Announcing
ScopeBites!
We’re excited to launch a new series of short clinical case clips—each featuring concise case descriptions with an educational focus. This series is brought to you in collaboration with Dr. Andy Tau (Austin Gastroenterology, Austin, Texas), and is now available on our platform with regular updates!
Case #1
Introduction:
66-year-old female with post-polypectomy bleeding (5 days after duodenal EMR for 40mm adenoma) despite endoscopic suture closure.
Case Details:
Sudden onset bleeding occurred from the exposed vessel on contact with the bipolar probe. Visualization was maintained by tamponading the vessel with a clear cap while suction was unavailable (instrument in channel).
Take Home Point:
Clear cap tamponade is useful in tight areas like the duodenum (and esophagus) to preserve the visual field from red out.
Case #2
Introduction:
A 72-year-old patient presents with hemorrhagic shock, melena, and has a history of heavy NSAID use.
Case Details:
A visible vessel in this anterior duodenal ulcer is seen, which is larger than the diameter of the gold probe (3.3 mm, 10 Fr). Attempting cautery in this scenario risks triggering arterial bleeding, even after epinephrine injection. The decision was made to use a primary (first-line) over-the-scope clip (OTSC) due to its large volumetric capture. Excellent tissue capture was achieved, and hemostasis was durable and without complications.
Take Home Point:
If a vessel is larger than 3 mm (i.e., larger than the thermal device), consider using OTSC as primary therapy.
Case #3
Introduction:
1) A patient with aortic stenosis presented with persistent melena and was found to have an actively bleeding gastric AVM.
Confirmation that the vessel was captured during active bleeding was achieved by closing the forceps and washing prior to cauterization. Hemostatic forceps elegantly combine temporary mechanical pressure with cautery.
2) A patient on anticoagulation had persistent bleeding following esophageal disimpaction.
The forceps can be gently used in a closed position to resemble a heater probe. Significant compression should be avoided due to the use of monopolar cautery.
3) A patient on anticoagulation experienced post-polypectomy bleeding with a visible vessel on the apex of a fold.
The forceps are more precise and stable for capturing a vessel on a ridge or fold than a bipolar probe, which can slip.
Take Home Point:
Hemostatic forceps are ideal for precise capture of actively bleeding vessels, especially those on the apex of a fold or in areas where compression is unsafe due to thin walls. Soft coagulation generates shallow cautery and is safe even with the jaws closed.
Case #4
Introduction:
A patient with persistent iron deficiency anemia (IDA) from gastric antral vascular ectasia (GAVE) refractory to argon plasma coagulation (APC).
Case Details:
Endoscopic band ligation was performed for nodular GAVE.
Care should be taken to avoid banding too close to the pylorus, as this can cause nausea and pain.
Take Home Point:
Band ligation for GAVE—especially the nodular type—can be more effective than APC.
Case #5
Introduction:
Modern through-the-scope (TTS) clips can be opened and closed repeatedly without limitation.
In a case of actively bleeding AVM, the clip was closed but not immediately deployed. Irrigation was used prior to deployment to confirm hemostasis. The clip was only deployed when confident the vessel was fully ligated.
Similarly, in a case of immediate post-polypectomy bleeding, the clip was closed and only deployed once the bleeding stopped. This approach reduces the number of clips needed. In active bleeding, one well-placed clip is more effective than multiple indirect ones.
Take Home Point:
Close TTS clips, but resist the urge to deploy prematurely—especially under the stress of active bleeding. Irrigate first, confirm hemostasis, and only then deploy the clip.
Case #6
Introduction:
Three methods to control immediate polypectomy bleeding and prevent post-polypectomy bleeding include cauterization, clipping, or hemostatic gel application.
Thermal Technique – Snare Tip Coagulation:
For immediate post-polypectomy bleeding, snare tip coagulation (soft or spray coagulation, 60W) is quickest, as the snare is already in the channel. Pre-program your preferred coagulation setting for the blue pedal. A brief tap of the blue pedal is sufficient for small vessels.
Thermal Technique – Hemostatic Forceps:
For larger bleeding vessels, exchange for monopolar hemostatic forceps (soft coagulation, 60W). Close on the vessel, wash (to ensure bleeding has stopped), and then cauterize. Avoid tenting the vessel excessively.
To prevent post-polypectomy bleeding, prophylactically cauterize exposed vessels with monopolar hemostatic forceps.
Mechanical Technique – Clip Closure:
The gold standard for prevention remains mechanical closure with clips. Some large defects can be closed with anchor-pronged clips starting from the widest aspect of the defect to make one wide defect into two smaller ones.
Topical Technique – Hemostatic Gel:
Topical hemostatic gels are a very efficient alternative for prevention of bleeding and are well suited for awkward, large, or sensitive (papilla) defects that cannot be completely closed with clips.
Take Home Point:
Thermal, mechanical, and topical hemostasis are three effective strategies for post-polypectomy bleeding. Consider a combination with clip closure (gold standard).
Case #7
Introduction:
A duodenal ulcer with an adherent clot was identified at the duodenal bulb apex. When the clot was disrupted, arterial bleeding ensued.
Case Details:
The bipolar probe could not be effectively used due to the stiffness of the catheter and the unstable position, with blood pooling back into the stomach and obscuring the pylorus.
A clear cap was used for tamponade to buy time while an over-the-scope clip (OTSC) was prepared on another gastroscope.
The OTSC, preloaded to save time, offered full tip flexibility as only the deployment string occupied the channel. Deployment achieved durable hemostasis. The patient did not require further endoscopy or embolization.
Take Home Point:
Clear cap tamponade can stabilize visualization and provide time for definitive therapy. OTSC offers flexibility and reliable hemostasis in challenging duodenal bleeding cases.
Case #8
Introduction:
A patient presented with Buried Bumper Syndrome, where the internal bumper of the PEG tube was not visible and could not be pushed back into the stomach.
Case Details:
The “tube-in-tube” technique was used to replace the PEG safely. The PEG tube was pulled through the existing tube in a single move after cutting the external portion short. A guidewire was passed through the old tube, looped through the cut G-tube, and then grasped and pulled out of the mouth. The new G-tube was tied to the wire using a square knot and pulled into the old tube. Using a hemostat to securely hold the “tube-in-tube,” the entire assembly was removed and replaced in one controlled step.
Take Home Point:
The “tube-in-tube” technique is an efficient method to replace PEG tubes in cases of buried bumper syndrome, allowing safe and controlled removal and replacement in a single step.
Case #9
Introduction:
A patient with a duodenal ulcer and a large visible vessel underwent primary hemostasis with an over-the-scope clip (OTSC).
Case Details:
Initial OTSC deployment provided mechanical closure of the ulcer base; however, bleeding persisted despite clip placement. Bipolar cautery was then applied safely, as the OTSC provided a mechanical buttress, stabilizing the tissue and minimizing the risk of perforation. It was noted that small gaps within the OTSC can allow residual blood flow, highlighting the importance of confirming complete hemostasis after deployment.
Take Home Point:
In cases of duodenal ulcer bleeding treated with OTSC, bipolar cautery can be safely applied when bleeding persists, as the OTSC provides a buttress. Residual bleeding may occur through small gaps in the clip, requiring reassessment.
Case #10
Introduction:
A patient was found to have massive esophageal varices with a white nipple sign, a classic stigmata of recent hemorrhage.
Case Details:
Bleeding occurred upon contact with the cap. A clean cap was then used to tamponade the vessel, allowing visualization of the bleeding site at the 11 o’clock position. Band ligation was subsequently performed, achieving hemostasis.
Take Home Point:
In massive variceal bleeding, the white nipple sign identifies recent hemorrhage. Cap tamponade can control bleeding temporarily and facilitate safe and effective band ligation.
Case #11
Introduction:
A large cap was used to facilitate removal of a substantial bolus.
Case Details:
The large cap allowed for effective en bloc capture and removal of the bolus. The cap was taped for extra security, ensuring stability throughout the procedure.
Take Home Point:
Using a large, securely taped cap can improve stability and allow for safe, efficient en bloc removal of large bolus material.
Case #12
Introduction:
A 36-year-old patient presented with melena and upper GI bleeding but no typical risk factors. Imaging with CT revealed an infiltrative gastric mass along the greater curvature, consistent with a bleeding GIST.
Case Details:
The patient underwent detachable loop ligation of the bleeding GIST.
Take Home Point:
Actively bleeding gastric GISTs are excellent candidates for detachable loop ligation, which provides rapid temporary hemostasis and, in some cases, definitive therapy if the tumor necroses after ligation. While detachable loops can be challenging in tight spaces, the stomach’s roomy anatomy makes deployment easier and effective for large lesions.
Case #13
Introduction:
The most common complication of fully covered self-expanding metal stents (FCSEMS) is stent migration, particularly once the patient resumes oral intake. Options for stent fixation include the OTSC Stentfix (Ovesco), TTS clips, through-the-scope suturing (X-tack), or over-the-scope endoscopic suturing—though the latter can be cost-prohibitive when used solely for stent fixation.
Video 1:
Demonstration of OTSC Stentfix placement. This system securely anchors the stent and can later be removed using a dedicated bipolar removal device.
Video 2:
A Mantis clip (Boston Scientific) is used to fix the distal aspect of the stent to the more robust gastric mucosa. This is a very effective alternative, especially when multiple clips are applied.
Take Home Point:
OTSC Stentfix and TTS clips—particularly when placed distally—are fast, cost-effective solutions for stent fixation. OTSC Stentfix requires a dedicated generator-based bipolar removal device.
Case #14
Introduction:
Endoscopic perforations must be promptly recognized and managed during the index procedure to limit contamination of the extraluminal space.
Video 1:
At the base of a recently cauterized duodenal ulcer, a perforation was identified by the presence of “sliding,” white, glistening mesentery. An OTSC was used to close the defect, capturing and inverting a small patch of mesentery.
Video 2:
A colonic perforation occurred due to looping-related scope trauma. In this case, the patient required surgical intervention, as endoscopic clipping would not achieve a secure closure.
Take Home Point:
When perforation is suspected, perform a meticulous inspection. Recognizing “sliding” mesentery, although exceedingly rare, is critical for accurate identification.
Case #15
Introduction:
A 69 year old patient presented with melena, obstructive jaundice, RUQ pain, and fever after liver biopsy.
She was found on EGD to have blood exuding from papilla — consistent with hemobilia. ERCP was performed to relieve biliary obstruction and cholangitis. Balloon sweep extracted blood clots.
Fully covered metal stent was placed to maintain patency at the expense of potentially loss of more blood (loss of tamponade effect). The pt underwent transarterial embolization by IR for definitive hemostasis immediately after endoscopy.
Take Home Point:
Hemobilia is rare adverse event of liver biopsy. While it is most often diagnosed endoscopically, hemobilia cannot be halted endoscopically. Consult IR immediately for embolization, while addressing clot related biliary obstruction.