Identification of active gastric bleeding and achievement of endoscopic hemostasis via gel immersion endoscopy

The presence of blood clots in the gastric body makes it difficult to identify the source of bleeding and achieve endoscopic hemostasis in patients with acute upper gastrointestinal bleeding [1]. Changing the patient’s position is useful for identifying the bleeding site, but it may be challenging depending on the patient's condition [2].

This report describes a case in which the bleeding site was identified in the upper gastric body via gel immersion endoscopy, and endoscopic hemostasis was achieved by clipping [3] [4]. Changing the patient’s position was difficult because of intubation and venoarterial extracorporeal membrane oxygenation (VA-ECMO).

A 78-year-old woman underwent artificial replacement of a thoracoabdominal aortic aneurysm and returned to the intensive care unit under endotracheal intubation. Two days after surgery, the patient developed postoperative septic shock, refractory atrial fibrillation, and right heart failure. Therefore, intra-aortic balloon pumping implantation and VA-ECMO were performed. Six days after the initiation of ECMO, the patient was referred to our department for hematemesis.

Contrast-enhanced computed tomography (CECT) showed extravasation of contrast material in the posterior wall of the upper gastric body ([Fig. 1]). The gastric body was filled with a large amount of clotted blood and endoscopic suction was ineffective. Identifying the bleeding site was difficult due to blood clots in the gastric body ([Fig. 2]). The injection of gel (Viscoclear; Otsuka Pharmaceutical Factory) created a space between the gastric wall and the blood clots. This technique provides a clear field of view to avoid clotting ([Fig. 3], [Video 1]). Active bleeding was observed on the posterior wall of the upper gastric body, consistent with CECT findings ([Fig. 4]). Endoscopic hemostasis was achieved by clipping ([Fig. 5]). Gel immersion endoscopy is useful when the source of bleeding cannot be identified due to the presence of large blood clots in the gastric body and difficulties in changing the patient’s position.

Fig. 1 Contrast-enhanced computed tomography showed extravasation of contrast material in the posterior wall of the upper gastric body. a Arterial phase. b Venous phase.

Fig. 2 The presence of blood clots in the gastric body made it difficult to identify the source of bleeding.

Fig. 3 The injection of gel created a space between the gastric wall and the blood clots, providing a clear field of view to avoid clotting.

Fig. 4 Active bleeding was observed on the posterior wall of the upper gastric body.

Fig. 5 Endoscopic hemostasis was achieved by clipping.

Identification of active gastric bleeding and achievement of endoscopic hemostasis by gel immersion endoscopy in a situation in which changing the patient’s position was difficult.Video 1

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• References

• 1 Stollman NH, Putcha RV, Neustater BR. et al. The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes. Gastrointest Endosc 1997; 46: 324-327
• 2 Mori H, Kobara H, Fujihara S. et al. Accurate hemostasis with a new endoscopic overtube for emergency endoscopy. World J Gastroenterol 2013; 19: 2723-2726
• 3 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 4 Yano T, Takezawa T, Hashimoto K. et al. Gel immersion endoscopy: Innovation in securing the visual field - Clinical experience with 265 consecutive procedures. Endosc Int Open 2021; 9: E1123-E1127