Combined over-the-scope clip and detachable snare placement as a rescue therapy for gastric ulcer rebleeding

An 85-year-old woman, who had been admitted to an intermediate care unit of a peripheral hospital with relapsing ulcer bleeding, was referred to our department for upper gastrointestinal (GI) endoscopy for management of rebleeding. She had a history of hypertension and hypothyroidism, but was not taking antiplatelet or anticoagulant therapy. Two previous upper GI endoscopies had shown a Forrest IIa ulcer in the posterior wall of the proximal gastric body, which has been treated with adrenaline and through-the-scope (TTS) clips. The last endoscopic therapy had been performed 1 week previously.

Endoscopy revealed a Forrest IIa ulcer in the same location, with four previously placed TTS clips present, but not embedding the vessel ([Fig. 1 a]). The intention was to place an over-the-scope (OTS) clip, so the TTS clips were removed using a foreign body forceps ([Fig. 1 b]), after which an 11/3 OTS clip was deployed. Despite correct placement of this clip, rebleeding started immediately at the base of the OTS clip ([Fig. 1 c]), suggesting that the jaws might not be fully obliterating the vessel. Two detachable snares were then sequentially placed with different orientations beneath the jaws of the OTS clip, with bleeding being controlled only after placement of the second detachable snare ([Fig. 1 d]; [Video 1]). Hemostatic spray was applied at the end of procedure ([Fig. 1 e]). The patient was discharged 9 days later, having experienced no further episodes of bleeding.

Fig. 1 Endoscopic images showing: a a Forrest IIa ulcer in the posterior wall of proximal gastric body, with four previously placed through-the-scope (TTS) clips, which were not embedding the vessel; b the gastric ulcer after TTS clip removal using a foreign body forceps; c immediate rebleeding at the base of the over-the-scope (OTS) clip despite correct placement; d two detachable snares placed beneath the jaws of the OTS clip, achieving successful hemostasis; e hemostatic spray applied at the end of procedure.

Video 1 Combined over-the-scope clip and detachable snare placement to achieve hemostasis of a rebleeding gastric ulcer.

OTS clipping is a safe and effective modality for the treatment of ulcer bleeding, particularly if a rebleed occurs [1]. Unfortunately, in some cases, hemostasis may not be achieved [2] or OTS clip placement may even worsen the bleeding [3]. Alternative tools should be considered in the event of failure to control bleeding after OTS clip deployment. Detachable snare placement (more than one if necessary) beneath the clip may allow the incorporation of a larger thickness of the gastric wall around the vessel [4], leading to complete vessel obliteration and subsequent control of bleeding [5]. It should be considered a valid add-on therapy if bleeding persists after OTS clipping, either where the clip has been misplaced or when hemostasis is incomplete despite correct placement of the clip.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Gralnek IM, Stanley AJ, Morris AJ. et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy 2021; 53: 300-332
• 2 Koh CJ, Tan EXX. Failure of over-the-scope clip to control duodenal ulcer bleeding despite successful application. VideoGIE 2019; 5: 24-25
• 3 Daire E, Forte E, Mennassel B. et al. Over-the-scope clip used to treat duodenal ulcer can cause damage to ulcer base and massive bleeding. Endoscopy 2019; 51: E213-E214
• 4 Rodrigues-Pinto E, Morais R, Macedo G. Combined over-the-scope clip and detachable snare placement for closure of an enterocutaneous fistula. Endoscopy 2019; 51: E247-E248
• 5 Jung C, Sportes A, Ellenrieder V. et al. Endoloop rescue therapy for a duodenal ulcer that re-bled under the clip base after application of an 11/3 traumatic over-the-scope clip. Endoscopy 2020; 52: E253-E254

Publication History

Article published online:
04 August 2022