Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-0001, Japan.
Clin J Gastroenterol. 2020 Aug;13(4):615-620. doi: 10.1007/s12328-020-01100-z. Epub 2020 Feb 12.
An 80-year-old man was admitted to our hospital for repeated tarry stools and hemorrhage. He was taking aspirin and warfarin for atrial fibrillation and obstruction of the central retinal artery. Upper gastrointestinal endoscope revealed a large blood clot at the distal duodenum; however, further insertion was difficult. Insertion of a colonoscope attached with a transparent hood from the mouth enabled the visualization of the third portion of the duodenum. It revealed a large clot, which completely blocked the diverticulum and prevented visualization of the bleeding point. It was extremely difficult to remove the clot through the use of grasping forceps due to poor vision and maneuverability. Finally, the large clot was broken off and removed completely using a snare. The diverticulum was over 20 mm, and a large volume of fresh blood was continuously gushing out from an erosion of the diverticulum. Replacing the tip of the endoscope with a short ST hood and keeping an insulating distance from the bleeding point enabled maneuvering around the steep angles, achieving hemostasis using clips. We report a case of duodenal diverticular bleeding treated endoscopically with great effort in maneuvering to remove a blood clot using snare in a difficult position.
一位 80 岁男性因反复黑便和出血而被收入我院。他因心房颤动和视网膜中央动脉阻塞而服用阿司匹林和华法林。上消化道内镜检查发现远端十二指肠有大量血块；然而，进一步插入很困难。从口腔插入附有透明罩的结肠镜，能够观察到十二指肠的第三部分。发现一个大血块，完全阻塞了憩室，无法观察到出血点。由于视力和可操作性差，使用抓钳取出血块非常困难。最后，使用圈套器将大血块完全折断并取出。憩室超过 20mm，大量新鲜血液不断从憩室的侵蚀处涌出。用短 ST 罩更换内镜尖端，并与出血点保持绝缘距离，能够在陡峭的角度周围进行操作，使用夹钳止血。我们报告了一例在难以操作的位置使用圈套器清除血凝块以进行内镜治疗的十二指肠憩室出血病例。
