A bred to remnant stomach bleeding Herein, we will discuss a case of a 55-year-old female patient who presented with melana and hemoglobin drop. The patient had a past medical history of hypertension, alcohol abuse, obesity, and by past surgery. Two weeks prior to presentation, she had a fibular fracture and was taking ibuprofen over the hour. A serious scan of the abdomen showed multiple lower-falling defects throughout the GI tract, indicating blood clots with no active bleeding. A paleontoscopy was normal and didn't identify any bleeding. A double-malignantoscopy failed to reach the second part of the duodenum, or stomach, but a pancreatic co-biliary limb showed multiple blood clots. An angiogram was also done, didn't reveal any active bleeding, but empiric embolization of the left gastric artery was done. It was planned then to do an endoscopic ultrasound to evaluate the remnant stomach and placement of a human opposing metal stent to explore that area to aid in identification of the source of the bleeding and eventually achieving hemostasis. Endosonographic images of the stomach were impressive, showing a very large blood clot burrowing within the body of the excluded stomach. The therapeutic endoscope was then advanced into the gastric pouch, and a 19-gauge FNA needle was used to puncture through the pouch wall into the excluded stomach. The human opposing metal stent and electrocuting introduction catheter was introduced through the walking channel of the echo endoscope and advanced to the gastric wall. The stent-introducing catheter was advanced into the excluded stomach, and a 20x10 mm lumen opposing metal stent was placed with the phalanges in a close approximation to the walls of the excluded stomach and the gastric pouch through a gastro-gastrostomy. The latitium balloon was introduced over a wire, and the stent was dilated to 20 mm successfully. To fix the stent, a double-channel therapeutic endoscope was applied with overstitched device. No overtube was used here. To running 2-0 polypropylene sutures securing the stent to the gastric pouch wall was placed to prevent migration during use of the stent to access the excluded stomach and suspected area of bleeding. Blood clots were appreciated across the lumen opposing metal stent, and approximately one hour was required for removal of the large burden of blood clots from the excluded stomach using a combination of a single-channel therapeutic, a double-channel therapeutic, as well as a super-secure large-channel endoscope for clot evacuation. After removal of all blood from the stomach and the duodenum, it became apparent that a very deep but fairly localized ulcer with a clot and active hemorrhage was localized to the posterior wall of the proximal duodenum at the level of the duodenal sweep. The ulcer was then cleaned and irrigated to identify the exact location of bleeding, after which the bed of the ulcer was actively bleeding. Calculation for hemostasis using bipolar golden probe at 15W was performed, but it was unsuccessful in achieving complete hemostasis in the duodenal pulp. The area in the duodenal sweep where the hemorrhage was injected with a 12mL of a 0.1mg per mL solution of epinephrine for hemostasis. However, this was not completely successful in achieving hemostasis. Further calculation to the area was done, but the bleeding didn't stop. Giving poor visualization of the area, we finally opted for the thin French hemo spray device, which was advanced through the walking tunnel of the endoscope. Flushed initially with air, and then hemostatic powder was applied liberally throughout the adrenal pulp and the second portion of the duodenum, with complete cessation of bleeding. The second part of the duodenum and the duodenal sweep was examined carefully to make sure that the bleeding does not occur. A repeat endoscopy was done at 24 hours, which indicates no further bleeding, and the ulcer starts to heal. Two months later, the lumenopoietic mitral stent was removed, and the gastro-gastric defect was closed with algal plasma coagulation and TAG helix system. Upper GI series was done two months after removing the lumenopoietic mitral stent, and it didn't show any gastro-gastric fistula. For a patient who has a one-way gastric bypass anatomy, permanent stomach bleeding should be considered if they present with symptoms and signs of upper GI bleeding. If no source of upper GI bleeding was identified, lumenopoietic mitral stent shows an interesting tool to access the remnant stomach in such patients. And for poorly visualized GI ulcers and cauterization non-responsive ulcers, hemostatic powder is a great option, with a close follow-up. In conclusion, lumenopoietic mitral stents plays an important role to evaluate the remnant stomach for possible bleeding in run-like gastric bypass patients. And different and multiple modalities of hemostasis might be used to treat an upper GI bleeding, as we saw in this case.

melena

blood clots

endoscopic ultrasound

ulcer

hemostasis