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Bleeding malignant gastric ulcer: successful endoscopic hemostasis with an over-the-scope clip

Open AccessPublished:February 05, 2020DOI:https://doi.org/10.1016/j.vgie.2019.12.013

      Abbreviation:

      OTSC (over-the-scope clip)
      There are limited published data on the role of the over-the-scope clip (OTSC) in hemostasis from upper-GI tract neoplasia.
      • Wedi E.
      • Gonzalez S.
      • Menke D.
      • et al.
      One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas.
      The use of OTSCs in other locations (ie, esophagus and colon) has been shown to be effective for refractory GI bleeding
      • Baron T.H.
      • Song L.M.
      • Ross A.
      • et al.
      Use of an over-the-scope clipping device: multicenter retrospective results of the first U.S. experience (with videos).
      ,
      • Kim H.
      Over-the-scope clip in the management of gastrointestinal defect and intractable non-variceal bleeding.
      ; 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.
      • Prosst R.L.
      • Kratt T.
      A randomized comparative trial of OTSC and Padlock for upper GI hemostasis in a standardized experimental setting.
      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 thumbnail gr1
      Figure 1Ulcerated area in the gastric antrum.
      Figure thumbnail gr2
      Figure 2Ulcerated 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.
      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.
      • Banerjee S.
      • Barth B.A.
      • Bhat Y.M.
      • et al.
      Endoscopic closure devices.
      An OTSC (14/6t; Ovesco Endoscopy AG, Tuebingen, Germany) was successfully placed over the vessel (Figs. 4 and 5).
      Figure thumbnail gr4
      Figure 4Over-the-scope clip properly placed over the visible vessel.
      Figure thumbnail gr5
      Figure 5Large 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.
      • Koh K.H.
      • Kim K.
      • Kwon D.H.
      • et al.
      The successful endoscopic hemostasis factors in bleeding from advanced gastric cancer.
      ,
      • Song I.J.
      • Kim H.J.
      • Lee J.A.
      • et al.
      Clinical outcomes of endoscopic hemostasis for bleeding in patients with unresectable advanced gastric cancer.
      In patients bleeding from upper-GI neoplasia, endoscopic hemostasis can be performed to avoid urgent surgery and reduce blood transfusion requirements.
      • Gralnek I.M.
      • Dumonceau J.M.
      • Kuipers E.J.
      • et al.
      Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
      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.
      • Honegger C.
      • Valli P.V.
      • Wiegand N.
      • et al.
      Establishment of over-the-scope-clips (OTSC®) in daily endoscopic routine.

      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.

      Supplementary data

      References

        • Wedi E.
        • Gonzalez S.
        • Menke D.
        • et al.
        One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas.
        World J Gastroenterol. 2016; 22: 1844-1853
        • Baron T.H.
        • Song L.M.
        • Ross A.
        • et al.
        Use of an over-the-scope clipping device: multicenter retrospective results of the first U.S. experience (with videos).
        Gastrointest Endosc. 2012; 76: 202-208
        • Kim H.
        Over-the-scope clip in the management of gastrointestinal defect and intractable non-variceal bleeding.
        Clin Endosc. 2017; 50: 3-5
        • Prosst R.L.
        • Kratt T.
        A randomized comparative trial of OTSC and Padlock for upper GI hemostasis in a standardized experimental setting.
        Minim Invasive Ther Allied Technol. 2017; 26: 65-70
        • Banerjee S.
        • Barth B.A.
        • Bhat Y.M.
        • et al.
        Endoscopic closure devices.
        Gastrointest Endosc. 2012; 76: 244-251
        • Koh K.H.
        • Kim K.
        • Kwon D.H.
        • et al.
        The successful endoscopic hemostasis factors in bleeding from advanced gastric cancer.
        Gastric Cancer. 2013; 16: 397-403
        • Song I.J.
        • Kim H.J.
        • Lee J.A.
        • et al.
        Clinical outcomes of endoscopic hemostasis for bleeding in patients with unresectable advanced gastric cancer.
        J Gastric Cancer. 2017; 17: 374-383
        • Gralnek I.M.
        • Dumonceau J.M.
        • Kuipers E.J.
        • et al.
        Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
        Endoscopy. 2015; 47: a1-a46
        • Honegger C.
        • Valli P.V.
        • Wiegand N.
        • et al.
        Establishment of over-the-scope-clips (OTSC®) in daily endoscopic routine.
        United European Gastroenterol J. 2017; 5: 247-254