S4146 “Top Gun” Techniques of Hemostasis for the Practicing Gastroenterologist

Introduction: Gastrointestinal (GI) bleeding is the most common GI-related cause of hospitalization. We present 2 cases showcasing multiple endoscopic modalities, to help the practicing gastroenterologist gain confidence in various hemostatic techniques. Case Description/Methods: Case 1 is a 73-year-old woman who initially presented to an outside hospital with melena and hematemesis. Index esophagogastroduodenoscopy (EGD) at the outside hospital did not lead to durable hemostasis. The patient left against medical advice, but presented to our hospital 2 days later with recurrent symptoms. Repeat EGD showed a 2–3 cm ulcer with an adherent clot along the lesser curvature of the gastric body. Unroofing of the clot during the procedure led to brisk arterial bleeding. A multi-modal endoscopic approach was employed: an over-the-scope clip temporarily stopped the bleeding, though it recurred after a brief period of observation. Next hemostatic powder was applied for temporizing purposes. After careful inspection, the bleeding vessel was identified, and definitive hemostasis was achieved using monopolar coagulation grasping forceps. The patient recovered well and was discharged home. Case 2 is an 83-year-old man with a history of celiac disease was admitted with melena. On admission, his hemoglobin had dropped from 15.4 to 8.6 g/dL. EGD revealed an actively spurting dieulafoy lesion in the descending duodenum. This location was difficult for endoscopic intervention, and a distal attachment cap was then added for improved stability. Hemostasis was achieved with injection of 2 mL of epinephrine and precise placement of a hemoclip. Discussion: Initial evaluation and treatment of GI bleeding requires urgent endoscopic diagnosis and intervention. While angiographic embolization and surgery remain options for refractory bleeding, endoscopy remains one of the best and most immediately accessible approaches to hemostasis. Initial hemostasis in both cases used standard endoscopic therapy with epinephrine and hemoclips for a high-volume bleed. In addition, case 2 demonstrated the utility of a distal attachment cap to aid with visualization and stability. An escalating, multi-modal strategy demonstrated in case 1, included an over-the-scope clip, hemostatic powder, and further coagulation attempts. While early multidisciplinary approaches to severe bleeding is always recommended, we hope these case reports demonstrate a broad range of techniques for the practicing gastroenterologist to manage challenging GI bleed cases. Watch the video: https://tinyurl.com/25ACG4146