Endoscopy 2013; 45(10): 855
DOI: 10.1055/s-0033-1344391
Letters to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Endoloop/clip technique for gastrointestinal hemorrhage: rescue or first-line line therapy?

Gabriele Curcio
,
Mario Traina
,
Neville Azzopardi
,
Luca Barresi
,
Ilaria Tarantino
,
Antonio Granata
Further Information

Publication History

Publication Date:
25 September 2013 (online)

We read with interest the study by Lee et al. [1]. The authors describe their experience with the use of clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal upper gastrointestinal bleeding (UGIB). They report a case series of seven patients who underwent endoscopic hemostasis using the combined method of CDS. The success rate of endoscopic hemostasis with CDS was 86 %: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully.

The authors clearly explain that the detachable snare may be seen as an adjunct to endoclip hemostasis in nonvariceal UGIB. They further state that when there is no effective choice for re-treatment because of previously applied hemoclips, laying an endoloop with a bundle of hemoclips may be an effective rescue method. The authors conclude that rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGIB when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible.

In a previous report by our group in 2011 [2], we described a case of refractory gastric ulcer bleeding that was treated using the endoloop/clips technique. A 38-year-old woman at the 25th week of gestation developed H1N1 flu and fulminant respiratory failure that required extracorporeal membrane oxygenation (ECMO). On Day 6 in intensive care, UGIB was noticed and an esophagogastroduodenoscopy showed a spurting vessel on the lower border of a gastric ulcer. First-line treatment by endoclip placement was successful but the patient developed recurrent bleeding 1 week later. In order to minimize the risks to the fetus, we avoided electrocautery and epinephrine injection. The endoloop/clips technique was used successfully to control the bleeding. We concluded that this technique is feasible and useful when the endoscopist faces difficult-to-treat bleeding and is limited in the use of standard hemostatic strategies, as is the case with pregnant patients and patients for whom anticoagulation cannot be suspended, such as in ECMO-treated patients.

Following this case, in gastrointestinal bleeding in critically ill patients with a high risk of recurrence, endoloop/clips technique has represented, in our experience, not only an adjunct to standard treatment, but also a useful first-line option for the control of bleeding.

In conclusion, in our opinion the endoloop/clips technique may be considered not only for rescue endoscopic control of nonvariceal UGIB as reported by Lee et al., but also as first-line therapy when the endoscopist is limited in the use of standard hemostatic strategies or, particularly, when the risk of recurrence is high and associated with high mortality.

 
  • References

  • 1 Lee JH, Kim BK, Seol DC et al. Rescue endoscopic bleeding control for nonvariceal upper gastrointestinal hemorrhage using clipping and detachable snaring. Endoscopy 2013; 45: 489-492
  • 2 Curcio G, Traina M, Panarello G et al. Refractory gastric ulcer bleeding treated with new endoloop/clips technique. Dig Endosc 2011; 23: 203-204