Giant duodenal bleeding ulcer with a large visible vessel treated with an over the scope clip

A 83-year-old female patient was admitted to the emergency room (ER) of another hospital with melena. She was treated with apixaban for atrial fibrillation. She reported epigastric pain in the previous month and had excessive use of nonsteroidal anti-inflammatory drugs for osteoarticular disease. She presented with hypovolemic shock (heart rate 130 bpm, blood pressure 70/40 mmHg) and the hemoglobin level was 5.9 g/dl. Stabilization, transfusion of 2 units of red blood cells (RBC) and a bolus (80 mg) of intravenous pantoprazole followed by infusion (8 mg/h) were performed and the patient was transferred to our ER for esophagogastroduodenoscopy (EGD). On EGD, 3 gastric ulcers without bleeding stigmata were identified. In addition, a giant deep ulcer with a large adherent blood clot (Forrest IIb) in the duodenal bulb and another in the transition to the second part of the duodenum were observed. Due to the large size of both the ulcer and the blood clot, no endoscopic therapy was performed.