Emergency Clipotripsy

An 86-year-old man with atrial fibrillation on anticoagulation was admitted to another hospital for an upper gastrointestinal bleed after accidental ingestion of a plastic bread clip. He required 11 units of packed red blood cells for resuscitation. Esophagogastroduodenoscopy demonstrated the clip firmly wedged onto a duodenal fold (Figure 1) with bleeding from adjacent mucosa. Attempts to remove the clip with standard technique using alligator forceps were unsuccessful due to large size of the clip and inadequate grip on a smooth surface. The patient was transferred to our institution for surgical management or repeat attempt at endoscopic management. We decided to attempt breaking the plastic clip with a mechanical lithotripter (LithoCrushV, Olympus America, Center Valley, Pennsylvania), typically used for lithotripsy of bile duct stones. This appeared successful when performed ex vivo on a similar plastic clip (Figure 2). The lithotripsy basket was introduced through a therapeutic upper endoscope (GIF-1TQ160, Center Valley, Pennsylvania), and the wires were manipulated around the clip. The wires were tightened until the clip was successfully broken into 2 fragments (Figure 3). The fragments were then easily manipulated off the duodenal fold. The endoscope was withdrawn then reintroduced through an overtube. Final retrieval of the clip fragments was accomplished using a Roth net (Figure 4).