S4565 Direct Clip Deployment into a Bleeding Diverticulum: A High-Skill Solution for a High-Stakes Problem

Introduction: Colonic diverticular bleeding is a leading cause of lower gastrointestinal bleeding in older adults, accounting for up to 40% of cases While many episodes resolve spontaneously, 20%-30% require intervention. Endoscopic clipping is often preferred due to its safety and durable hemostasis, but placement inside a diverticulum is rarely attempted due to technical difficulty. We present a case of successful clip deployment inside a diverticulum harboring an actively bleeding angioectasia. Case Description/Methods: A 74-year-old man with chronic obstructive pulmonary disease (COPD), hypertension, atrial fibrillation on apixaban, and chronic anemia presented with dyspnea and was diagnosed with COPD exacerbation and type 2 non-ST-elevation myocardial infarction. Hemoglobin was 6.3 g/dL, improving to 7.1 after transfusion. He had a 1-year history of intermittent hematochezia. A prior colonoscopy in 2023 showed non-bleeding diverticulosis and internal hemorrhoids. Apixaban was held. Esophagogastroduodenoscopy was unremarkable. Colonoscopy revealed grade 2 internal hemorrhoids and extensive diverticulosis. In the proximal ascending colon, an actively bleeding angioectasia was seen within a diverticulum. Argon plasma coagulation (0.8 L/min, 20 W) provided partial hemostasis. A single hemostatic clip was then skillfully deployed inside the diverticulum, achieving complete hemostasis. A tattoo was placed 2 cm distal to the site. Discussion: Diverticular bleeding typically arises from rupture of the vasa recta at the dome of the diverticulum. Clipping offers effective control of bleeding, but placing a clip within a diverticulum is rare due to technical limitations. In this case, APC alone was inadequate. Definitive control was achieved with intracavitary clip placement, an advanced technique that prevented the need for radiologic or surgical intervention. This case highlights a rare, skillful, and effective approach to diverticular bleeding. In select cases, clip placement inside a diverticulum can achieve successful hemostasis when performed by experienced endoscopists.