An over-the-scope clip placed for large colonic perforation can be complicated by delayed bleeding despite its known hemostatic mechanical effect

The efficacy and safety of the over-the-scope clip (OTSC) to manage acute gastrointestinal defects have been demonstrated for several years [1]. Data have shown a technical success rate of almost 100 % [2], with very good safety [3]. The most common complication after the use of an OTSC for acute gastrointestinal defects is peritonitis, which occurs when leaks remain [4]. We present a case of delayed bleeding after the closure of an iatrogenic colonic perforation with an OTSC ([Video 1]).

Video 1 An over-the-scope clip (OTSC) placed for a large colonic perforation was complicated by delayed bleeding despite its known hemostatic mechanical effect.

A 48-year-old woman underwent a colonoscopy to rule out a colorectal tumor in the context of paraneoplastic polymyositis with severe malnutrition and ongoing corticosteroid therapy over several days. The colonoscopy was complicated by a sigmoid perforation caused by the scope (> 1 cm). This iatrogenic perforation was managed as per procedure by placement of an OTSC, with technical success. No surgery was necessary in the aftermath. However, 6 days after the successful closure, the patient developed hematochezia and a fall in her hemoglobin was noted. At the time, she was receiving ongoing anticoagulation for a mechanical mitral valve. A second endoscopy confirmed that there was bleeding at the site of the OTSC ([Fig. 1 a]). In fact, an enlarged pulsating vessel with active non-pulsating bleeding could be seen in the middle of the clip teeth ([Fig. 1 b, c]). Hemostasis was achieved with hot biopsy forceps coagulation ([Fig. 1 d]).

Fig. 1 Endoscopic images of delayed bleeding complicating the placement of an over-the-scope clip (OTSC) for colonic perforation showing: a bleeding from the center of the mucosa that had been trapped into the OTSC; b a vessel drawn into the OTSC teeth; c active bleeding after contact with the forceps; d the appearance after hot biopsy forceps coagulation.

This case highlights an unusual outcome of an OTSC that has not been well described in safety studies [4]. Furthermore, it is important to be aware of this surprising cause of bleeding, even though OTSCs are well known for their use in controlling bleeding.

In conclusion, bleeding can be a complication of an OTSC and it can present in a delayed manner. Despite the hemostatic features of OTSCs, it is important to do a second-look endoscopy to re-examine the OTSC site in patients who present with delayed bleeding.

Endoscopy_UCTN_Code_CPL_1AJ_2AZ

Competing interests

None

• References

• 1 Nishiyama N, Mori H, Kobara H. et al. Efficacy and safety of over-the-scope clip: including complications after endoscopic submucosal dissection. World J Gastroenterol 2013; 19: 2752-2760
• 2 Goenka MK, Rai VK, Goenka U. et al. Endoscopic management of gastrointestinal leaks and bleeding with the over-the-scope clip: a prospective study. Clin Endosc 2017; 50: 58-63
• 3 Raithel M, Albrecht H, Scheppach W. et al. Outcome, comorbidity, hospitalization and 30-day mortality after closure of acute perforations and postoperative anastomotic leaks by the over-the-scope clip (OTSC) in an unselected cohort of patients. Surg Endosc 2017; 31: 2411-2425
• 4 Manta R, Mangiafico S, Zullo A. et al. First-line endoscopic treatment with over-the-scope clips in patients with either upper or lower gastrointestinal bleeding: a multicenter study. Endosc Int Open 2018; 6: E1317-E1321