Stephanie Ibarra, MD, Zarak Khan, MD, Danielle Hoo-Fatt, MD, Prashant Mudireddy, MD East Carolina University, Greenville, NC
Introduction: Endoscopic clips are devices used in the nonsurgical treatment of GI bleeding as a means to achieve hemostasis. The Over-the-scope clip (OTSC), also called Ovesco clip, is a recently introduced clipping device used for acute GI bleeding, iatrogenic perforations, GI wall defects, and anastomosis leaks. This system produces a stronger mechanical tissue compression compared to standard endoclips. Thus, although uncommon, current endoscopic practices favor the use of Ovesco clips in cases of refractory bleed, following failed standard therapy.
Case Description/Methods: A 50-year-old male with past medical history of HFpEF, atrial fibrillation, mechanical aortic valve on warfarin, CKD, HTN, HLD, and new decompensated cirrhosis presented to the ED with acute blood loss anemia in the setting of hematochezia without abdominal pain. Laboratory findings were significant for hemoglobin of 8.4 g/dL, hematocrit 26.5%, and BUN 42 mg/dL. INR was within goal at 2.6 (target 2.5-3.5). The patient underwent EGD and colonoscopy after anticoagulation reversal. EGD findings were unremarkable, however colonoscopy showed a 12 mm rectal varix that was successfully banded x1. He was discharged but returned two weeks after with recurrent bright rectal bleeding and an associated hemoglobin of 5.8 g/dL. It was decided to proceed with flexible sigmoidoscopy with findings consistent with active bleeding of previously banded varix, now protruding in nature and unsuccessfully treated with epinephrine and hemospray. Regardless of therapeutic efforts, the patient continued to have intermittent hematochezia with requirements for blood transfusion with a total of 7 units of pRBCs. He underwent a second flexible sigmoidoscopy showing an actively bleeding varix in distal rectum at previous banding site. This was injected with ethanolamine and an Ovesco clip was successfully placed for hemostasis.
Discussion: The OTSC system via Ovesco clipping is a contemporary technique in modern endoscopy that provides means for strong closure of GI defects with minimal ischemia or laceration. This is possible due to its various teeth configurations that improve anchoring whilst allowing blood circulation within the spaces between each prong. Indications for its use as first-line therapy have not been fully established due to limited available evidence. However, the case above demonstrates the uncommon but successful use of OVESCO clips in variceal bleed and their clinical hemostatic significance moving forward.
Figure: Image depicting a recently banded rectal varix that was found ulcerated and with recent stigmata of bleeding. Approximately 3 cc of Ethanolamine was injected into the varix and the site was observed for post intervention bleeding. Some oozing was observed therefore an Ovesco clip (12/6a) was applied to the varix with achievement of hemostasis. There was no bleeding at the end of the procedure.
Disclosures:
Stephanie Ibarra indicated no relevant financial relationships.
Zarak Khan indicated no relevant financial relationships.
Danielle Hoo-Fatt indicated no relevant financial relationships.
Prashant Mudireddy indicated no relevant financial relationships.
Stephanie Ibarra, MD, Zarak Khan, MD, Danielle Hoo-Fatt, MD, Prashant Mudireddy, MD. P2336 - OVESCO to Rescue – Novel Use of OVESCO Clip in Variceal Bleed, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
