P3509 - Usage of Padlock Over-the-Scope-Clip for Sustained Hemostasis in Difficult-to-Control, Recurrent Gastrointestinal Bleeding Due to a Gastric Fundus Dieulafoy Lesion

John Joyce, MBBS¹, Dhruv Sarwal, MBBS², Vishnu Kumar, MBBS³, Dayana Nasr, MD⁴, Gayatri Pemmasani, MBBS⁵, Ganesh Aswath, MD⁵, Hafiz M. Khan, MD², Savio John, MD^2
1SUNY Upstate University Hospital, Syracuse, NY; ²SUNY Upstate Medical University, Syracuse, NY; ³SUNY Upstate, Syracuse, NY; ⁴SUNY Upstate Medical University Hospital, Syracuse, NY; ⁵Upstate University Hospital, Syracuse, NY

Introduction: Dieulafoy lesions (DL) are a rare cause of acute gastrointestinal bleeds (GIB). The Over-the-Scope-Clip Padlock System (OTSC-P) was created for full-thickness defect closure in the event of a perforation, but use has expanded to treatment of GIB. Here we describe OTSC-P use to treat a gastric fundus DL with recurrent bleeding despite other interventions




Case Description/Methods: An 85-year-old female with hematemesis and melena, with an acute drop in hemoglobin, underwent upper endoscopy, showing a gastric fundus with large clots. Suctioning revealed a mucosal protuberance with a potential submucosal, “caliber-persistent” artery protruding through fundic mucosa, without primary or surrounding ulceration or an underlying gastric fundal varix (Figure 1).






A further drop in hemoglobin without overt melena necessitated repeat endoscopy, which reaffirmed a likely DL at the previously seen protuberance (Figure 2). No intervention was attempted as there were no signs of active GIB.






Unfortunately, an ongoing fall in hemoglobin necessitated a third endoscopy for management. As no other lesions to explain bleeding were noted, three hemostatic clips were placed over the prior lesion (Figure 3).






Further significant GIB led to hemorrhagic shock days after the attempted endoscopic hemostasis. CTA and tagged RBC scans did not show active hemorrhage. After resuscitation, previously placed hemostatic clips were removed with rat-tooth forceps and an OTSC-P (Figure 4) was deployed. No further bleeding was noted after OTSC-P assisted endoscopic hemostasis.

Discussion: We illustrate effective and safe application of OTSC-P for endoscopic hemostasis of GIB from a submucosal artery such as in DL.

OTSCs are metal clips mounted on transparent caps, delivered via endoscope. Their size allows control of larger bleeding lesions, provides enhanced tissue stability and approximation, and the firmer clip grasp reduces rebleeding or clip dislodgement. This is essential in complex lesions requiring precise clip application.

GIB from DL occurs possibly because the focal pressure from the aberrant “caliber-persistent” vessel thins the overlying mucosa, leading to erosion of vessel wall and subsequent hemorrhage.

Endoscopic hemostasis in DL may be achieved with a combination of injection therapy, thermal probe, TTS hemoclips, band ligation, or OTSC hemoclips. Rebleeding may be reduced via combination therapy or OTSC-P hemoclips as this allows better eradication of submucosal arterial blood flow compared to injection or monotherapy.










Disclosures:


John Joyce, MBBS¹, Dhruv Sarwal, MBBS², Vishnu Kumar, MBBS³, Dayana Nasr, MD⁴, Gayatri Pemmasani, MBBS⁵, Ganesh Aswath, MD⁵, Hafiz M. Khan, MD², Savio John, MD². P3509 - Usage of Padlock Over-the-Scope-Clip for Sustained Hemostasis in Difficult-to-Control, Recurrent Gastrointestinal Bleeding Due to a Gastric Fundus Dieulafoy Lesion, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.