This 67 year old man presents with hematochezia one day after colonoscopic resection of a large hepatic flexure polyp. This polyp had been removed using the saline lift technique, followed by piecemeal resection. Active bleeding can now be seen from the defect along the fold. Aggressively lavaging the area, the specific site of bleeding from the base of the defect can be better seen and permits a more targeted application of the first hemoclip across the base of the polypectomy site. Note how the hooks of the clip are embedded in the margins of the defect such that when deployed, the clip successfully reapposes these margins thus sealing the defect closed.
After the first clip is placed, the area is again lavaged and persistent slow oozing is demonstrated and thus a targeted second clip is deployed. At this point the area is injected with a 1:10,000 epi/saline solution to ensure hemostasis. The benefit of epinephrine may be additive and can be employed prior to clipping to control bleeding. Because the submucosal bleb caused by the injection can transiently distort the field and obscure the bleeding site , the operator may chose to inject epinephrine following clipping as in this example although there is no data that supports one technique other another.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital