This 87 year old lady was transferred in from a rehab facility with melena. She was recovering from a hip fracture sustained in a motor vehicle accident and was receiving decadron for management of cerebral edema.
At the time of this endoscopy, the patient was hypotensive, and tachycardic. High volume bleeding is seen but as yet no ulcer base or feeding vessel can be identified due to the poor visualization. Clipping could not be performed until injection therapy in the region of the bleeding vessel achieved a brief period of hemostasis. The perimeter of the ulcer base could now be identified and the base of the ulcer was clipped. A second clip was placed. Bu after placement of the third clip, the lesion began to rebleed. The patient was brought to the OR where a large ulcer of the duodenal cap was oversown. The patient survived the surgery and was eventually discharged back to the rehab facility.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital