MULTIPLE OVER-THE-SCOPE CLIPS (OTSCS) AS FIRST-LINE THERAPY OF WIDE DUODENAL BLEEDING ULCER IN ANTICOAGULATED PATIENT: A VIDEO REPORT

The Over-The-Scope Clip (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) is a safe and effective tool for the treatment of bleeding and perforations of the gastrointestinal (GI) tract.

Concerning GI bleeding, it is recommended as rescue therapy after failure of primary hemostasis, but it is also useful as first-line therapy, particularly in high-risk lesions located in difficult sites (i.e. angulus, posterior duodenal wall) or in high-risk patients (ongoing anti-thrombotic therapy).

To the best of our knowledge, the successful placement of 3 adjacent OTSCs as primary hemostasis of a wide high-risk duodenal ulcer has not been described in medical literature.

Here, we report the case of a 76-years-old man hospitalized for pneumonia complicated by new-onset atrial fibrillation. After the beginning of anticoagulation therapy, melena and anemia occurred. Emergency upper GI endoscopy showed a wide (40 mm in diameter) Forrest IIa ulcer, with 3 bleeding vessels, on the supero-anterior duodenal wall, near to the Vater papilla.

Considering the overall high risk of therapeutic failure and rebleeding, three non-traumatic 11/6 mm OTSCs adjacent to each other were successfully deployed with suction technique, paying attention to avoid any involvement of Vater papilla. Complete hemostasis was obtained and no lumen stenosis occurred.

Few days later, second endoscopic look confirmed the 3 OTSCs with progressive ulcer's healing and the patient was discharged home on anti-thrombotic therapy.

In conclusion, even though the procedure is challenging, the closely placement of 3 OTSCs is feasible and effective as first-line treatment of wide high-risk ulcer in patient ongoing anti-thrombotic therapy. However, particular caution is necessary to avoid biliary and/or pancreatic injuries.