OTSC Monotherapy for Massive Duodenal Ulcer Bleeding

A middle-aged patient was admitted with hematemesis and hemorrhagic shock. After hemodynamic stabilization, EGD was performed, showing active bleeding and a partially adherent blood clot on a huge duodenal ulcer. The blood and blood clot were removed with a water flush. However, if a clot is more tightly adherent, I prefer not to remove it.

Inspection revealed a large ulcer (B, yellow oval) and a visible large vessel (B, C, yellow arrows). A one-stop hemostatic procedure was accomplished with an 11/6t over-the-scope clip (D). The OTSC nicely compressed the ulcer bed and the massive visible vessel. 

Since the advent of OTSC, the concept of endoscopic hemostasis has completely changed, because now a single endoscopic therapy may be enough to achieve permanent hemostasis, instead of the previous approach of using "dual" endoscopic therapy. Originally, OTSC was introduced as rescue therapy for massive upper GI bleeding (1). Nowadays, OTSC is considered a first-line monotherapy for bleeding upper GI lesions (2, 3). Of course, dual or triple endoscopic therapy may be required for some cases, but it is not a "routine" approach anymore.

References:

1. Skinner M, Gutierrez JP, Neumann H, Wilcox CM, Burski C, Mönkemüller K. Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding. Endosc Int Open. 2014 Mar;2(1):E37-40. doi: 10.1055/s-0034-1365282. Epub 2014 Mar 7. PMID: 26134611; PMCID: PMC4423243.

2. Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut. 2022 Jul;71(7):1251-1258. doi: 10.1136/gutjnl-2021-325300. Epub 2022 Mar 23. PMID: 35321938.

3. Faggen AE, Kamal F, Lee-Smith W, Khan MA, Sharma S, Acharya A, Ahmed Z, Farooq U, Bayudan A, McLean R, Avila P, Dai SC, Munroe CA, Kouanda A. Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis. Dig Dis Sci. 2023 Jun;68(6):2518-2530. doi: 10.1007/s10620-023-07888-3. Epub 2023 Mar 21. Erratum in: Dig Dis Sci. 2024 Jan;69(1):311-313. doi: 10.1007/s10620-023-08159-x. PMID: 36943590.