Endoscopic Management of Complex Duodenal Ulcer Bleeding Using Over-the-Scope Clips: Clinical Insights From a Regional Core Hospital

Objectives

Over-the-scope clips (OTSCs) are considered an effective endoscopic tool for managing upper gastrointestinal bleeding, including duodenal ulcers, mostly based on data from high-volume centers with expert endoscopists. This study aimed to evaluate the clinical safety of OTSCs in regional hospital backgrounds and identify the factors associated with unsuccessful hemostasis.

Methods

We conducted a retrospective study of 30 patients with duodenal ulcer bleeding who underwent OTSC placement at a regional core hospital in Japan between April 2014 and January 2025. Clinical outcomes, rebleeding rates, complications, and subgroup analyses by ulcer location, Forrest classification, and operator experience were evaluated.

Results

Primary hemostasis was achieved in 28 of 30 patients (93.3%). Rebleeding occurred in two cases (6.7%) but was successfully managed endoscopically. Both hemostasis failures involved Forrest Ia ulcers on the posterior duodenal wall. Subgroup analysis revealed significantly lower success rates for Forrest Ia (66.7%) and posterior wall lesions (33.3%). No significant differences in outcomes were observed between experienced and less-experienced endoscopists. Postprocedural complications included mild pancreatitis and duodenal stricture, both managed conservatively. OTSC was used as a first-line modality in 10 cases and as salvage therapy in 20, with all failures occurring in the latter.

Conclusion

OTSC is a safe and effective hemostatic modality for duodenal ulcer bleeding, even in regional hospitals with limited resources and staffing. It is particularly useful when rapid intervention is required and alternative treatments are not readily available. However, anatomical challenges such as posterior wall location and Forrest Ia classification may predict technical failure.