Bleeding on the right, channel on the left: what would you do?

Your channel is on the left. The bleeder is on the right.

A 2.5-minute case from my upper GI bleeding lecture. Watch the case, pick your move, then see what we did.

This is the bleed that makes a night call long. The vessel is in view. The needle is out. It will not go where the blood is.

1. The case

A massively bleeding Dieulafoy lesion in the posterior duodenum, on the right side of the screen.

2. Torque, reposition, still bleeding

The working channel of most gastroscopes is on the left, usually at 7 o’clock, and at 8 o’clock on some therapeutic scopes. This lesion was on the right, at 3 o’clock. The fellow could not reach it to inject or target it, despite torquing and changing position. There was no way to treat it with a clip or injection from that scope. The bleeding continued.

3. What would you do?

Pick one before you read on:

A. Call interventional radiology for angiography.
B. Change the endoscope.
C. Change the method: over-the-scope clip or hemostatic powder.

All three are reasonable and correct. One of them is a trick we published about 10 years ago, and I use it often for lesions on the right side.

Why is a right-sided duodenal bleeder hard to reach with a gastroscope?

The working channel of most gastroscopes exits on the left, at about 7 o’clock, and at 8 o’clock on some therapeutic scopes. In this case the lesion sat on the right, at 3 o’clock, so the needle could not reach it despite torque and position changes.

What are the options when you cannot reach a bleeding duodenal lesion?

The lecture lists three: interventional radiology (angiography), changing the endoscope, or changing the therapeutic method, such as an over-the-scope clip or hemostatic powder. Klaus calls all three reasonable and correct.