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Management of a Dieulafoy ulcer bleed with an over-the-scope clip

Open AccessPublished:April 23, 2017DOI:https://doi.org/10.1016/j.vgie.2017.03.010
      A 50-year-old man presented with massive hematemesis. Upper-GI endoscopy revealed a visible vessel in the center of a small ulcer over a small submucosal bulge in the anterior wall of the first part of duodenum (Fig. 1A ). The differential diagnosis of submucosal mass with an eroding vessel, Forrest IIa peptic ulcer, and Dieulafoy ulcer was considered. A small ulcer with massive bleeding suggested the possibility of a Dieulafoy lesion EUS color Doppler showed a vessel entering the submucosa with arterial signals and confirmed the diagnosis of Dieulafoy ulcer (Figs. 1B and C; Video 1, available online at www.VideoGIE.org). During deployment of the first clip, pulsatile bleeding started from the visible vessel and could not be controlled even after 3 more clips were deployed. Around 20 mL of epinephrine was injected (1:10000 dilutions), which also failed to control the bleeding (Fig. 1D). An over-the-scope clip (OTSC) (Type T clip, size 11 mm, cap depth 6 mm) was deployed over the vessel, incorporating the hemoclips and the ulcer (Fig. 1E). Complete hemostasis was achieved with an OTSC (Fig. 1F). No additional bleeding episodes occurred during 1 week of follow-up.
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      Figure 1A, Small ulcer over a submucosal bulge in anterior wall of first part of duodenum. B, EUS color Doppler view showing submucosal vessel with feeding perforator. C, EUS pulse Doppler view showing feeding artery of submucosal arteriole. D, Hemoclips were deployed on the Dieulafoy ulcer and epinephrine was injected. E, Deploying over-the-scope clip (OTSC) over the lesion. F, OTSC over the Dieulafoy ulcer with no further bleeding. OTSC, over-the-scope clip.
      Dieulafoy lesion is responsible for 1% to 2% of cases of GI bleeding. It is a congenital single nonbranching tortuous submucosal arteriole whose caliber varies from 1 mm to 5 mm, which is more than 10 times that of mucosal capillaries. Endotherapy with hemoclips, injection therapy, thermal probes, laser therapy, endoscopic band ligation, and a combination of these modalities have been described. Bleeding can recur in 15% of cases. The reported success of standard therapeutic endoscopy for DL is more than 90%. Surgery and angiography are the current options for failure of conventional therapeutic endoscopy. In such cases, an OTSC may be an appropriate alternative to surgery or angiography.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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