There are limited published data on the role of the over-the-scope clip (OTSC) in hemostasis from upper-GI tract neoplasia.1 The use of OTSCs in other locations (ie, esophagus and colon) has been shown to be effective for refractory GI bleeding2,3; nonetheless, reports of the use of OTSCs in the setting of malignant bleeding in these locations are also scarce. In the setting of refractory GI bleeding, the OTSC is a valuable tool and has been shown to perform better than Padlock devices.4
A 76-year-old man with a medical history of Parkinson's disease and bradyarrhythmia was admitted to the emergency department because of hematemesis. At admission, he was experiencing hypotension (blood pressure 87/69 mm Hg), and his hemoglobin level was 6.6 g/dL. After his condition was stabilized, and a transfusion of 2 units of red blood cells and a bolus (80 mg) of intravenous pantoprazole followed by infusion (8 mg/h), the patient underwent EGD, which showed an ulcerated neoformation with a large adherent blood clot (Video 1, available online at www.VideoGIE.org). Because the endoscopic findings were suggestive of gastric neoplasia (Figs. 1 and 2), biopsies were performed. Hemostasis was not attempted once the patient was sent for surgical treatment. Staging examinations were ordered, but the next day, after continued evidence of bleeding, temporary endoscopic hemostasis was attempted to avoid urgent surgery during the wait for histologic evaluation.
Figure 1.
Ulcerated area in the gastric antrum.
Figure 2.
Ulcerated neoformation with a large adherent blood clot.
A second EGD was performed, in which the previously described blood clot was removed. A large 6-mm vessel without active bleeding was observed (Fig. 3). High-definition endoscopes with narrow-band imaging (Olympus GIF-H185; Olympus Medical Systems Co. Ltd, Tokyo, Japan) were used in both evaluations.
Figure 3.
Large adherent blood clot.
Considering the high-risk characteristics of the lesion, namely, excavated fibrotic ulcer with high-risk stigmata (visible large-caliber artery), we decided to place an OTSC; a type t (pointed) OTSC was chosen to assure tissue capture and decrease the risk of the clip slipping, considering the presence of fibrotic tissue in the lesion.5 An OTSC (14/6t; Ovesco Endoscopy AG, Tuebingen, Germany) was successfully placed over the vessel (Figs. 4 and 5).
Figure 4.
Over-the-scope clip properly placed over the visible vessel.
Figure 5.
Large visible vessel (6 mm) after over-the-scope clip placement.
After endoscopic therapy, no recurrent bleeding occurred. Histologic examination confirmed the diagnosis of gastric adenocarcinoma. Hospitalization was prolonged as a result of Citrobacter koseri bacteraemia, which was successfully treated with ceftazidime. The patient was discharged after 15 days with a hemoglobin level of 11.0 g/dL. After 8 weeks, he was admitted for elective subtotal gastrectomy.
Bleeding is one of the most serious adverse events of gastric cancer and is associated with a poor prognosis.6,7 In patients bleeding from upper-GI neoplasia, endoscopic hemostasis can be performed to avoid urgent surgery and reduce blood transfusion requirements.8 The OTSC is an innovative device that can be used in multiple settings, namely, GI bleeding, acute perforation, prophylaxis for perforation, anastomotic leakage, and stent fixation.9
Acknowledgment
Supported by a Robert W. Summers grant from the American Society for Gastrointestinal Endoscopy.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Footnotes
If you would like to chat with an author of this article, you may contact Dr Silva at joaocarosilva@gmail.com.
Supplementary data
Ulcerated neoformation with a large adherent blood clot in the gastric antrum. After removal of the blood clot a large vessel was observed. An over-the-scope clip was successfully placed over the vessel.
References
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Associated Data
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Supplementary Materials
Ulcerated neoformation with a large adherent blood clot in the gastric antrum. After removal of the blood clot a large vessel was observed. An over-the-scope clip was successfully placed over the vessel.