Esophageal variceal bleeding is one of the most common complications in patients with cirrhosis. Endoscopic variceal ligation (EVL) is the main method for treating esophageal variceal bleeding. Compared with endoscopic sclerotherapy, it has the advantages of fewer complications and better results. However, EVL may cause serious ulcer complications, with a bleeding rate of about 3.6% and a mortality rate of up to 27.3%. There is currently no clear standard treatment for EVL-induced ulcer bleeding. This case will detail a new treatment method that combines endoscopic clips and endoscopic snares to provide a safe, economical and effective option. Below is the details:
The patient was a 72-year-old male who was diagnosed with chronic hepatitis C infection and esophageal variceal bleeding. The patient had received EVL to control acute bleeding 4 months ago.
Initial findings
Endoscopy revealed an ulcer formed after EVL, with obvious bleeding vessels at the bottom. Repeated EVL ligation was attempted, but hemostasis was not successful due to poor tissue elasticity.
Initial intervention
In an emergency, a Sengstaken–Blakemore (SB) balloon tube was placed to temporarily control bleeding. However, after the SB tube was removed the next day, endoscopic reexamination revealed that the patient had active bleeding again.
Innovative treatment process
Considering that the tissue condition was not suitable for re-EVL ligation, the team decided to use an innovative treatment method of endoscopic clips combined with endoscopic snares. The specific steps are as follows:
1. Endoscopic clip fixation of bleeding vessels
Using a two-channel endoscope and disposable tissue clips, three tissue clips were placed near the bleeding vessels to anchor the surrounding tissues.
2. Endoscopic snare compression of bleeding points
Using Grasping Forceps to cover the blood vessels under the mucosa, and ENDOLOOP was delivered to the bottom of the mucosa through a two-channel endoscope. The snare was then tightened in a "purse string suture" manner.
3. Successful hemostasis
The bleeding at the wound was successfully controlled without further intervention. Endoscopic reexamination 3 months after surgery showed that the ulcer was completely healed without any signs of rebleeding.
Although there are currently a variety of treatments for EVL-induced ulcer bleeding, including:
- Endoscopic injection sclerotherapy
- OTSC over-range clip treatment
- Self-expandable metal stent (SEMS) placement
- Transjugular intrahepatic portosystemic shunt (TIPS)
However, these methods may have problems such as technical complexity, high cost or potential complications, which limit their application in some patients.
Advantages of the endoscopic clip + snare method
The treatment method of endoscopic clip combined with endoscopic snare used in this case has the following significant advantages:
1. High safety: It avoids the complications that may be caused by sclerotherapy or metal stents.
2. Strong economical: It can be completed using conventional endoscopic accessories without the need for special equipment.
3. Simple operation: This method is easy to learn and promote, especially in areas with limited medical resources.
4. Wide adaptability: In addition to EVL-induced ulcers, this method has been successfully used to treat bleeding after polypectomy and non-varicose upper gastrointestinal bleeding.
This case shows that the treatment method of endoscopic clip combined with endoscopic snare has a significant effect in controlling EVL-induced ulcer bleeding. This method is not only economical and practical, but also reduces the treatment risk of patients, providing an innovative option for endoscopic treatment of complex gastrointestinal bleeding. In the future, it is necessary to further verify the efficacy and safety of this method through research with a larger sample size.
Reference: Innovative rescue therapy for ulcer bleeding after band ligation: New ENDOLOOP/clips/grasping forceps technique(https://link.springer.com/article/10.1007/s12664-021-01177-5)
