Hemostasis Achieved Endoscopically for Diverticular Bleeding from the Horizontal Portion of the Duodenum

Abstract

Diverticulum of the horizontal portion of the duodenum is a rare cause of upper gastrointestinal (GI) bleeding. Since it is difficult to access the horizontal portion of the duodenum by standard upper GI endoscopy, only a very few cases of endoscopic hemostasis have been reported. Herein, we report a case of diverticular bleeding from the horizontal portion of the duodenum for which hemostasis was achieved using a small-caliber colonoscope, which has an insertion part designed with a passive-bending function/high-force transmission and a transparent tip hood.

Keywords: diverticular bleeding; duodenum; endoscopic hemostasis; passive-bending function.

Figure 1

Endoscopic images. (A) No blood was retained in the duodenal bulb; however, a small volume of fresh blood was observed in the inferior duodenal angulus. (B) After the scope was replaced with Olympus PCF-PQ260L, continuously gushing blood was observed from a diverticulum in the horizontal portion of the duodenum. (C and D) Subsequently, hemostasis was performed by argon plasma coagulation after the lesion was anteriorly viewed through a transparent tip hood.

Figure 2

Contrast-enhanced abdominal CT images taken after hemostasis. A clip for marking persisted. There was no free air or other changes around the diverticulum.

Figure 3

Hypotonic duodenal images. A solitary diverticulum measuring 15 mm was detected at the cranial part of the horizontal portion of the duodenum.

Figure 4

Fluoroscopic images comparing the approaches to the duodenum between Olympus GIF-Q260J and PCF-PQ260L. By using training models for upper gastrointestinal endoscopy under fluoroscopic monitoring, we examined how the endoscopes approached the duodenum. (A and B) Upper gastrointestinal endoscopes such as Olympus GIF-Q260J can reach only up to the descending portion. (C) The horizontal portion of the duodenum can be easily approached with Olympus PCF-PQ260L because the passive-bending function is effectively utilized in addition to its length.