Hemostatic Clip in Gastrointestinal Bleeding

Objectives

Gastrointestinal bleeding is one of the most common emergencies in gastroenterology practice. In about 90% of patients, the source of bleeding is localized to the upper gastrointestinal tract, in 9% to the colon, and in 1 % to the small bowel. Thus most lesions are accessible for endoscopic treatment. Amongst the common causes of severe upper gastrointestinal bleeding, gastroduodenal ulcers and esophageal varices are the leading ones. Less common causes include Mallory-Weiss tears, Dieulafoy lesions, angiomas, and antral vascular ectasia, etc. In the lower gastrointestinal tract, hemorrhoids, colonic diverticula, arteriovenous malformations, polypectomy, and, rarely, rectal injuries can induce severe bleeding. On the other hand, acute bleeding from polyps and tumors is rare. Most lesions located in the upper and lower gastrointestinal tract are accessible for endoscopic treatment. The different endoscopic hemostatic methods available include injection (using sclerosants like polidocanol, ethanolamine, alcohol, hypertonic saline, etc., or nonsclerosing substances like diluted epinephrine), thermal treatment (heater probe, monopolar or multipolar electrocoagulation, laser, argon plasma coagulation, etc.), and more recently mechanical methods (hemoclip, endoloop, and band ligation) [1].

Of all the nonvariceal causes, bleeding from gastroduodenal ulcers is the most extensively studied. The outcome of ulcer bleeding depends on the age of the patient, presence of co-morbid conditions, type of bleeding (spurting or oozing, Forrest classification), and the endoscopic technique used to obtain hemostasis. The only variable that we can readily affect is the endoscopic intervention in patients with spurting arterial bleeding or in those with nonbleeding visible vessels. Hayashi et al. pioneered the development of a staunch clip for endoscopic use in 1975 [2]. Later, Hachisu improved the mechanics of the clip applicator to enable endoscopic hemostasis [3]. With the availability and widespread use of the reusable, rotatable hemoclip device, there is already a significant trend towards improvement in the rebleeding rates in a particular subset of patients with spurting arterial bleeds [4],[5].

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