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An endoclip for life?

      A 48-year-old man with cirrhosis (Child score C) due to non-alcoholic steatohepatitis that was complicated by prior variceal bleeding presented to our institution with melena. The patient had gastric variceal bleeding 22 months before the current presentation, at which time he had an endoclip placed on the bleeding gastric varix before transfer to our institution (A). At our hospital, he immediately underwent an upper endoscopy followed by transjugular intrahepatic portosystemic shunt (TIPS) placement. On this presentation, the patient was tachycardic, somnolent, and unable to answer any questions. He appeared jaundiced and had icteric conjunctivae. His abdomen was obese, soft, and non-tender; there was no ascites. His blood work results were significant for a hemoglobin value of 11.4 g/dL, which dropped to 8.3 g/dL over the next 12 hours, a platelet count of 68,000/mm3, international normalized ratio of 1.9, total bilirubin of 12.3 mg/dL, blood urea nitrogen of 34 mg/dL, and creatinine of 1.2 mg/dL. The patient was intubated, and an upper endoscopy was performed that revealed large gastric varices in the gastric fundus. The endoclip that was placed 22 months earlier now was found embedded in the gastric varix (B), with an adjacent platelet plug. The patient underwent an abdominal US examination that showed a patent TIPS. Coil embolization of his prominent gastric varices was performed (C). The patient was discharged from the hospital 7 days after his bleeding episode, and at a 2-month follow-up, he was doing well without recurrence of GI bleeding.
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