Upper gastrointestinal bleeding due to duodenum diverticulum: a challenge for the endoscopist.

An 80-year-old woman with a mechanic mitral valve treated with acenocumarol and was admitted to the hospital reporting tarry stools during the last two days and hemoglobin levels of 5.6 g/dL. She had not biliar pathology. An emergent esophagogastroduodenoscopy showed lots of fresh clots over the second part of the duodenum that seemed to come from the major papilla. In order to get a direct view a duodenoscopy was performed, remarking a huge clot near the papilla. Its removal with a polypectomy snare revealed a big duodenum diverticulum with little saculations inside, one of which showed a visible, actively bleeding vessel. Sclerosis with epinephrine was performed and subsequently two through-the-scope CookR 11mm clips were placed, achieving the cessation of the hemorrhage. Several attempts with different clips were needed since they were separated by the elevator nail of the duodenoscope. No complication was developed during the procedure and neither once the anticoagulation was restarted.