DOI: 10.1097/01.mcg.0000165707.81703.73
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PMID: 15942445
Issn Print: 0192-0790
Publication Date: 2005/07/01
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Excerpt
Endoscopic placement of clips for hemostasis during acute upper and lower GI bleeding as well as for marking and mucosal closure has become increasingly used.1-5 Several reports have demonstrated the efficacy of hemostatic clipping for major vessel bleeding such as the Dieulafoy's artery.6,7 We have experienced a unique problem when a hemostatic clip has been closed but fails to firmly grasp tissue. If the clip is aspirated, an alarming situation may arise, often during a critical phase of the endoscopic procedure.
Case 1: A 45-year-old man with acute upper GI bleeding was found to have arterial bleeding from a suspected Dieulafoy's artery (“exulceratio simplex Dieulafoy”) at emergency upper endoscopy. Injection of dilute epinephrine was ineffective in controlling the bleeding, and it was decided to place an endoscopic hemostatic clip (Quikclip, Olympus America, Melville, NY). Bleeding persisted despite apparent clip placement, although the dropped clip could not be identified. In preparation to place a second clip, the fundus of the stomach was aspirated of blood, at which point the suction button of the therapeutic gastroscope became stuck in the down position, which leaves the suction channel open. The stomach collapsed, rendering visualization impossible. A hemostat forceps was used to attempt to extract the stuck down suction button to no avail, and the endoscope was removed from the patient despite active ongoing bleeding. At the bedside, it was not possible to dislodge the suction button forcefully. A flush from the umbilical cord through the entire endoscope with the suction button held down was performed. The endoscope suction channel contents were collected, and the closed, dropped clip was expelled from the channel, freeing the suction button and permitting the endoscopy to resume. Successful clipping of the Dieulafoy's lesion was then accomplished.
Case 2: A 68-eight-year old man with a large right-sided colon polyp underwent colonoscopy for definitive removal. Despite pure coagulation current and slow snare closure, brisk bleeding from a large vessel within the base of the stalk occurred upon transsection of the polyp. Dilute epinephrine injection failed to stem the arterial bleeding, and a hemostatic clip was indicated. A preloaded hemostatic clip was advanced through the biopsy channel of the endoscope; the clip was closed but failed to firmly attach to the artery resulting in continued bleeding. Aspiration of the bleeding field again resulted in abrupt sticking of the suction button of the endoscope in the down position (open suction channel). The colon lumen collapsed due to aspiration of remaining air and fluid, and the view of the bleeding vessel was lost. Immediately, a 30-mL saline flush from the umbilical cord end of the endoscope was performed while holding the suction button down. The “stuck” suction button was immediately freed, permitting reinflation of the colon; the expelled clip, which had caught within the valve stem producing this alarming phenomenon, was identified and reaspiration was avoided. Successful clip placement was performed.
The finely machined suction valve of the endoscope obstructs the suction channel when a spring pushes the button into the up or closed position (Figure 1). The stem of the suction button contains a hole that, when depressed, aligns with the suction channel and permits passage of liquid material at a right angle down the barrel of the stem into the channel of the umbilical tube at a right angle. This arrangement often permits obstruction at this point, which is easily cleared by withdrawing the suction valve and its stem. However, a metal foreign body such as a clip will not permit withdrawal of the stem. The clip length is 10 mm, and when closed measures only 1 mm in diameter.
