Usage of Padlock Over-the-Scope-Clip in Difficult-to-Control Recurrent Gastrointestinal Bleeding Due to a Gastric Dieulafoy Lesion

Abstract

Dieulafoy’s lesions (DLs) are a rare cause of acute gastrointestinal bleeds (GIBs). Here we describe Over-the-Scope Clip Padlock System (OTSC-P) use to treat a gastric fundus DL with recurrent bleeding despite other interventions. The OTSC-P was created for full-thickness defect closure in the event of a perforation, but use has expanded to treatment of GIB. They consist of metal clips mounted on transparent caps, delivered via endoscope. Their size allows control of larger bleeding lesions, provides enhanced tissue stability and the firmer clip grasp reduces rebleeding or clip dislodgement.

Introduction

Dieulafoy’s lesion (DL) is a rare cause of gastrointestinal bleeding (GIB), accounting for less than 2% of all acute GIB. ¹ In a recent case series, the initial hemostasis rate of endoscopic treatment for DLs was nearly 90% and the overall success rate was 100%. Rebleeding after initially successful hemostasis was recognized as being common, reported to be in the range of 6% to 28%, and it carried a 30-day mortality rate as high as 27% in some studies. ²

The over-the-scope clip padlock system (OTSC-P) was initially developed for defect closure given its ability for full-thickness closure in the event of a perforation, but its use has expanded as a highly effective treatment of GIB.^3,4

It consists of an 11-mm nitinol ring with 6 needles on the inner aspect pointing toward each other, providing circumferential tissue approximation. The prongs approximate the tissue, while tissue controllers limit the depth of penetration. There is adequate spacing between needles to promote blood flow within the tissue and facilitate healing. ⁵ This design differs from the traditional Ovesco variety of OTSCs; however, there is limited data regarding its clinical use. ⁵

We describe the OTSC-P’s use to treat a gastric fundus DL causing recurrent bleeding despite other standard interventions.

Case

An 85-year-old female presented with hematemesis and melena, with an acute drop in hemoglobin. Upper endoscopy demonstrated large clots in the gastric fundus which upon suctioning revealed a mucosal protuberance with the suggestion of a potential submucosal “caliber-persistent” artery that protrudes through the mucosa at the gastric fundus without primary or surrounding mucosal ulceration (Figure 1).

Figure 1.

Mucosal protuberance with potential submucosal artery.

After confirming the absence of an underlying gastric fundal varix, a second endoscopy was performed when the patient had a further drop in Hb without overt melena, which reaffirmed the presence of a DL at the previously noted protuberance (Figure 2). There were no signs of an active GIB, and hence, no interventions were attempted. Unfortunately, a significant drop in hemoglobin necessitated a third endoscopy for further management. As no other lesions that could explain the source of melena were noted, 3 hemostatic clips were placed over this lesion (Figure 3).

Figure 2.

Likely Dieulafoy’s lesion at previously noted protuberance, with no signs of active GIB.

Figure 3.

Lesion with hemostatic clips in place.

The patient had significant GIB leading to hemorrhagic shock a few days after the attempted endoscopic hemostasis. Computed tomography angiography (CTA) and tagged red blood cell (RBC) scan were negative for active hemorrhage. After adequate resuscitation, we performed another endoscopy where the previously placed hemostatic clips were removed with rat tooth forceps, and an OTSC-P (Figure 4) was deployed at the site. The patient had no further bleeding with OTSC-P-assisted endoscopic hemostasis.

Figure 4.

Lesion with OTSC-P in place.

Discussion

Bleeding from DL occurs from a dilated submucosal artery that does not have the normal distal tapering or branching. The focal pressure from the aberrant “caliber-persistent” vessels possibly thins the overlying mucosa and leads to erosion of the vessel wall and subsequent hemorrhage. ⁶

The epidemiology of DL indicates a male preponderance with it being twice as likely to occur in males, usually seen in the sixth or seventh decades of life. Dieulafoy’s lesions are more commonly seen in patients with other comorbid conditions, for example, chronic kidney disease, cardiovascular risk factors such as hypertension and diabetes, in addition to debilitating conditions such as hypovolemic shock and respiratory failure requiring mechanical ventilation. ⁷

Consumption of alcohol and the usage of antiplatelet agents have been associated with DL in the upper gastrointestinal tract. Conversely, intake of nonsteroidal anti-inflammatory drugs has not. ⁸ The most common occurrence of DL is in the proximal stomach (60%-70%), followed by the duodenum (15%) and distal stomach (12%). An initial esophagogastroduodenoscopy (EGD) is only diagnostic of 70% of UGIB from DLs, and 33% of DLs required repeat EGD for diagnosis. If the initial endoscopy failed to treat the DL, recurrence of GIB from DL is frequent, especially in the first 72-h window. ⁹ Endoscopic hemostasis of DL may be achieved with combination therapy of injection therapy, thermal probe, through-the-scope (TTS) hemoclipping, rubber band ligation, or OTSC hemoclipping. ¹⁰ Rebleeding rates may be lower with combination therapy or OTSC-P hemoclipping because such an approach allows eradication of the submucosal arterial blood flow more effectively than by injection or monotherapy. ¹⁰

This case report illustrates the safe and effective application of the OTSC-P as an effective modality for endoscopic hemostasis of GI bleeding from large submucosal artery as in DL. Over-the-scope clips consist of a metal clip mounted on a transparent cap, delivered via an endoscope. Over-the-scope clips offer several advantages over the traditional through-the-scope clips (TTSCs). Owing to their larger size, they allow control of larger lesions, which is particularly useful when through-the-scope clips (TTSC) are inadequate. Over-the-scope clips also provide enhanced stability and tissue approximation. A firmer clip grasp reduces the risk of re-bleeding or clip dislodgement, especially in complex lesions or when precise clip application is crucial. In summary OTSCs have many advantages over TTSCs in terms of ease of application, depth of tissue and size of lesion grasped in addition to more closure power, as shown in many studies.^11-13 However, some reported adverse events of OTSC systems in published studies include clip dislodgement, accidental deployment, mucosal damage, secondary perforations, maceration of the perforated site, and tissue necrosis. ¹⁴

This case illustrated the treatment of a bleeding gastric fundal DL which was difficult to control using standard endoscopic interventions, requiring the deployment of the OTSC Padlock system. A literature review of cases where OTSC was used to treat DLs found the OTSC OVESCO System as the most common modality used.^4,15-19 Reports of the usage of OTSC Padlock system to treat a gastric fundus DL were far and few. This case presented a recurrent GI hemorrhage from a gastric fundus DL, requiring the need for multiple endoscopies and the application of the OTSC-P for sustained hemostasis in the setting of a difficult to treat DL. Further studies are needed to evaluate the efficacy and safety of OTSC-P in treatment of GIB compared to other endoscopic interventions.