OTSC Monotherapy for Massive Duodenal Ulcer Bleeding

Experienced teaching points

Clinical Pearls

Over-The-Scope Clips (OTSC) have evolved from a rescue therapy into a first-line, one-stop monotherapy for massive upper GI bleeding, often eliminating the need for traditional dual endoscopic therapy.
When confronted with a large duodenal ulcer and a massive visible vessel, an 11/6t OTSC can effectively compress both the ulcer bed and the vessel to achieve permanent hemostasis.
Vigorously flush the ulcer with water to clear loose clots and expose the vessel, but if a clot is tightly adherent to the ulcer base, it is safer to leave it undisturbed.

A middle-aged patient was admitted with hematemesis and hemorrhagic shock. After hemodynamic stabilization, EGD was performed, showing active bleeding and a partially adherent blood clot on a huge duodenal ulcer. The blood and blood clot were removed with a water flush. However, if a clot is more tightly adherent, I prefer not to remove it.

Inspection revealed a large ulcer (B, yellow oval) and a visible large vessel (B, C, yellow arrows). A one-stop hemostatic procedure was accomplished with an 11/6t over-the-scope clip (D). The OTSC nicely compressed the ulcer bed and the massive visible vessel.

Since the advent of OTSC, the concept of endoscopic hemostasis has completely changed, because now a single endoscopic therapy may be enough to achieve permanent hemostasis, instead of the previous approach of using "dual" endoscopic therapy. Originally, OTSC was introduced as rescue therapy for massive upper GI bleeding (1). Nowadays, OTSC is considered a first-line monotherapy for bleeding upper GI lesions (2, 3). Of course, dual or triple endoscopic therapy may be required for some cases, but it is not a "routine" approach anymore.

References:

1. Skinner M, Gutierrez JP, Neumann H, Wilcox CM, Burski C, Mönkemüller K. Over-the-scope clip placement is effective rescue therapy for severe acute upper gastrointestinal bleeding. Endosc Int Open. 2014 Mar;2(1):E37-40. doi: 10.1055/s-0034-1365282. Epub 2014 Mar 7. PMID: 26134611; PMCID: PMC4423243.

2. Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut. 2022 Jul;71(7):1251-1258. doi: 10.1136/gutjnl-2021-325300. Epub 2022 Mar 23. PMID: 35321938.

3. Faggen AE, Kamal F, Lee-Smith W, Khan MA, Sharma S, Acharya A, Ahmed Z, Farooq U, Bayudan A, McLean R, Avila P, Dai SC, Munroe CA, Kouanda A. Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis. Dig Dis Sci. 2023 Jun;68(6):2518-2530. doi: 10.1007/s10620-023-07888-3. Epub 2023 Mar 21. Erratum in: Dig Dis Sci. 2024 Jan;69(1):311-313. doi: 10.1007/s10620-023-08159-x. PMID: 36943590.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

Save this article as a PDF

Drop your email and we'll open a print-ready version you can save as a PDF — and you'll start getting our weekly GI endoscopy newsletter.

← All articles