients was 32% compared to 33% in the hemoclip treated group (p=0.91). However, the re-intervention rate was 40% in the hemoclip group as compared to 28% in the OTSC® group (p=0.02). The average cost related to OTSC use was $511 +/- 225, as compared to $807 +/- 538 (p=0.01) related to hemoclip use. This can be attributed to the total number of clips utilized in patients undergoing hemoclip placement (mean: 3 SD: 2) as compared to patients treated with OTSC (mean: 1 SD: 0.3). The mean INR was 1.3 and there were no treatment-related adverse events in either of the groups. Conclusion: Patients who underwent OTSC management for acute GDA territory duodenal ulcer bleeding demonstrated a statistically significant reduction in the cost of clipping and required fewer re-interventions during follow-up as compared to patients who underwent hemoclip placement. A randomized controlled trial is recommended to confirm these findings.

The Prophylactic Placement of Hemoclips to Prevent Delayed Post-polypectomy Bleeding: An Unnecessary Practice? A Case Control Study

With the recent, widespread availability of endoscopic hemoclips, it has become common clinical practice to apply hemoclips to some non-bleeding polypectomy sites "prophylactically" to prevent delayed post-polypectomy bleeding (PPB). Few published data support this practice, however. The aim of this study was to compare rates of delayed PPB in matched patients who had polypectomies performed with and without the prophylactic placement of hemoclips. We reviewed medical records of patients who had elective colonoscopy at our VA Medical Center between July 2008 and December 2009. We identified patients who had hemoclips applied prophylactically (cases) and compared their rate of delayed PPB within 30 days to that of patients who had polypectomy without hemoclipping (controls). Controls were matched 1:1 to cases based on age and on factors known to contribute to the risk of PPB including polyp size, morphology, technique of polyp removal, number of polyps removed, and use of anticoagulants. We identified 184 patients (cases) who underwent prophylactic hemoclipping and 184 well-matched controls. An average of 3.8 polyps per patient were removed in the case group compared to 3.3 polyps per patient in controls (p = 0.6). Delayed PPB occurred in three patients in the prophylactic hemoclip group and in one patient in the control group (1.6 vs. 0.5 %, p = 0.62). We found no significant difference in the rate of delayed PPB between patients who had prophylactic hemoclipping of polypectomy sites and a well-matched control group of patients who had polypectomy without prophylactic hemoclipping. These data call into question the expensive practice of prophylactic hemoclipping.

Endoscopic Management of Rectal Dieulafoy's Lesion: A Case Series and Optimal Treatment.

Rectal Dieulafoy's lesion (DL) is rare cause of lower gastrointestinal bleeding. Because of its rarity, there is no consensus on the optimal endoscopic hemostasis technique for rectal DL. We analyzed six patients who underwent endoscopic management for rectal DL after presenting with hematochezia at a single institute over 10 years. Of the six patients, three underwent endoscopic band ligation (EBL) and three underwent endoscopic hemoclip placement (EHP). Only one patient was treated with thermocoagulation. There were no immediate complications in any of the patients. None of the patients required a procedure or surgery for the treatment of rebleeding. Mean procedure times of EBL and EHP were 5.25 minutes and 7 minutes, respectively. Both EHP and EBL are shown to be effective in the treatment of bleeding rectal DL. We suggest that EBL may have potential as the preferred therapy owing to its superiority in technical and economic aspects, especially in elderly and high-risk patients.

Lower GI Bleed due to Dieulafoy Lesion in Ascending Colon with Histopathological Confirmation

Figure: No Caption available.Purpose: Dieulafoy disease is a rare cause of upper gastrointestinal bleeding and even rarer for colonic bleed. The dieulafoy lesion of the colon was first described by Barbier in 1985.We present a patient who had multiple dieulafoy lesions in the ascending colon, underwent endoscopic therapy and finally surgical resection with histopathologic confirmation of the dieulafoy lesion underneath endoscopically applied hemoclips. Patient is a 71-year-old male with past medical history of coronary artery disease, stroke, and pulmonary embolism on Coumadin presented with symptomatic anemia due to lower GI bleed in December 2011. His Hb was 9 with normal MCV. At that time he was found to have a Dieulafoy lesion of the ascending colon and underwent endoscopic ablation with endoscopic hemoclip placement. He presented with recurrent lower GI bleeding three times in next 8 months needing colonoscopy each visit and underwent endoscopic placement of hemoclips and epinephrine injection of dieulafoy lesions with successful hemostasis. Videos and still images of the bleeding lesion were obtained as well as images of endoscopic metallic clip placement and injection therapy. Due to his history of pulmonary embolism requiring anticoagulation therapy, coronary artery disease and need for multiple blood transfusions of each episodes of GI bleeding, surgical consultation for colonic resection was obtained. Following resection of the ascending colon, the pathologist was able to perform cuts on gross specimen between the two endoclips applied during his last endoscopy and histopathologic evaluation confirmed the presence of a colonic Dieulafoy lesion. The patient has remained clinically stable without the further signs of GI bleeding since his colon resection. Colonic Dieulafoy lesions are uncommon source for gi bleeding but confirmation with histopathologic proof of the clinical impression is exceedingly rare.

Su1346 Prophalactic Hemoclip Application At ERCP to Prevent Post-ES Bleeding in Patients Receiving Anticoagulation or Antiplatelet Therapy

The risk of immediate or delayed post-endoscopic sphincterotomy bleeding (PESB) is reported to range from 2.0-5.3%, but can be as high as 10% to 25% in the setting of high risk patients (pts) receiving anti-platelet agents or anti-coagulation therapy. These pts present a particular challenge when definitive ERCP sphincterotomy (ES) is indicated. Mechanical clipping of PESB has been reported but infrequently used due to the difficulty in placing the current generation of clips using ERCP endoscopes as well as the potential risk of inadvertent application of clips on the pancreatic orifice. However, hemoclip placement has been shown to be highly effective in mechanical closure of a wide variety of bleeding and potential bleeding lesions of the GI tract. We present our single center experience with prophylactic hemoclip placement to prevent PESB in the setting of antiplatelet/anticoagulation Rx.

Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping

Predictors of refractory colonic diverticular hemorrhage after endoscopic clipping (EC) remain unclear. To elucidate the predictors of uncontrolled bleeding after EC. Retrospective study. Two tertiary referral centers. Eighty-nine patients with colonic diverticular hemorrhage who underwent EC as a first-line treatment were included. If bleeding remained uncontrolled after 1 or 2 EC sessions, other interventions (transcatheter arterial embolization, endoscopic band ligation, or surgery) were performed. Patients were divided into EC-controlled and EC-uncontrolled groups; the characteristics of each group were compared. Comorbidities, location of bleeding diverticula, and EC technique (direct vs indirect placement). Initial treatment with EC was successful in 87 patients. Early rebleeding (primary failure) occurred in 30 of 87 patients (34%). Secondary failure occurred in 6 of 22 patients treated with reclipping (27%). Cumulatively, 78 patients were successfully managed with EC. Non-EC treatments were required in 11 patients. Location in the right side of the colon, particularly in the ascending colon, was significantly more common in the EC-uncontrolled group than in the EC-controlled group (P = .017 and P = .0029, respectively). Although the difference was not significant, bleeding was successfully managed in all 13 patients treated with direct placement. Bleeding remained uncontrolled after EC in 11 of 52 ascending cases (21%) treated with indirect placement. Diverticular hemorrhage in other locations was managed regardless of EC technique. Retrospective study. Location in the ascending colon is a significant predictor of refractory colonic diverticular hemorrhage after EC. Indirect placement of hemoclips in ascending lesions is ineffective.

Su1333 The Prophylactic Placement of Hemoclips to Prevent Delayed Post Polypectomy Bleeding: An Unnecessary Practice?

Su1333 The Prophylactic Placement of Hemoclips to Prevent Delayed Post Polypectomy Bleeding: An Unnecessary Practice?

Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation

The most suitable mechanical endoscopic hemostasis for a bleeding Dieulafoy's lesion (DL) is not yet well established. To compare the hemostatic efficacy and clinical outcome of endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL). Retrospective, single-center study. A tertiary-care referral university hospital. Sixty-six patients who received mechanical endoscopic hemostasis for bleeding DLs. Endoscopic hemostasis. Primary hemostasis and rebleeding rates. DLs accounted for 3.8% of cases of acute nonvariceal upper GI bleeding during the study period. Active bleeding from DLs was noted in 34 patients (51.5%). EHP and EBL were performed as a method of endoscopic hemostasis in 34 and 32 patients, respectively. There were no significant differences between the 2 groups with respect to baseline characteristics (except comorbidities) and endoscopic features of DLs. Primary hemostasis was achieved in all 66 patients (100%). There were 6 cases of recurrent bleeding: 5 (14.7%) and 1 (3.1%) in the EHP and EBL groups, respectively. Secondary hemostasis was achieved with endoscopic treatment and angiographic embolization in 5 patients and 1 patient, respectively, and no patients required surgery. The mean procedure time of endoscopic hemostasis was significantly longer in the EHP group (19.1 vs 11.5 minutes, P = .015). There was no bleeding-related mortality. Retrospective analysis. Both EHP and EBL are suitable for the treatment of bleeding DLs. EBL can be used as an initial hemostatic method for bleeding DLs because of a favorable clinical outcome comparable to that with EHP and a shorter procedure time.

Esophageal Dieulafoy Lesion: Rare Cause of Massive Upper GI Bleeding

Purpose: Introduction The Dieulafoy lesion is tortuous large caliber arteriole protruding through small mucosal defect. It is uncommon cause of upper GI bleeding and accounts for about 2% of cases of bleeding from upper GI tract. Esophageal Dieulafoy lesion is extremely uncommon and less than 10 cases have been reported so far. We report a case of massive upper GI bleeding related to esophageal Dieulafoy lesion that was successfully managed by epinephrine injection and placement of hemoclips. Case Presentation 37 year old Hispanic man with history of alcohol abuse and gastroesophageal reflux disease presented to the emergency room with sudden onset hematemesis. He was actively vomiting a large amount of fresh blood and was intubated for airway protection. There was no prior history of NSAIDs use. He underwent esophagogastroduodenoscopy (EGD) with the finding of a small actively bleeding lesion with fresh adherent clot in the lower esophagus. A total of 4 cc of epinephrine (1 mg, 1:10,000) was injected around the lesion and the clot was suctioned. After removal of clot and irrigation, it was noted that there was a very small mucosal defect with prominent visible vessel in the center with active oozing of blood. At this point two hemoclips were applied over this Dieulafoy lesion with cessation of bleeding. The EGD was otherwise normal. Patient was observed in the intensive care unit over next 24 hours and eventually discharged within 72 hours. Discussion Dieulafoy lesions can cause massive, recurrent and sometimes life threatening gastrointestinal bleeding. In the upper gastrointestinal tract, the clinical presentation is hematemesis with or without aspiration pneumonia and melena. About 75-95% of the Dieulafoy lesions are found in the stomach, predominantly along the lesser curvature. However, Dielafoy lesions are also reported in the esophagus, small intestine and colon. Esophageal Dieulafoy lesions are extremely rare. With advances in the endoscopic technique over the years, endoscopic therapeutic interventions for bleeding Dieulefoy lesions are preferred over surgery as the initial management. Epinephrine injection with or without application of band ligation or hemoclip application are described in the literature as therapeutic options. In the only published randomized control trial comparing epinephrine injection alone versus band ligation, lower rebleeding rates were observed with band ligation. However, therapeutic efficacy of hemoclips has not been compared with band ligation due to the rare nature of the disease.

Rectal Dieulafoy Lesion Following Manual Disimpaction Successfully Treated with Hemoclip

Purpose: Rectal Dieulafoy lesions are a rare cause of lower gastrointestinal bleed with few case reports describing the etiology and treatment of these lesions. A majority of Dieulafoy lesions are found in the stomach, but other locations including small intestine, colon, and rectum have been reported with increasing frequency. We report a case of a rectal Dieulafoy lesion secondary to trauma from recurrent disimpaction treated successfully with hemoclip. Results: A 54-year-old female with history of multiple sclerosis presented with bright red blood per rectum associated with a near syncopal event. She denied using non-steroidal anti-inflammatory medications, prior ulcer disease, or history of GI bleeding. As stated, she had a history of multiple sclerosis and required periodic self disimpaction. Upon presentation, she was noted to be hypotensive and tachycardic. Following aggressive resuscitation, her blood pressure improved, but she remained tachycardic. Her initial hemoglobin was 11.7 g/dL. During her evaluation in the emergency department, she continued to have bright red blood per rectum and a drop in hemoglobin to 10.1 g/dL. Flexible sigmoidoscopy was performed with visualization of a pulsating Dieulafoy lesion in the rectum approximately 4 cm from the dentate line. The Dieulafoy lesion was treated successfully with one hemoclip without further bleeding. She was monitored closely and placed on aggressive bowel protocol to alleviate the need for disimpaction. Her blood counts remained stable and there were no further episodes of bleeding. Upon follow up a couple months later, she was doing well with no further need for self disimpaction or recurrent bleeding.Figure: Rectal Dieulafoy lesion.Figure: Rectal Dieulafoy lesion following hemoclip placement.