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
Endoscopy_UCTN_Code_TTT_1AO_2AD
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