Use of an over-the-scope clip and a colonoscope for complete hemostasis of a duodenal diverticular bleed.

Duodenal diverticular bleeding has traditionally required invasive surgical repair. With improvements in endoscopic devices, endoscopic treatment has become the main therapy for such bleeding [1,2]. However, the question of which endoscopic devices should be used is still controversial because of complications and recurrent bleeding after treatment [3]. A newly developed device, the overthe-scope clip (OTSC) [4], has been reported to be useful for treatment of bleeding gastrointestinal lesions that are resistant to conventional therapy [5]. Here we report the first case of complete hemostasis using an OTSC system and a colonoscope for bleeding from a Dieulafoy lesion that was located in a duodenal diverticulum andwas resistant to conventional therapy. An 81-year-old man presented with tarry stool and severe anemia. Upper gastrointestinal endoscopy failed to detect the bleeding site. Re-bleeding occurred during a capsule endoscopy. Informed consent was obtained from the patient before the following treatment was undertaken. Because fresh blood had been found from the deep second portion of the duodenum toward the anal side, a colonoscope with a waterjet function (PCF-Q260AI; Olympus, Tokyo, Japan) was introduced. This contributed to clear identification of a Dieulafoy lesion at the edge of a large diverticulum in the third portion of the duodenum. Endoscopic hemostasis using hemostatic forceps (Coagrasper, FD-411UR; Olympus) only diminished the blood flow from spurting (●" Fig.1) to oozing. Because of the risk of perforation when using coagulation in the thin duodenal wall, an OTSC system (Ovesco Endoscopy, Tübingen, Germany) was selected as the next step. The entire defect of the bleeding ulcer was successfully closed using the OTSC as shown in the schema (●" Fig.2a– c), resulting in complete hemostasis (●" Fig.3, ●" Video1).