Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study

Abstract

Introduction: The over-the-scope-clip (OTSC) can potentially overcome limitations of standard clips and achieve more efficient and reliable hemostasis. Data on OTSC use for non-variceal upper gastrointestinal bleeding (NVUGIB) in patients with cardiovascular comorbidities are currently limited.

Patients and methods: We prospectively collected and retrospectively analyzed our database from February 2009 to September 2015 from all patients who underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19).

Results: One hundred patients mean age 72 (range 27 - 97 years) were included in this study. Fifty-one percent (n = 51) had severe cardiovascular co-morbidity (ischemic heart disease, congestive heart failure, hypertension, valvular heart disease, peripheral arterial occlusive disease and atrial fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation therapy. The median size of the treated ulcers was 3 cm (range 1 - 5 cm). In 94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term success during a mean 6-month follow-up without rebleeding was 86 % (n = 86).

Conclusions: In this cohort OTSC was demonstrated to be a safe and effective first- or second-line treatment for NVUGIB in high-risk patients with cardiovascular disease and complex, large ulcers.

Conflict of interest statement

Competing interests None

Figures

Fig. 1

A 57-year-old patient who had a pulmonary embolism 1 week before presenting a severe upper gastrointestinal bleeding due to 2 antral ulcers (Forrest IIa and Forrest III) (a, b). The patient was anticoagulated with Enoxaparin 2 × 10 000 UI. The Forrest IIa Ulcer had a size of 1.5 × 1.8 cm with a visible vessel and coagulum. This was treated successfully with a 17.5-mm traumatic OTSC (a–c). A second Forrest III ulcer 1 × 1.2 cm was also treated with a 17.5-mm traumatic OTSC (b–d).

Fig. 2

A 63-year-old patient who had a myocardial infarction in 2011 with stenting and was receiving antiplatelet therapy with aspirin 75 mg. He presented with epigastric pain and hematemesis. Emergency endoscopy revealed a Dieulafoy ulcer in the fundus with a large visible vessel (2.5 – 3 mm) (a). The lesion was treated after suction of the vessel into the OTSC effectively with a 17.5 traumatic OTSC (c–d).

Fig. 3

Study outcome failure group. Initial endoscopic hemostasis with the OTSC failed in 6 patients. In 4 a surgical treatment was performed, 2 patients died despite surgical treatment. One patient died due to hemorrhagic shock. In 1 patient no further treatment was desired because of a palliative situation.

Fig. 4

Study outcome in the early rebleeding group. Early rebleeding (≤ 24 hours) after an initial treatment occurred in 5 patients. In this group 2 patients died due to hemorrhagic shock, 1 despite radiologic embolization. Two other patients survived after additional therapy (1x endoscopic clipping, 1x radiologic embolization and 1 × surgical treatment). All lesions in the early rebleeding group were Forrest Ia. lesions.

Fig. 5

Study outcome late rebleeding group. Three patients presented with late rebleeding (≤ 30 days). In this group 2 patients died due to hemorrhagic shock. The third patient had a rebleeding on day 4 with oozing bleeding in between the OTSC teeth; that was treated by using fibrin glue.

Fig. 6

Rebleeding in anticoagulated patients.

Fig. 7

Bleeding-related mortality in cardiac and non-cardiac patients.