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Tandem utilization of a hemostatic clip and a banding device in the esophagus: a novel hemostatic technique
BRIEF REPORTS
Tandem utilization of a hemostatic clip and a banding device in the esophagus: a novel hemostatic technique Vikas Khurana, MD, FACP, FACG Shreveport, Louisiana, USA
Actively bleeding vascular lesions are a challenge to the endoscopist, and a variety of techniques are available for hemostasis. Endoclip application has been shown to be effective for the treatment of actively bleeding vascular lesions1 but has a higher rate of failure in the esophagus, given the tangential nature of the clip deployment. Band ligation has been used as an alternate procedure, with a better success rate, but banding as an initial modality can be technically difficult and has a high chance of failure during active arterial bleeding. We present 2 cases where a novel method of tandem application of endoclip and banding was performed for the control of active upper-GI hemorrhage.
CASE REPORT 1 A 47-year-old man presented with massive hematemesis. His medical history was significant for hepatitis B, hepatitis C, and alcoholic liver disease, with recurrent hematemesis and melena. Endoscopies done in the last 6 months showed grade 1 esophageal varices and a hiatal hernia, with an active Mallory-Weiss tear. On this admission, his blood pressure was 70/30 mm Hg, and the heart rate was 130 per minute. Findings of a physical examination were significant for spider nevi, gynecomastia, and ascites, with no hepatosplenomegaly. His hemoglobin (Hb) level was 7.8 g/dL (reference range: 13.9-16.3 g/dL), and hematocrit (HCT) was 23.9% (39%-55%). Prothrombin time (PT) was 23.7 seconds (12.0-14.7 seconds), and international normalized ratio (INR) was 2.2 (2.5-3.5), albumin was 1.9 g/dL (3.4-5.0 g/dL). The patient was initially stabilized with fresh frozen plasma and blood transfusion. Emergent EGD revealed an actively spurting vascular lesion in the distal esophagus. Initial attempts to decrease the bleeding with epinephrine injection and a first endoclip were unsuccessful because of the tangential nature of the deployment. The second and third clips were successfully placed, slowing the bleeding (Fig. 1). After this, an endoscope loaded with a band ligator was passed, and the bleeding site was brought to the en face view by pressing laterally with the cap on the wall of the esophagus proximal to the bleeding site. Two bands were deployed, and successful www.giejournal.org
hemostasis was achieved. Lavage after the procedure detected no more active bleeding. Follow-up endoscopy done after 1 day demonstrated the bands and the clips to be in place. The patient had an uneventful recovery. However, this patient presented again after 4 months, with severe hematemesis, and he was hemodynamically unstable. Repeat therapeutic endoclip and banding was unsuccessful because of rapid filling of blood in the distal esophagus. The patient did not survive.
CASE REPORT 2 A 58-year-old man presented with hematemesis. His medical history was significant for hepatitis C, degenerative joint disease, recurrent GI bleed, and alcohol abuse. The patient was taking nonsteroidal anti-inflammatory drugs (NSAID) for control of pain. In the previous 6 months, the patient underwent 2 endoscopies for upper-GI bleeding, which revealed hiatus hernia and an antral ulcer. The patient was started on a proton pump inhibitor and Helicobacter pylori eradication treatment. However, after 8 weeks, he presented again with hematemesis. On admission, he was hypotensive and tachycardic. Systemic examination was otherwise unremarkable. Hematologic studies revealed a Hb level of 13.6 g percentage and a HCT of 39.5 g percentage. A coagulation profile showed an INR of 1.6 with a PT of 18.8 seconds. Liver enzymes were elevated and serum albumin was 2.4 g/dL. The patient underwent emergent EGD, and an actively bleeding vascular lesion was noted in the gastroesophageal junction (Fig. 2). Two clips were placed to slow down the bleeding, followed by banding of the area with 2 bands by using the same technique described in case report 1. Minimal oozing was noticed from the side of the band, where another clip was used to achieve hemostasis. Lavage done after the procedure did not show any signs of active bleeding. The patient was followed in the clinic 10 weeks after the procedure and was free from recurrent bleeding.
DISCUSSION A variety of lesions can present as actively bleeding vascular lesions in the esophagus.2 Endoclip application Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 517
Brief Reports
Figure 1. A, Actively bleeding esophageal vessel. B, After initial clip placement. C, After banding, with hemostasis. D, Follow-up EGD 1 day later.
to control the bleeding of actively bleeding vascular lesions is an effective and safe endoscopic treatment.3 This technique was first used in Japan and, for the last 2 decades in Japan and Europe, has been in use for controlling GI bleeding. Its application in other endoscopic procedures is well documented in the literature.4-6 Its advantage over thermal coagulation and injection sclerotherapy is also well documented.3,7 Deployment of a clip is an established surgical technique, but, given the tangential nature of the application, it has a high rate of failure in controlling bleeding from actively bleeding esophageal vessels. Banding as an initial modality has a high chance of failure, because an active spurting vessel does not provide a clear view or adequate time for
successful band deployment. Even when visualized adequately, suction pressure cannot be achieved, because of rapid filling of the suction cap by the actively bleeding artery. Tandem utilization of the endoclip and the banding device facilitates better visualization and access to the bleeding vessel. The depth of the mucosal injury is also minimal with endoclip and band application. The technique of tandem application of a clip and banding is technically simple and can be done in any endoscopic unit where a band ligator and clips are available. In addition, the clip and band technique may be preferable in patients with coagulopathy. Both of the above cases illustrate a promising new approach for the treatment of an actively bleeding Dieulafoy’s lesion.
518 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 3 : 2006
www.giejournal.org
Brief Reports
Figure 2. A, Actively bleeding vessel. B, Initial clip placement. C, After banding. D, Hemostasis after additional clip.
REFERENCES 1. Binmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993;25:167-70. 2. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995;90:206-10. 3. Parra-Blanco A, Takahashi H, Mendez Jerez PV, et al. Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients. Endoscopy 1997;29:834-9. 4. Devereaux CE, Binmoeller KF. Endoclip: closing the surgical gap. Gastrointest Endosc 1999;50:440-2. 5. Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device. Gastrointest Endosc 1999;50:431-6. 6. Cipolletta L, Bianco MA, Rotondano G, et al. Endoclip-assisted resection of large pedunculated colon polyps [see comment]. Gastrointest Endosc 1999;50:405-6.
www.giejournal.org
7. Park CH, Sohn YH, Lee WS, et al. The usefulness of endoscopic hemoclipping for bleeding Dieulafoy lesions. Endoscopy 2003;35: 388-92.
Gastroenterology and Hepatology, LSU Health Sciences Center in Shreveport, Department of Veteran Affairs, Overton Brooks VA Medical Center, Shreveport, Louisiana, USA. A short abstract of this case report was a poster presentation at the American College of Gastroenterology 68th Annual Scientific Meeting, Baltimore, Maryland, October 12-15, 2003. Reprint requests: Vikas Khurana, MD, Department of Veteran Affairs, Overton Brooks VA Medical Center, 510, East Stoner Ave (111G), Shreveport, LA 71101. Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.09.038
Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 519
Tandem utilization of a hemostatic clip and a banding device in the esophagus: a novel hemostatic technique Vikas Khurana, MD, FACP, FACG Shreveport, Louisiana, USA
Actively bleeding vascular lesions are a challenge to the endoscopist, and a variety of techniques are available for hemostasis. Endoclip application has been shown to be effective for the treatment of actively bleeding vascular lesions1 but has a higher rate of failure in the esophagus, given the tangential nature of the clip deployment. Band ligation has been used as an alternate procedure, with a better success rate, but banding as an initial modality can be technically difficult and has a high chance of failure during active arterial bleeding. We present 2 cases where a novel method of tandem application of endoclip and banding was performed for the control of active upper-GI hemorrhage.
CASE REPORT 1 A 47-year-old man presented with massive hematemesis. His medical history was significant for hepatitis B, hepatitis C, and alcoholic liver disease, with recurrent hematemesis and melena. Endoscopies done in the last 6 months showed grade 1 esophageal varices and a hiatal hernia, with an active Mallory-Weiss tear. On this admission, his blood pressure was 70/30 mm Hg, and the heart rate was 130 per minute. Findings of a physical examination were significant for spider nevi, gynecomastia, and ascites, with no hepatosplenomegaly. His hemoglobin (Hb) level was 7.8 g/dL (reference range: 13.9-16.3 g/dL), and hematocrit (HCT) was 23.9% (39%-55%). Prothrombin time (PT) was 23.7 seconds (12.0-14.7 seconds), and international normalized ratio (INR) was 2.2 (2.5-3.5), albumin was 1.9 g/dL (3.4-5.0 g/dL). The patient was initially stabilized with fresh frozen plasma and blood transfusion. Emergent EGD revealed an actively spurting vascular lesion in the distal esophagus. Initial attempts to decrease the bleeding with epinephrine injection and a first endoclip were unsuccessful because of the tangential nature of the deployment. The second and third clips were successfully placed, slowing the bleeding (Fig. 1). After this, an endoscope loaded with a band ligator was passed, and the bleeding site was brought to the en face view by pressing laterally with the cap on the wall of the esophagus proximal to the bleeding site. Two bands were deployed, and successful www.giejournal.org
hemostasis was achieved. Lavage after the procedure detected no more active bleeding. Follow-up endoscopy done after 1 day demonstrated the bands and the clips to be in place. The patient had an uneventful recovery. However, this patient presented again after 4 months, with severe hematemesis, and he was hemodynamically unstable. Repeat therapeutic endoclip and banding was unsuccessful because of rapid filling of blood in the distal esophagus. The patient did not survive.
CASE REPORT 2 A 58-year-old man presented with hematemesis. His medical history was significant for hepatitis C, degenerative joint disease, recurrent GI bleed, and alcohol abuse. The patient was taking nonsteroidal anti-inflammatory drugs (NSAID) for control of pain. In the previous 6 months, the patient underwent 2 endoscopies for upper-GI bleeding, which revealed hiatus hernia and an antral ulcer. The patient was started on a proton pump inhibitor and Helicobacter pylori eradication treatment. However, after 8 weeks, he presented again with hematemesis. On admission, he was hypotensive and tachycardic. Systemic examination was otherwise unremarkable. Hematologic studies revealed a Hb level of 13.6 g percentage and a HCT of 39.5 g percentage. A coagulation profile showed an INR of 1.6 with a PT of 18.8 seconds. Liver enzymes were elevated and serum albumin was 2.4 g/dL. The patient underwent emergent EGD, and an actively bleeding vascular lesion was noted in the gastroesophageal junction (Fig. 2). Two clips were placed to slow down the bleeding, followed by banding of the area with 2 bands by using the same technique described in case report 1. Minimal oozing was noticed from the side of the band, where another clip was used to achieve hemostasis. Lavage done after the procedure did not show any signs of active bleeding. The patient was followed in the clinic 10 weeks after the procedure and was free from recurrent bleeding.
DISCUSSION A variety of lesions can present as actively bleeding vascular lesions in the esophagus.2 Endoclip application Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 517
Brief Reports
Figure 1. A, Actively bleeding esophageal vessel. B, After initial clip placement. C, After banding, with hemostasis. D, Follow-up EGD 1 day later.
to control the bleeding of actively bleeding vascular lesions is an effective and safe endoscopic treatment.3 This technique was first used in Japan and, for the last 2 decades in Japan and Europe, has been in use for controlling GI bleeding. Its application in other endoscopic procedures is well documented in the literature.4-6 Its advantage over thermal coagulation and injection sclerotherapy is also well documented.3,7 Deployment of a clip is an established surgical technique, but, given the tangential nature of the application, it has a high rate of failure in controlling bleeding from actively bleeding esophageal vessels. Banding as an initial modality has a high chance of failure, because an active spurting vessel does not provide a clear view or adequate time for
successful band deployment. Even when visualized adequately, suction pressure cannot be achieved, because of rapid filling of the suction cap by the actively bleeding artery. Tandem utilization of the endoclip and the banding device facilitates better visualization and access to the bleeding vessel. The depth of the mucosal injury is also minimal with endoclip and band application. The technique of tandem application of a clip and banding is technically simple and can be done in any endoscopic unit where a band ligator and clips are available. In addition, the clip and band technique may be preferable in patients with coagulopathy. Both of the above cases illustrate a promising new approach for the treatment of an actively bleeding Dieulafoy’s lesion.
518 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 3 : 2006
www.giejournal.org
Brief Reports
Figure 2. A, Actively bleeding vessel. B, Initial clip placement. C, After banding. D, Hemostasis after additional clip.
REFERENCES 1. Binmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993;25:167-70. 2. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995;90:206-10. 3. Parra-Blanco A, Takahashi H, Mendez Jerez PV, et al. Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients. Endoscopy 1997;29:834-9. 4. Devereaux CE, Binmoeller KF. Endoclip: closing the surgical gap. Gastrointest Endosc 1999;50:440-2. 5. Scotiniotis I, Ginsberg GG. Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device. Gastrointest Endosc 1999;50:431-6. 6. Cipolletta L, Bianco MA, Rotondano G, et al. Endoclip-assisted resection of large pedunculated colon polyps [see comment]. Gastrointest Endosc 1999;50:405-6.
www.giejournal.org
7. Park CH, Sohn YH, Lee WS, et al. The usefulness of endoscopic hemoclipping for bleeding Dieulafoy lesions. Endoscopy 2003;35: 388-92.
Gastroenterology and Hepatology, LSU Health Sciences Center in Shreveport, Department of Veteran Affairs, Overton Brooks VA Medical Center, Shreveport, Louisiana, USA. A short abstract of this case report was a poster presentation at the American College of Gastroenterology 68th Annual Scientific Meeting, Baltimore, Maryland, October 12-15, 2003. Reprint requests: Vikas Khurana, MD, Department of Veteran Affairs, Overton Brooks VA Medical Center, 510, East Stoner Ave (111G), Shreveport, LA 71101. Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.09.038
Volume 63, No. 3 : 2006 GASTROINTESTINAL ENDOSCOPY 519