Over-the-scope clip as primary therapy for duodenal ulcer bleed with visible vessel: An alternative to surgery

Vincent Jayakumar A¹, Thinakar Mani B², Arivarasan Kulandaivelu³, Rajakumari⁴

¹Resident, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

²Senior Consultant, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

³Senior Consultant, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

⁴Resident, Department of Medical Gastroenterology, Kauvery Hospital, Trichy

Introduction

Upper gastrointestinal (UGI) bleeding remains a significant medical emergency, with peptic ulcer disease—particularly duodenal ulcers—being a leading cause.¹ Traditionally, patients presenting with massive or recurrent bleeding were often managed surgically, especially when initial medical therapy failed.² However, advancements in endoscopic techniques have revolutionized the approach to such cases, allowing for effective, minimally invasive hemostasis that significantly reduces the need for surgery.³

Endotherapy, including injection therapy, thermal coagulation, and mechanical clipping, has become the cornerstone of acute management in bleeding peptic ulcers.⁴ These interventions not only provide immediate hemostasis but also reduce re-bleeding rates, transfusion requirements, hospital stay, and procedure-related morbidity.⁵ With growing experience and technical advancements, endoscopic hemostasis is now recommended as the first-line approach, even in high-risk or previously surgically managed patients.⁶

We report a case of a patient with active UGI bleed secondary to a duodenal ulcer who was successfully managed with endoscopic therapy, without requiring surgical intervention. This case highlights the critical role of early endoscopic evaluation and treatment in acute UGI bleeding and reinforces the shift in clinical practice toward less invasive yet highly effective strategies.

Case Presentation

A 65-year-old male presented to the emergency room with complaints of one episode of melena and hematemesis. The patient was known to have type 2 diabetes mellitus, with a history of consumption of over-the-counter non-steroidal anti-inflammatory drugs for the past year.

On receiving, patient exhibited signs of hypovolemic shock (BP: 100/60mmHg, PR: 120 bpm). General physical examination revealed pallor with mild pedal edema. Per rectal examination revealed no melena.

Blood panel showed severe anemia, Hb-3.7 g/dl; other investigations were within normal limits.

Patient was admitted to the intensive care unit. He was transfused 2 units of packed red blood cells and started on fluids and IV antibiotics. He was also given an injection Pantoprazole 80mg stat followed by 8mg/hr infusion. His blood pressure normalized, and the pulse rate became normal. Upper GI endoscopy showed a 2*2 ulcer in the superior wall of the duodenal Bulb with a prominent vessel, corresponding to Forrest class 2A (Fig. 1). Under mild sedation patient underwent coagulation therapy with injection of Adrenaline around the coagulated area. The patient had no further episodes of melena or hematemesis.

The next day review upper GI scopy was done, which showed an impending bleed from the visible vessel within the ulcer post coagulation (Fig: 2) , Hence patient was taken for application of OVESCOPE^TM(over the scope clip ) over ulcerated area to prevent further bleeding( Fig: 3)

Post application of the over-the-scope clip(OTSC) patient had no further complaints of bleeding. Over the course of admission in the hospital, his Hb level rose to 9.4 without any further transfusions. Patient was also started on H Pylori treatment regimen containing Clarithromycin, Amoxicillin and Esomeprazole. The patient was started on oral feeds on the third day without any complaints.

Discussion

Upper gastrointestinal (UGI) bleeding remains a common and potentially life-threatening emergency, particularly when massive in volume. ¹ Initial management should focus on hemodynamic stabilization using a multimodal approach, including volume resuscitation, correction of coagulopathy, and early pharmacologic therapy. ⁷ Diagnostic evaluation is critical to localize the bleeding source. In cases where a bleeding duodenal ulcer with a visible vessel is identified, timely and appropriate endoscopic intervention is essential. The Forrest IIa lesion (visible vessel without active bleeding) is associated with a high risk of re-bleeding if left untreated. ⁸

Conventionally, endoscopic hemostasis has been achieved using thermal coagulation or injection therapy. ⁴ However, in cases where the ulcer base is fibrotic or the vessel is large and pulsatile, standard endotherapies may be inadequate. ⁹ The over-the-scope clip (OTSC) system offers a promising alternative due to its ability to achieve full-thickness tissue approximation and durable mechanical hemostasis. ¹⁰ ¹¹

Conclusion

This case illustrates the successful use of OTSC as a primary hemostatic tool in a patient with a bleeding duodenal ulcer and visible vessel. In elderly or high-risk individuals, early and appropriate endoscopic decision-making is vital, as surgical intervention carries increased perioperative risk and potential complications. In our patient, the prompt application of OTSC resulted in immediate bleeding control and eliminated the need for surgical management. This not only reduced the risk of morbidity but also potentially shortened the hospital stay and resource utilization.

Our experience reinforces the growing role of OTSC (over the scope clip) as an effective first-line modality in selected cases of non-variceal UGI bleeding—particularly when conventional methods may be insufficient or when surgery poses substantial risk. Careful patient selection and timely use of advanced endoscopic techniques can lead to better outcomes in high-risk bleeding scenarios.

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Over-the-scope clip as primary therapy for duodenal ulcer bleed with visible vessel: An alternative to surgery