Endoscopic treatment is available for variceal and nonvariceal upper
gastrointestinal (UGI) bleeding [1]
[2]. Blood clots in the stomach hamper endoscopic treatment
by obscuring the bleeding source. Aspiration of clots, however, results in
obstruction of the working channel, while grasping clots with a basket or snare
leads to cutting up of the clots [3]. We describe the
usefulness of an attachable distal cap to remove blood clots from the stomach
during endoscopic treatment of UGI bleeding.
Two patients in the intensive care unit had active UGI bleeding with
hemodynamic instability requiring transfusion. Urgent UGI endoscopy revealed
blood clots filling the stomach, obscuring the bleeding source. Attempts to
remove the clots using aspiration and a polypectomy snare were unsuccessful. To
improve the aspiration force and contact surface, we attached a distal cap
intended for esophageal endoscopic mucosal resection (Disposable Distal
Attachment D-206-04; Olympus Medical Systems Corp., Tokyo, Japan). This cap has
an oblique shape (18 mm diameter) with a distal rim. As can been seen
from [Fig. 1] and [2], the
cap allows firm aspiration of large blood clots, which can be easily removed
from the stomach with retraction of the endoscope.
Fig. 1 Distal oblique cap with
a rim attached to the endoscope. After aspiration of the clot into the cap, the
endoscope is retracted; in this way large clots can be easily removed from the
stomach.
Fig. 2 The large blood clot is
easily removed from the cap when aspiration ceases. The flexible oblique shape
allows rapid reintubation of the endoscope into the stomach.
After removal of the gastric clot, a bleeding fundic ulcer was seen
in the first patient and a bleeding fundic varix in the second; both were
controlled by conventional endoscopic hemostatic treatment.
Disposable distal attachment caps are available to facilitate
mucosal resection and submucosal dissection procedures. We present two cases of
UGI bleeding in which the use of a rimmed oblique cap was helpful to remove
blood clots from the stomach during endoscopic hemostasis. Clots were aspirated
into the cap, and the wide oblique opening with rim proved ideal to keep the
clot inside the cap while retracting the endoscope. By repeating this
procedure, the stomach was rapidly cleared of clots, the bleeding source was
visualized, and endoscopic hemostasis performed.
Endoscopy_UCTN_Code_TTT_1AO_2AD
