Standard Endoscopic Therapy Research Articles

Efficacy and safety of over-the-scope-clips in the therapy of acute nonvariceal upper gastrointestinal bleeding: Meta-analysis.

Acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is a frequent life-threatening acute condition in gastroenterology associated with high morbidity and mortality. Over-the-scope-clip (OTSC) is a new endoscopic hemostasis technique, which is being used in ANVUGIB and is more effective. To summarize and analyze the effects of the OTSC in prevention of recurrent bleeding, clinical success rate, procedure time, hospital stay, and adverse events in the treatment of ANVUGIB, to evaluate whether OTSC can replace standard endoscopic therapy as a new generation of treatment for ANVUGIB. The literature related to OTSC and standard therapy for ANVUGIB published before January 2023 was searched in PubMed, Web of Science, EMBASE, Cochrane, Google, and CNKI databases. Changes in recurrent bleeding (7 or 30 days), clinical results (clinical success rate, conversion rate to surgery, mortality), therapy time (procedure time, hospital stay), and adverse events in the OTSC intervention group were summarized and analyzed, and the MD or OR of 95%CI is calculated by Review Manager 5.3. This meta-analysis involved 11 studies with 1266 patients. Total risk of bias was moderate-to-high. For patients in the OTSC group, 7- and 30-days recurrent bleeding rates, as well as procedure time, hospital stay, and intensive care unit stay, were greatly inhibited. OTSC could significantly improve the clinical success rate of ANVUGIB. OTSC therapy did not cause serious adverse and was effective in reducing patient mortality. OTSC may provide more rapid and sustained hemostasis, and thus, promote recovery and reduce mortality in patients with ANVUGIB. In addition, the safety of OTSC is assured.

Pancreatic extracorporeal shock wave lithotripsy: a key technology truly improves treatment model for pancreatic stones

Abstract Chronic pancreatitis (CP) is characterized by irreversible destruction of pancreatic parenchyma, inflammatory cell infiltration and progressive fibrosis of pancreatic tissue. Obstruction of pancreatic duct by pancreatic stone is the common pathological change in the course of CP with the incidence of over 50 % at the diagnosis of CP. These ductal stones would cause pancreatic parenchymal hypertension and local ischemia, which was eventually followed by recurrent episodes of painful pancreatitis or other manifestations of pancreatic exocrine and endocrine insufficiency. Removing pancreatic stones has been confirmed as the core to reduce pressure, improve drainage and lessen pain. Surgical therapy achieves satisfying pain relief with more complications, higher cost and less repeatability compared with endoscopic therapy. Endoscopic retrograde cholangiopancreatography, which used to be the standard endoscopic therapy for pancreatic stones, would fail if these stones are large or complex, while pancreatic extracorporeal shock wave lithotripsy (P-ESWL), which has been applied since 1987, could overcome this problem. Up to now, a large number of guidelines have recommended the P-ESWL as the first-line treatment strategy for radiopaque obstructive main pancreatic duct stones larger than 5 mm located in the head/body of the pancreas, and P-ESWL had completely changed the traditional treatment model for CP patients with pancreatic stones. In this article, we will focus on the technical progress, efficacy, safety and potential research areas of P-ESWL, we also give us suggestions for lithotripters improvement.

The use of cap-mounted clips as a primary hemostatic modality in nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized trials.

Cap-mounted-clips, especially Over-The-Scope-Clip (OTSC™), are recommended for recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB). There has been recent interest in their use as an initial hemostatic modality. We performed a systematic review of randomized controlled trials (RCTs) assessing cap-mounted clips' efficacy as a primary hemostatic modality in NVUGIB. A literature search of MEDLINE, EMBASE, and ISI Web of Science databases up to April 2024 identified RCTs comparing cap-mounted clips to standard endoscopic therapy (SET) as a primary hemostatic modality in NVUGIB. The primary endpoint was the composite outcome of further bleeding (persistent or recurrent) at 30 days. Secondary outcomes included persistent bleeding at index endoscopy and 30-day rebleeding, individually. Other pertinent outcomes were also recorded. A meta-analysis was performed to determine pooled risk ratios (RRs), comparing cap-mounted clip to SET. Out of 516 citations, five RCTs (n = 555), all assessing OTSC™, were included. The composite outcome of further bleeding was lower with cap-mounted clip versus SET (RR = 0.33 [95% confidence interval {CI}: 0.20-0.54]). There was no difference in persistent bleeding at initial endoscopy (RR = 0.30 [95% CI: 0.07-1.30]), but 30-day rebleeding was lower with cap-mounted clip (RR = 0.38 [95% CI: 0.21-0.70]). There were no differences in other outcomes. Grading of the evidence ranged from very low to moderate, mainly due to risk of bias and imprecision. Cap-mounted clips may be an efficacious primary hemostatic modality, associated with a lower further bleeding at 30 days compared to SET in NVUGIB. However, due to limitations in existing evidence, further research must better characterize an optimal subgroup of patients benefiting most from this approach before adopting its routine use.

The efficacy of sclerotherapy as the initial treatment in patients with bleeding from Dieulafoy's lesion of the upper gastrointestinal tract.

Dieulafoy's lesion (DL) is a rare and important cause of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), however, there is a lack of clear guidelines focus on the endoscopic hemostasis treatment for DL. Sclerotherapy, as the ANVUGIB guideline recommended endoscopic hemostasis method, is widely used in clinical practice. The aim of this study is to investigate the efficacy of sclerotherapy as the initial treatment for Dieulafoy's lesion of the upper gastrointestinal tract (UDL). Patients with UDL who underwent the ANVUGIB standard endoscopic hemostasis between April 2007 and January 2023 were enrolled. The endoscopic therapy method was left to the discretion of the endoscopist. In total, 219 patients were finally obtained, with 74 (33.8%) receiving sclerotherapy and 145 (66.2%) receiving other standard endoscopic therapy. The rebleeding within 30days was significantly lower in the sclerotherapy group compared to the other standard group (5.8% vs. 16.8%, p = 0.047). There were no significant differences between the two groups in terms of successful hemostasis rate (93.2% vs. 94.5%, p = 0.713), median number of red blood cell transfusions (3.5 vs. 4.0 units, p = 0.257), median hospital stay (8.0 vs. 8.0days, p = 0.103), transferred to ICU rate (8.1% vs. 6.2%, p = 0.598), the need for embolization or surgery rate (12.2% vs. 9.7%, p = 0.567) and 30-day mortality (0 vs. 2.1%, p = 0.553). In addition, we found no difference in efficacy between sclerotherapy alone and combination (3.1% vs. 8.1%, p = 0.714). Further analysis revealed that thermocoagulation for hemostasis was associated with a higher rate of rebleeding (28.6% vs. 3.1%, p = 0.042) and longer hospital stay (11.5 vs. 7.5days, p = 0.005) compared to sclerotherapy alone. Sclerotherapy represents an effective endoscopic therapy for both alone and combined use in patients with upper gastrointestinal Dieulafoy's lesion. Therefore, sclerotherapy could be considered as initial treatment in patients with bleeding of UDL.

Over-the-scope clip as first-line treatment of peptic ulcer bleeding: a multicenter randomized controlled trial (TOP Study).

First-line over-the-scope (OTS) clip treatment has shown higher efficacy than standard endoscopic therapy in acute nonvariceal upper gastrointestinal bleeding (NVUGIB) from different causes. We compared OTS clips with through-the-scope (TTS) clips as first-line mechanical treatment in the specific setting of peptic ulcer bleeding. We conducted an international, multicenter randomized controlled trial on consecutive patients with suspected NVUGIB. Patients with Forrest Ia-IIb gastroduodenal peptic ulcer were randomized 1:1 to OTS clip or TTS clip treatment. The primary outcome was the rate of 30-day rebleeding after successful initial hemostasis. Secondary outcomes included the rates of successful initial hemostasis and overall clinical success, defined as the composite of successful initial hemostasis and no evidence of 30-day rebleeding. 251 patients were screened and 112 patients were randomized to OTS (n = 61) or TTS (n = 51) clip treatment. The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/51) in patients treated with OTS clips and TTS clips, respectively (Kaplan-Meier log-rank, P = 0.46). Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P = 0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P = 0.001). Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy than TTS clips in achieving successful initial hemostasis and overall clinical success.

Valuing innovative endoscopic techniques: hemostatic powder for the treatment of GI tumor bleeding

Access to new endoscopic treatment modalities often depends on price. To resolve this gap and therefore help to ensure that care delivery can occur on a clinical basis, we aimed to establish the value to insurers of novel hemostatic powder to treat GI tumor bleeding. A decision-analytic model developed to assess the impact of endoscopic intervention on the risk of 30-day readmission for GI bleeding from an insurer perspective was adapted to assess GI tumor bleeding with hemostatic powder or standard endoscopic therapy. Costs were derived from Medicare populations. Outcomes were derived from a recent multicenter randomized clinical trial. Costs ranged from $651 to $1613 to treat upper GI tumor bleeding and from $531 to $1014 to treat lower GI tumor bleeding based on risk reduction in 30-day hospital readmission for recurrent bleeding. These valuations should represent medical device and incremental facility costs in addition to incremental physician and staff time. Coverage for novel endoscopic hemostatic powder therapy seems cost-saving to insurers.

Precise application of topical tranexamic acid to enhance endoscopic hemostasis for peptic ulcer bleeding: a randomized controlled study (with video)

Peptic ulcer recurrent bleeding occurs in 20% to 30% of patients after standard endoscopic hemostasis, particularly within 4 days after the procedure. The application of additional tranexamic acid (TXA) to the ulcer may enhance hemostasis. This study investigated the effectiveness of TXA powder application on bleeding ulcers during endoscopic hemostasis. This study enrolled patients who had peptic ulcer bleeding between March 2022 and February 2023. After undergoing standard endoscopic therapy, the patients were randomly assigned to either the TXA group or the standard group. In the TXA group, an additional 1.25 g of TXA powder was sprayed endoscopically on the ulcer. Both groups then received 3 days of high-dose (8 mg/h) continuous infusion proton pump inhibitor therapy. Second-look endoscopy was conducted on days 3 to 4. The primary end point of early treatment failure was defined as ulcer recurrent bleeding within 4 days or major stigmata of recent hemorrhage on the second-look endoscopy. Sixty patients (30 in each group) with peptic ulcer bleeding and balanced baseline characteristics were randomly assigned to a treatment group. The early treatment failure rate was lower in the TXA group (6.7%) than in the standard group (30%) (P= .042). The freedom from treatment failure periods for 4 and 28 days was significantly longer in the TXA group than in the standard group (P= .023). No adverse events from TXA were recorded. The precise delivery of topical TXA alongside standard endoscopic hemostasis reduced the early treatment failure rate in patients with bleeding peptic ulcers. (Clinical trial registration number: NCT05248321.).

Hemostatic spray (TC-325) vs. standard endoscopic therapy for non-variceal gastrointestinal bleeding: A meta-analysis of randomized controlled trials.

Background and study aims Hemospray (TC-325) is a mineral powder with adsorptive properties designed for use in various gastrointestinal bleeding (GIB) scenarios. We conducted a systematic review & meta-analysis of randomized controlled trials (RCTs) comparing TC-325 to standard endoscopic therapy (SET) for non-variceal GIB (NVGIB). Methods Multiple databases were searched through October 2022. Meta-analysis was performed using a random-effects model to determine pooled relative risk (RR) and proportions with 95 % confidence intervals (CI) for primary hemostasis, hemostasis failure, 30-day rebleeding, length of stay (LOS), and need for rescue interventions. Heterogeneity was assessed using I 2 %. Results Five RCTs with 362 patients (TC-325 178, SET 184) - 123 females and 239 males with a mean age 65 ± 16 years). The most common etiologies were peptic ulcer disease (48 %), malignancies (35 %), and others (17 %). Bleeding was characterized as Forrest IA (7 %), IB (73 %), IIA (3 %), and IIB (1 %). SET included epinephrine injection, electrocautery, hemoclips, or a combination. No statistical difference in primary hemostasis between TC-325 compared to SET, RR 1.09 (CI 0.95-1.25; I 2 43), P = 0.2, including patients with oozing/spurting hemorrhage, RR 1.13 (CI 0.98-1.3; I 2 35), P = 0.08. Failure to achieve hemostasis was higher in SET compared to TC-325, RR 0.30 (CI 0.12-0.77, I 2 0), P = 0.01, including patients with oozing/spurting hemorrhage, RR 0.24 (CI 0.09 - 0.63, I 2 0), P = 0.004. We found no difference between the two interventions in terms of rebleeding, RR 1.13 (CI 0.62-2.07, I 2 26), P = 0.8 and LOS, standardized mean difference (SMD) 0.27 (CI, -0.20-0.74; I 2 62), P = 0.3. Finally, pooled rate of rescue interventions (angiography) was statistically higher in SET compared to TC-325, RR 0.68 (CI 0.5-0.94; I 2 0), P = 0.02. Conclusions Our analysis shows that for acute NV GIB, including oozing/spurting hemorrhage, TC-325 does not result in higher rates of primary hemostasis compared to SET. However, lower rates of failures were seen with TC-325 than SET. In addition, there was no difference in the two modalities when comparing rates of rebleeding and LOS.

Use of over-the-scope clip (OTSC) versus standard therapy for the prevention of rebleeding in large peptic ulcers (size ≥1.5 cm): an open-labelled, multicentre international randomised controlled trial

IntroductionOver-the-scope clip (OTSC) has been used recently for primary haemostasis of peptic ulcers. This study aimed to compare the efficacy of OTSC to standard endoscopic therapy in primary treatment of...

S2576 Application of Hemospray for Metastatic Bleeding Gastric Adenocarcinoma: A Case Report

Introduction: TC-325 hemostatic powder (Hemospray) is a mineral-based topical agent that acts as a mechanical barrier over a bleeding site. It is a non-invasive, safe, and effective modality in controlling active GI bleeding, with immediate response. Here, we present a case of bleeding metastatic gastric adenocarcinoma managed with Hemospray after the failure of standard endoscopic therapy. Case Description/Methods: A 64-year-old male presented to the emergency room (ER) for symptomatic anemia. His hemoglobin was 4.6 g/dL. CT imaging showed gastric cardia lesion with multiple hepatic metastases. After blood transfusion, EGD (Figure 1a) showed a cardia lesion with oozing blood from multiple sites. Endoscopic ultrasound with fine-needle aspiration, showing atypical cells. The patient continued to have melena requiring transfusions. CT angiogram was negative. Partial gastrectomy was not performed due to peritoneal carcinomatosis. Endoscopic hemostasis with epinephrine and clips failed (Figure 1b). Hemospray was deployed (Figure 1c) with an immediate response. Later patient underwent left gastric artery embolization (Figure 1d), liver biopsy and peritoneal node sampling that suggested metastatic adenocarcinoma with primary gastric malignancy. The patient and his family opted for palliative care and was discharged. Discussion: Gastric cancer accounts for 2-8% of overall UGIB and 58% bleeding risk compared to other GI malignancies. There are no specific guidelines and only limited evidence was available on managing malignancy-related UGIB. Nonresponsive, inoperable metastatic gastric cancer bleeding is challenging and extremely difficult to manage using conventional hemostasis techniques. Based on our case, we recommend utilizing Hemospray as a first-line, monotherapy or in combination to control bleeding until a definitive treatment, reducing morbidity and mortality.Figure 1.: (A) Submucosal gastric fundal mass distal to gastroesophageal junction with blood oozing from multiple sites (arrows), (B) Image showing endoscopic hemostatic clips placement (arrowheads), (C) Application of Hemospray over the Gastric Mass after unsuccessful attempts using standard-of-care hemostatic methods, (D) Showing embolization of the left gastroepiploic artery.

Number of endoscopic sessions to eradicate varices identifies high risk of rebleeding in cirrhotic patients

Background and aimsRisk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding.Patients and methodsConsecutive cirrhotic patients received sequential endoscopic therapy between January 2015 and March 2020 were enrolled. Endoscopic treatment was performed every 1–4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding.ResultsA total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times versus ≤ 3 times (61.5% vs. 17.5%, p < 0.001). Variceal rebleeding of patients with endoscopic sessions ≤ 3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p < 0.001) and endoscopic therapy (15.9% vs. 47.1%, p = 0.028) respectively.ConclusionThe number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered.

Over-the-Scope Clip Applications as First-Line Therapy in the Treatment of Upper Non-variceal Gastrointestinal Bleeding, Perforations, and Fistulas.

BackgroundThe over-the-scope clip (OTSC) is an innovative device and has been successfully used in endoscopic treatment, however, there is a lack of clinical data from China. The aim of this study is to investigate the OTSC applications in the treatment of upper non-variceal gastrointestinal bleeding (UNVGIB), perforations, and fistulas in China.MethodsIn total, 80 patients were treated with one OTSC respectively as first-line therapy in our endoscopy center between January 2016 and November 2020. Among them, 41 patients had UNVGIB, 34 patients had perforations, and five patients had fistulas. The technical and clinical success rates were used to assess the efficacy of OTSC on the above diseases. In addition, we compared the hemostatic efficacy of OTSC with the standard endoscopic therapy in ulcer bleeding and Dieulafoy's lesion by propensity score matching analysis.ResultsIn general, the OTSCs were applied successfully in all patients and achieved 100% (80/80) technical success. The clinical success of all patients was 91.3% (73/80). Among 41 patients with UNVGIB, the clinical success was 85.4% (35/41); 6 patients presented with recurrence. For patients of Dieulafoy's lesion and under antithrombotic therapy, we found that OTSC treatment had both efficient and reliable hemostasis effects. In addition, according to the characteristics of ulcers, site of bleeding lesion, and Blatchford score, all patients received similar and reliable clinical success rates. After propensity score matching, we found that OTSC treatment had low rebleeding rates when compared with standard endoscopic therapy in both Dieulafoy's lesion (15.0 vs 30.0%) and ulcer bleeding (17.6 vs 29.4%). Among 34 patients with perforations, the clinical success was 100% (34/34). Among five patients with fistulas, only one patient failed in maintaining the OTSC before esophageal fistula healing, and the clip achieved an overall clinical success of 80% (4/5).ConclusionThe OTSC represents a safe and effective endoscopic therapy for UNVGIB, perforations, and fistulas as first-line treatment, especially for Dieulafoy's lesion or patients under antithrombotic therapy for UNVGIB, etc. However, OTSC application in these specific lesions or patients lacks adequate evidence as first-line treatment. Therefore, further larger sample and multi-center clinical trials are required to improve its indications in clinical treatment.

Over-the-scope clip as first-line therapy for ulcers with high-risk bleeding stigmata is efficient compared to standard endoscopic therapy.

Background and study aims Ulcers with high-risk stigmata have significant rebleeding rates despite standard endoscopic therapy. Data on over-the-scope clip (OTSC) for recurrent bleeding is promising but data on first line therapy is lacking. We report comparative outcomes of OTSC as first-line therapy versus standard endoscopic therapy in ulcers with high-risk stigmata. Patients and methods Consecutive adults who underwent endoscopic therapy for ulcers with high-risk stigmata between July 2019 to September 2020 were included. Patients were grouped into OTSC or standard therapy based on first-line therapy used on index endoscopy. Outcomes measured included: 1) intra-procedural hemostasis based on endoscopic documentation of adequate hemostasis; 2) 7-day rebleeding (> 2 g/dL drop in hemoglobin, hematochezia or hemorrhagic shock); 3) cost of endoscopic interventions; and 4) procedure duration measured as endoscope insertion to removal time. Cost of tools used during the index endoscopy was included. Results Sixty-eight patients were included, 47 were in standard therapy and 21 in the OTSC group. Hemostasis was achieved in 95.2 % in the OTSC group compared to 83.0 % in the standard therapy group ( P = 0.256, number needed to treat [NNT]: 9). Procedure time was shorter in the OTSC group (23 vs. 16 minutes, P = 0.002). Cost of endoscopic interventions were comparable, P = 0.203. Early rebleeding was less often in OTSC group, two (9.5 %) compared to 10 (21.3 %) in standard therapy group, NNT 9. Conclusions Use of OTSCs as first-line treatment for ulcers bleed probably improves hemostasis and decreases early rebleeding. Use of OTSC as first-line therapy shortened procedure duration without increasing the cost of endoscopic interventions.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.

S3179 Over-the-Scope Clip vs Standard Endoscopic Hemostatic Therapy in Upper GI Bleeding: Meta-Analysis of Randomised Control Trials

INTRODUCTION: Endoscopy hemostasis is an effective way to treat upper GI bleeding from causes like peptic ulcer disease, AVMs etc. However, recurrence of bleeding is also common and is associated with significant morbidity and mortality. The methods of hemostasis are adrenaline combined with through-the-scope clips (TTSCs) or thermal/heat methods which is also considered to be the standard endoscopic therapy (ST). Lately, Over-the-scope clips (OTSC) have been increasingly used for the treatment of severe upper gastrointestinal bleeding. We conducted a meta-analysis of randomized control trials (RCT) which compared ST vs OTSC for hemostasis in upper GI bleeding and risk of rebleeding. To our knowledge, this is the first meta-analysis that includes only RCT studies pertaining to this topic. METHODS: PubMed, Embase and Web of knowledge, reference lists of retrieved articles, and conference abstracts were searched for relevant studies (Search date May-2020). Only Randomized control studies were included. Standardized forms were used to extract data. Data was extracted by two reviewers independently. Statistical analysis was performed using Comprehensive Meta- analysis software. Heterogeneity and publication bias were also assessed. RESULTS: Only Two studies met our inclusion criteria. Pooled number of patients in ST group was 58 (sample size as 23-35) and in the OTSC group were 57 (Sample size as 24-33). Age ranged from 66-78 in both groups. Female gender ranged from 16 to 48% in ST group and 25% to 39.3% in OTSC group. The average blood transfusion required in ST was 3.2 (range 2-4) as compared to OTSC group was 2.4 (range 1.8-3). OTSC was associated with a lower rate of 30 days re-bleeding rate when compared with ST (RR 0.27, 95% CI 0.08-0. 82; P = 0.021). Other secondary endpoints including mortality, surgery, need for embolization were statistically not different in both groups. CONCLUSION: OTSC was associated with a lower 30-day re-bleeding rate as compared to ST.Figure 1

Endoscopic vacuum therapy with instillation (iEVT) - a novel endoscopic concept for colorectal anastomotic leak and perianal complications.

IntroductionAnastomotic leaks remain the most fearful complications.AimWe present a novel endoscopic salvage therapy known as endoscopic vacuum therapy with instillation (iEVT) as a combination of standard endoscopic vacuum therapy (EVT) and negative pressure wound therapy with instillation (iNPWT).Material and methodsA case series of 6 consecutive patients treated with iEVT is presented. A Redon drain and a central venous catheter were introduced within polyurethane foam used as a self- made device for iEVT and antimicrobial solution was instilled.ResultsA total of 6 patients with the mean age of 29.5 ±8.9 were treated with iEVT. The mean number of iEVT sessions was 5.8 ±2.3. The mean time of iEVT management was 20.7 ±8.8 days. Locally, a reduction in purulent discharge and defect’s dimension with contraction were revealed confirmed with imaging studies.ConclusionsiEVT is a very encouraging, novel method for complicated perianal diseases and anastomotic leak.

3129 Management of a Massive Peptic Ulcer Bleed With Over-the-Scope Clip

INTRODUCTION: Actively bleeding ulcers located in the posterior duodenal bulb are often difficult to manage with conventional endoscopic treatment. We present a case of a successful use of over-the-scope-clip (OTSC) of a spurting artery after failing multiple standard endoscopic therapies. CASE DESCRIPTION/METHODS: A 60 year-old man with a history of myocardial infarction in 2014 on aspirin and plavix presented with pre-syncopal symptoms and five episodes of melena that started one day prior to admission. The patient denied prior use of anticoagulants and history of gastrointestinal bleeding. Upon presentation, his vitals were stable and initial lab values were as follows: hemoglobin 9.8 g/dL (baseline 15 g/dL), platelet count 342 K/uL, INR 1.2, and BUN 29 mg/dL. He was started on an intravenous proton pump inhibitor. An esophagogastroduodenoscopy showed multiple large cratered ulcers measuring 1-2.5 cm involving most of the duodenal bulb. There was evidence of active bleedingfrom a spurting pulsatile vessel along the posteroinferior wall at the apex of the duodenal bulbnear the sweep (Figure 1). Initial attemptsat hemostasis wereunsuccessful despite injection of 1:10,000 solution of epinephrine andthe use of thehemostatic spray. The use of a coagulation forceps was unsuccessful as well. Given the location of the vessel and mucosal friability, the lesion was not amenable to through the scope clipping. Hemostasis was finally achieved after successful placement of a 12 mm OTSC (Figure 2). In addition, the area was retreated with the remainder of the hemostatic spray (Figure 3). The patient was transferred to the medical intensive care unit where overnight, the hemoglobin decreased from 8.2 g/dL to 7.2 g/dL without overt evidence of bleeding. The patient underwent angiography which did not reveal any active extravasation and empiric coil embolization of the gastroduodenal artery was performed. DISCUSSION: We present a case of a massive peptic ulcer bleed that was difficult to manage with standard treatment based on the large size and posterior bulb location. OTSC is commonly used for severe recurrent bleeding but its role during the index endoscopy is still unclear. OTSC should be considered as a potential first line therapy in bleeding lesions at high risk of standard endoscopic treatment failure.

1682 Jejunal Dieulafoy's Lesion

INTRODUCTION: Dieulafoy’s lesions (DLs) comprise 2% of acute gastrointestinal bleeds and are most commonly found in the stomach, though 3.5% of DLs occur in the small bowel. Jejunal DLs pose unique diagnostic and treatment challenges due to low incidence and the absence of standardized therapy. We present a case of acute, symptomatic anemia secondary to a jejunal DL. CASE DESCRIPTION/METHODS: A 64-year-old Hispanic woman with no significant past medical history presented with symptomatic anemia after three days of melena. She was hemodynamically stable with palpable internal hemorrhoids and brown stool on digital rectal exam. Her hemoglobin was 4.8 g/dL and responded to transfusion. Bidirectional endoscopy found antral erosions without stigmata of bleeding, small hemorrhoids, and dark stool throughout the colon. Capsule endoscopy revealed bright red blood at 23% progress through the small bowel. Subsequent anterograde single-balloon enteroscopy demonstrated an actively spurting DL in the mid-jejunum. Hemostasis was achieved with epinephrine injection and bipolar diathermy. The patient was followed for six months without evidence of re-bleeding. DISCUSSION: DLs are non-inflammatory, solitary mucosal defects with protrusion of an aberrant artery. Jejunal DLs comprise 1% of all DLs. Diagnosis is made endoscopically, but lesions are often unrecognized due to small size and preservation of surrounding mucosa. As such, multiple endoscopies are often required to reach a diagnosis. Initial endoscopy and colonoscopy are followed by capsule endoscopy in hemodynamically stable patients with suspicion of a mid-gastrointestinal bleed. Further approach with single or double balloon enteroscopy is preferred for the evaluation of jejunal DLs. With the expansion of endoscopic techniques, endoscopy has replaced surgery as first line treatment for small bowel DLs. However, there is no current standard endoscopic therapy, given that there is limited data directly comparing modalities for jejunal DLs. For general DLs, mechanical therapy is superior to either thermal or injection therapy. For ulcerative diseases, the use of two endoscopic techniques is superior to a single technique, alone. Thus, it has been suggested that the optimal treatment for jejunal DLs utilizes two endoscopic modalities, with one being mechanical, though further research is needed. Watch the video: http://bit.ly/2YZE0Zj.

Alternative approach to hemostatic particle spraying for treatment of GI bleeding by the use of cross-platform devices.

Background and AimsGI bleeding is a leading cause of morbidity and mortality in the United States, with an estimated 20,000 deaths per year. Some subgroups of patients show refractory recurrent bleeding despite standard endoscopic therapy. The U.S. Food and Drug Administration has recently approved a hemostatic spray for clinical use in nonvariceal bleeding. Despite its efficacy, not all endoscopy units have access to this spray, at times because of cost. Our aim was to determine the safety and efficacy of a plant-based hemostatic particle spray in nonvariceal GI bleeding by use of a cross-platform setup.MethodWe present 3 cases in which plant-based particle spray was used for hemostasis with a cross-platform delivery system. Conventional therapies failed in the first 2 cases, and in the third case hemostatic particle spray was used as a primary therapy.ResultsSuccessful immediate hemostasis was achieved in all 3 patients. No immediate adverse events or recurrence of bleeding was noted.ConclusionsPlant-based hemostatic particle spray is safe and effective as a temporizing measure in refractory ulcer and postnecrosectomy cavity bleeding. Further studies are needed to establish the safety and comparative efficacy of plant-based hemostatic powder. The cross-platform system used here for plant-based hemostatic particle spray presents a less-expensive alternative in selected cases.

Esophageal Stenting for Refractory Esophageal Variceal Bleeding

Esophageal variceal bleeding is a lethal complication in patients with cirrhosis. Occasionally, esophageal variceal bleeding is refractory to standard endoscopic and pharmacologic therapies. We discuss a case of bleeding esophageal varices that was treated with esophageal stenting as a bridge to emergent transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old female with a past medical history of alcoholic and hepatitis C virus (HCV) cirrhosis presented with large volume hematemesis. One week previously, she was admitted with hematemesis and during upper endoscopy, five bands were placed treating large distal esophageal varices. During the current admission, labs were remarkable for a hemoglobin of 8.8, down from 9.6 two days earlier, INR of 1.7, platelets of 146, and MELD-Na of 22. The patient was transfused one unit of packed red blood cells (PRBC) and maintained on intravenous octreotide and pantoprazole. During endoscopy, multiple large varices were found in the middle and distal third of the esophagus. Two bands were placed on the esophageal varices in the distal esophagus. One band detached immediately and large volume bleeding ensued. Placement of additional bands at the bleeding site was not possible due to scarring. A temporizing covered esophageal stent was deployed across the gastroesophageal junction to achieve hemostasis by tamponade while emergent TIPS was arranged. Meanwhile, her vitals remained stable and there were no further episodes of hematemesis. She underwent emergent TIPS with retrograde embolization of the esophageal collaterals, which she tolerated well. The plan was to remove the esophageal stent in two weeks. Unfortunately, the patient continued to decompensate and passed away during liver transplantation surgery. Current standard management of acute variceal bleeding includes adequate resuscitation, vasoactive medications, acid suppression, antibiotic prophylaxis, and endoscopic banding. Previously balloon tamponade was used and had complications including migration, aspiration, and tissue ischemia with mortality rates around 20%. Placement of self-expanding metal stents (SEMS) is an effective option for refractory variceal bleeding due to its high initial bleeding control rate, low rebleeding rate, and lower rate of adverse events compared to balloon tamponade. Our case revealed that SEMS is an effective temporizing measure for refractory esophageal variceal bleeding until TIPS can be performed.1981_A Figure 1. Large esophageal varices with presence of postbanding ulcer1981_B Figure 2. Wallflex stent deployed