Bleeding Duodenal Ulcer Managed with Coag Grasper + Hemoclips

Bleeding Duodenal Ulcer Managed with Coag Grasper + Hemoclips.

Presentation: 86-year-old male presenting with melena and hypotension, he was under oral anti coagulation clopidogrel. After resuscitation, Hb was at 6 with transfusion done passed to 7.5.

First EGD done 6 hours before, revealed an actively bleeding duodenal ulcer (Forrest Ia), with no localization of the precise site.

Patient referred for endoscopic treatment.

Procedure: Under sedation, gastroscope was advanced. The bleeding site was identified in the anterior first duodenum, a 10 mm ulcer, classified as Forrest 1A. Another Forrest 3 ulcer was seen.

We get the scope out to place a distal attachment cap to get a better stability, initially we controlled the bleeding using a coagulation grasper soft coag 4.0, for targeted hemostasis, take your time with the coag grasper, until bleeding stops, you can use irrigation with saline to minimize deep thermal injury. Following thermal contact, no vessel was seen.

Two hemoclips were deployed precisely to close the defect and secure mechanical closure.

Outcome: Immediate cessation of bleeding. Patient remained hemodynamically stable post-procedure. No signs of rebleeding at 48-hour follow-up with stability of hemoglobin.

No endoscopy control was done as most guidelines (e.g., ASGE, ESGE) suggest selective use of second-look endoscopy rather than routine application.

Technique Rationale: Distal cap attachment  enable scope view stability and also hemostasis by tamponade.

Coag Grasper: Enabled accurate grasping and coagulation of the bleeding vessel. Ideal for pinpoint hemostasis in challenging angulations, and in patient under anticoagulation.

Hemoclips: Reinforced vessel sealing and provided sustained mechanical compression to minimize rebleeding. 

Teaching Point: Combination of thermal and mechanical modalities can offer superior durability in high-risk ulcer bleeding. Coag grasper adds precision in thermocoagulation, particularly in anatomically complex zones.