Post written by John Gubatan, MD, from the Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
We present a case of a 79-year-old woman with a history of cirrhosis who presented with hematemesis and was found to have a large blood clot in the lesser curvature and fundus of the stomach. The clot obscured visualization and prevented localization of the bleeding lesion. Despite promotility agents to help with clearance, the clot continued to enlarge with ongoing bleeding. Attempts to mechanically disrupt and remove the clot with cold snare, Roth net, and Biovac were ineffective because of the size of the clot. Through novel application of an endoscopic morcellator (EndoRotor®), we were able to liquefy and clear the large clot. Clearance of the clot did reveal a bezoar which could not be completely cleared by the endoscopic morcellator due to fibrous material. The bezoar was quickly cleared with metoclopramide ultimately revealing a 5-mm Forrest Class IIA cratered ulcer in the posterior wall of the stomach. Hemostasis was successfully achieved after bipolar thermal therapy.
Our case illustrates a not uncommon scenario encountered by endoscopists in evaluating patients with upper-GI bleeding and the limitations of our current endoscopic arsenal when faced with large obscuring clots. Difficulties and delays in localizing the culprit bleeding lesion can lead to multiple endoscopies and longer hospitalizations. Application of the endoscopic morcellator likely decreased the time to identifying an intervenable lesion and decreased the length of hospitalization in our patient.
The endoscopic morcellator was designed to remove benign mucosal tissue throughout the GI tract such as ablation of nonneoplastic Barrett’s esophagus and direct endoscopic pancreatic necrosectomy. We demonstrate that this novel technology can also be applied to liquefy blood clots and may be an adjunct to our standard therapies for GI bleeding.
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