Hemostasis via an endoscopic full-thickness suturing device with extended cap length method and red dichromatic imaging for deep colonic diverticular bleeding

Diverticular bleeding accounts for approximately 60% of cases of acute lower gastrointestinal bleeding and is a common disease [1]. Endoscopic hemostasis is mainly achieved using endoclips or endoscopic band ligation (EBL), although rebleeding may occur. For such cases, an OTS-clip has been reported as an effective option [2] [3]. Furthermore, red dichromatic imaging (RDI) can facilitate the identification of the diverticular bleeding site [4] [5]. Herein, we describe a case of recurrent diverticular bleeding successfully treated by modifying the OTS-clip setup with an extended cap length method (ECLM) to increase the suction depth and by using RDI to improve the visualization of the bleeding site ([Video 1]). A 74-year-old man who was taking aspirin for essential thrombocythemia was presented with hematochezia. Computed tomography revealed multiple diverticula, and upon emergency colonoscopy, we discovered active bleeding from a diverticulum of the ascending colon. After marking clips were fixed near the diverticulum, hemostasis was achieved via clipping; however, the diverticulum was so deep that the clips were hidden ([Fig. 1] a–d). Rebleeding occurred the following day, and EBL yielded temporary hemostasis ([Fig. 1] e, f), but bleeding recurred several hours later. As both clipping and EBL had failed, hemostasis via an OTS-clip was planned during third colonoscopy. Because the diverticulum was deep and the band had detached ([Fig. 1] g), the OTS-clip was attached with an extended cap to increase the suction width ([Fig. 2]). RDI was used to enhance the visibility of the bleeding site within the diverticulum. The diverticulum was fully inverted into the elongated OTS-clip cap, and the clip was deployed, resulting in complete hemostasis ([Fig. 1] h–l). No further bleeding occurred.

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Hemostasis achieved via an OTS-clip with an extended cap length method and red dichromatic imaging for bleeding from a deep colonic diverticulum.Video 1

Fig. 1 Endoscopic images. a Active bleeding was observed from a diverticulum in the ascending colon (green dotted circle). b A marking clip was placed near the responsible diverticulum. c A clip was inserted into the diverticulum, which yielded hemostasis. d Primary hemostasis was achieved; however, the diverticulum was so deep that the clips were hidden. e Rebleeding was observed from the previously clipped diverticulum. f Endoscopic band ligation yielded temporary hemostasis. g During the third colonoscopy for recurrent bleeding, we discovered that the previously applied band had detached. h An endoscopic image under white-light imaging. i An endoscopic image under red dichromatic imaging. j The entire diverticulum was suctioned into an OTS-clip via an extended cap length method. k The OTS-clip was successfully deployed. l The OTS-clip was firmly fixed, resulting in successful hemostasis.

Fig. 2 Schema of an OTS-clip deployed using an extended cap length method. a Schema of the normal deployment of the OTS-clip. b Appearance of the normal deployment of the OTS-clip. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 6 mm. c An endoscopic view of the normal deployment of the OTS-clip. d Schema of the OTS-clip deployed via the extended cap length method (ECLM). e Appearance of the OTS-clip deployed via the ECLM. The cap length (from the endoscope tip to the tip of the OTS-clip cap) is 12 mm. f An endoscopic view of the OTS-clip deployed via the ECLM. The endoscopic view is slightly narrower than that with normal deployment, but it does not interfere with the procedure.

In conclusion, an OTS-clip attached via the ECLM enabled the complete inversion and reliable hemostasis of a deep diverticulum. Combined with RDI, this approach may be useful as treatment for refractory diverticular bleeding.

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Contributorsʼ Statement

Takahiro Muramatsu: Conceptualization, Visualization, Writing – original draft. Masakatsu Fukuzawa: Supervision. Fumito Yamanishi: Investigation. Makoto Arashiyama: Investigation. Fumi Naruse: Investigation. Tomohiro Kaketani: Investigation. Takao Itoi: Supervision, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We would like to thank Editage (www.editage.jp) for English language editing.

• References

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• 2 Doi H, Sasajima K, Takahashi M. Using an over-the-scope clip for colonic diverticular hemorrhage. Dig Endosc 2019; 31: e80-e81
• 3 Yamaguchi D, Tanaka Y, Nomura T. Over-the-scope clip rescue method of endoscopic hemostasis for severe acute colonic diverticular bleeding. Dig Endosc 2024; 36: 506-507
• 4 Saino M, Aoyama T, Fukumoto A. et al. Tracking the target in colonic diverticular bleeding using red dichromatic imaging. Endoscopy 2021; 53: E425-E426
• 5 Fukuda S, Sakamoto T, Suzuki H. et al. Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding. Video GIE 2022; 7: 149-151

Publication History

Article published online:
13 January 2026