An 87-year-old woman who was taking nonsteroidal anti-inflammatory drugs for fracture of the right distal radius underwent esophagogastroduodenoscopy (EGD) for melena at another hospital. The EGD revealed a large ulcer with a blood clot on the anterior wall of the duodenal bulb ([Fig. 1]), and she was referred to our hospital for treatment.
Fig. 1 A large ulcer with a blood clot on the anterior wall of the duodenal bulb.
Active bleeding occurred during blood clot removal, but hemostasis by cauterization with hemostatic forceps was difficult ([Video 1]). The bleeding temporarily ceased due to reduced blood pressure. A conventional reopenable endoclip was used to prevent rebleeding. However, the endoclip could not completely capture the large exposed vessel, leading to rebleeding and, ultimately, dislocation of the clip. While the bleeding point could not be visualized under carbon dioxide insufflation, it was visualized with red dichromatic imaging using the gel immersion technique [1] ([Fig. 2]). As additional cauterization may result in delayed perforation, a reopenable endoclip with a sharp claw (Mantis Clip; Boston Scientific, Marlborough, Massachusetts, USA) [2]
[3], which was able to grasp the vessel along with the surrounding tissue ([Fig. 3]), was applied, and hemostasis was achieved ([Fig. 4]).
Hemostasis of active bleeding in the duodenal bulb using a sharp-clawed reopenable endoclip under gel immersion endoscopy.Video 1
Fig. 2 The bleeding point was visualized by gel immersion technique (arrowheads).
Fig. 3 Use of a reopenable endoclip with a sharp claw (Mantis Clip; Boston Scientific, Marlborough, Massachusetts, USA) for the visible bleeding point.
Fig. 4 Hemostasis was achieved using the endoclip.
A follow-up endoscopy at 4 days postoperatively revealed loss of the endoclip, but the ulcer was healing ([Fig. 5]). Oral intake was resumed 7 days postoperatively, and the patient was transferred to another hospital for walking rehabilitation 17 days postoperatively.
Fig. 5 The ulcer was healing 4 days after the procedure.
Hemorrhagic duodenal ulcers are a life-threating disease [4]. In cases of endoscopic hemostasis failure, transcatheter arterial embolization or surgery are necessary [5]. Endoscopic hemostasis is often difficult because the bleeding point is not visible, and the large vessel in the ulcer cannot be completely captured. In the current case, these issues were solved using the gel immersion technique and endoclipping with a sharp claw, leading to the clinical advantage of avoiding invasive transcatheter arterial embolization or surgery.
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