Post written by Calvin J. Koh, MBBS, from the Division of Gastroenterology and Hepatology, Medicine, National University Hospital, and Faculty of Medicine, National University of Singapore, Singapore.

This case shows a patient with a large, oozing (Forrest 1b) duodenal ulcer for which an over-the-scope clip was deployed successfully to the ulcer base with the bleeding point centered in the middle of the clip, but for which ulcer bleeding point persisted.  Hemostasis was subsequently achieved with through-the-scope clips over the existing over-the-scope clip. Several pointers for duodenal deployment of the over-the-scope were discussed, and possible explanations for failure of hemostasis were discussed.

Over-the-scope clips have shown to be very useful both for primary and repeat ulcer hemostasis, but their size and design make it challenging for further salvage therapy.  After application of conventional through-the-scope clips on an ulcer site, applying an additional over-the-scope clip is challenging; hence for large ulcers, applying an over-the-scope clip as first-line therapy is an appealing option. While most unsuccessful applications have been attributed to technique and malposition rather than device failure, this case shows that the clip is in the right location, with closure of the device, but hemostasis is unsuccessful.

The over-the-scope clip is playing an increasing role in ulcer hemostasis, with studies showing benefits for both primary and re-look endoscopies compared with conventional hemostasis. This is a cautionary case demonstrating that despite everything being in position, this device can fail to achieve hemostasis.

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