Abstract
A 90-year-old woman, under apixaban for atrial fibrillation, presented to the emergency department with hemodynamically stable hematochezia. Upon admission, her hemoglobin level was 7.1 g/dL (N >11.8) and she received one unit of packed red blood cells. Rectosigmoidoscopy revealed a small diverticulum at the sigmoid colon with active oozing hemorrhage after aspiration of a fresh clot, which was treated with an injection of diluted epinephrine (1:10,000) and four through-the-scope (TTS) clips. Three days later, recurrent bleeding occurred requiring the application of two additional TTS clips in a visible vessel at the neck of the diverticulum. On the fifth day, an active pulsatile bleeding was identified adjacent to two TTS clips. Both clips were removed, and the contralateral wall was marked with methylene blue. An atraumatic over-the-scope clip (OTSC®, 11/6a, Ovesco Endoscopy AG, Tübingen, Germany) was deployed using a therapeutic gastroscope and gentle suction, achieving immediate hemostasis. No further rebleeding occurred and the patient was discharged after 10 days post-admission.