Successful treatment with an over-the-scope clip of Dieulafoy’s gastric lesion resistant to conventional endoscopic treatment

Dieulafoy’s lesion is a rare vascular abnormality in which a minute mucosal defect in an ectatic submucosal artery can be the cause of massive gastrointestinal hemorrhage [1].

A 69-year-old woman with history of hypothyroidism attended our endoscopic unit because of an episode of melena. Blood examination showed hemoglobin 7.0 g/dL and an esophagogastroduodenoscopy (EGD) was carried out, which showed a Dieulafoy’s bleeding lesion in the proximal third of the posterior wall of the gastric body. The lesion was treated with epinephrine injection and application of two metallic clips. The patient also received blood transfusion and 2 days after the endoscopic procedure she was discharged. However, the patient attended the emergency room 3 days later because of a new episode of melena and blood examination showed hemoglobin 7.1 g/dL. After three blood transfusions the patient underwent a second EGD, which did not show any bleeding lesion apart from the known, but not apparently active, gastric Dieulafoy’s lesion with the clips correctly placed. The patient was admitted and 4 days later had another episode of melena with hemorrhagic shock. Hemoglobin was 6.9 g/dL and after hemodynamic stabilization, the patient underwent a third EGD under general anesthesia, which again showed the known Dieulafoy’s lesion, now actively bleeding. A submucosal injection of epinephrine was given to reduce the blood flow, and a 9-mm diameter over-the-scope clip (OTSC) with blunt teeth (OVESCO Endoscopy, Tübingen, Germany) was applied on the lesion, which completely stopped the bleeding ([Video 1]). Because of her poor clinical condition, the patient was transferred to the intensive care unit, and 3 days later another EGD was carried out, which confirmed correct placement of the OTSC. After 7 days the patient was discharged and at the 30-day endoscopic follow-up, the clip was still in place and the patient in good clinical condition.

Application of an over-the-scope clip (OTSC) in a 69-year-old woman with an actively bleeding Dieulafoy’s lesion.

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• References

• 1 Schmulewitz N, Baillie J. Dieulafoy lesions: a review of 6 years of experience at a tertiary referral center. Am J Gastroenterol 2001; 96: 1688-1694