Introduction: Over the scope clip (OTSC) or Ovesco is indicated for non-variceal upper refractory bleed (NVUGIB), to close fistulas and perforations. Rebleeding is a common adverse event (AE) associated with it. In this report, we present a case of severe intramural duodenal hematoma related to OVESCO clip placement. To our knowledge, this is the first report of such complication.
Case Description/Methods: A 76-year-old male with recent pulmonary embolism on Eliquis presents with syncope and melena. He was noted to have baseline acute normocytic anemia with hemoglobin(Hb) of 12.3 g/dL with a drop to 10.9 g/dL. Esophagogastroduodenoscopy(EGD) revealed a 5 mm duodenal bulb ulcer with oozing of blood which was injected with epinephrine and clipped using T-OVESCO. Overnight patient complained of abdominal pain followed by hemorrhagic shock (Hb 8.1 g/dl), lipase elevation at 954 U/L and features of gastric outlet obstruction(GOO). Computed tomography(CT) scan showed an evidence of large complex fluid collection(CFC) encasing duodenum representing an intramural duodenal hematoma and adjacent acute pancreatitis. Patient was managed conservatively for GOO and pancreatitis with nasogastric tube (NG) to suction and was started on total parenteral nutrition (TPN). Concurrently patient was noted to have worsening liver function tests(LFTs), predominantly cholestatic pattern. Magnetic resonance cholangiopancreatography showed persistent CFC adjacent to descending, third portion and proximal fourth portion measuring 11.5x6.5x6.5 cm and no biliary obstruction was noted. Repeat EGD revealed non-bleeding duodenal ulcer and a free floating OVESCO clip which was removed using forceps. An attempt to place NG failed due to inability to traverse space occupying para-duodenal hematoma. For his abnormal LFTs, liver biopsy was performed, which showed evidence of centrilobular hepatocellular injury and cholestasis likely due to TPN that was held. Patient was continued on conservative management as repeat CT on day 16 showed evidence of decreasing size of hematoma.
Discussion: Ovesco clip is a novel device with high efficacy in achieving hemostasis in NVUGIB as compared to standard endoscopic techniques. Recent meta-analysis reported a mortality rate of 10.9% related to rebleeding (3.9%), other (7%). Our case report describes a life threatening complex intramural duodenal hematoma developed as a complication of OTSC placement in a patient with anticoagulation. Further data on safety of these devices is warranted in similar scenarios.
Dalbir Sandhu indicated no relevant financial relationships.
Komal Thind indicated no relevant financial relationships.
Dalbir S. Sandhu, MD1, Komal Thind, MD2. P1489 - Treat with Caution: Complications With OVESCO, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.