The Bump Trick for Hemostasis (and Closure of Mucosal Defects)

By Klaus Mönkemüller, MD, PhD, FASGE, FJGES and Joel Joseph, MD

Virginia Tech Carilion School of Medicine, Virginia, USA

image via endocollab.com

Often, bleeding lesions are located on the right (Panel A), as in this case of gastric ulcer located in the distal antrum. Many gastroscopes have the working channel on the LEFT (Panel B, green arrow), which makes a targeted delivery of the clip or injection difficult. What are our options to overcome this problem?

One, change to a pediatric colonoscope, with working channel on the right. 

Two, use over the scope clip (which allows for en-face approach).

Three, use a transparent distal cap, which may allow for a more targeted approach by "expending" the scope tip and thus angulation capabilities.

Four, use hemospray or hemostatic gels.

Five, as in this case, use the "bump trick". The initial clip is used to create a mucosal “bump” (pink arrow). The second (or hemostatic) clip can now be better targeted to the lesion, as the bump has lifted some folds (D, pink arrow) on the left side and allows for better capture of the ulcer on the right E, light blue arrow).

The bump trick is also useful when closing mucosal defects. The first clip is used to create a mucosal bump, which then allows for easier application of the second clip, and secure closure of the defect (see picture below).

No COI by KM with any of the companies/utensils or products mentioned in this article.