Underwater detection and clipping using a reopenable clip with a long hood for colonic diverticular bleeding

There are multiple treatments available for diverticular hemorrhage.¹ Endoscopic identification of stigmata of recent hemorrhage (SRH), especially visible vessels, is important but often difficult.² Exposed vessels are identified by aspirating the diverticulum with a long transparent hood and inverting it. However, some diverticula cannot be visualized inside and are inverted owing to inflammation when the exposed bleeding duct (SRH) is identified. The underwater method improves visibility. Using the opened-it-halfway reopenable clip method³ enables hemostasis without inversion.

The patient, a 77-year-old man, presented with stable vital signs. Computed tomography revealed no obvious sources of bleeding. A colonoscopy (PCF 290TI; Olympus, Tokyo, Japan) with a long hood (MAJ663; Olympus Medical Systems, Tokyo, Japan) (tip protrusion length, 12 mm) was performed using the underwater method to identify the SRH (Fig. 1). Subsequently, we inserted a closed 8 mm SureClip (Micro-Tech, Nanjing, China), opened it halfway, deployed it into the diverticulum (Fig. 2), and performed clipping, successfully achieving hemostasis (Video S1). Other methods do not use a long hood and invert before clipping⁴; however, our method can be used in cases where inversion is impossible. Small diverticula or diverticula that cannot be inverted owing to inflammatory changes can be observed with underwater immersion.⁵ When SRH was identified, a clip was inserted using the opened-it-halfway reopenable clip method, and clip hemostasis was performed. Initial avoidance of underwater procedures was due to potential significant bleeding and fecal masses in patients with diverticular hemorrhage. The use of a long hood offers the advantage of enclosing the diverticulum within the hood without a slit, enabling its observation using the magnification effect and fluid force offered by underwater immersion.

Authors declare no conflict of interest for this article.