Challenges in Diagnosing and Managing Dieulafoy’s Lesions: A Case Report Highlighting the Importance of Clinical Suspicion and Multidisciplinary Approach in Obscure Gastrointestinal Bleeding

Upper gastrointestinal bleeding remains a significant cause of hospital admissions. Even though the incidence of peptic ulcer disease and gastritis is decreasing, the incidence rates in neoplasm, Dieulafoy’s lesions, angiodysplasia, and esophagitis are trending up, which necessities physicians to be aware of those pathologies and their specifics. Here, we represent a case of a 62-year-old male on dual antiplatelet therapy who was transferred to our hospital due to severe melena with suspicion of upper gastrointestinal bleeding. Due to hemodynamic instability, the patient was intubated and started on vasopressors. However, several repeated EGDs and CTs of the abdomen with GI bleeding protocol did not reveal the location of active bleeding to stop it. At the same time, clinically, the patient was hemodynamically unstable with continued melena. On the last EGD, a small area of concern resembling gastric varix was clipped for identification purposes, and the patient underwent a selective angiogram with further diagnosis of Dieulafoy’s lesion, which was successfully embolized. Our case demonstrates that Dieulafoy’s lesions can present as severe life-threatening hemorrhage, hard to diagnose with traditional methods such as EGD or CTs, in which case it is recommended to proceed with an angiogram sooner rather than later for further diagnosis and treatment if needed.

Uremic Bleeding in 2 Patients with Dieulafoy’s Lesion: Case Report and Literature Review

Dieulafoy’s lesions are rare vascular malformations of the gastrointestinal tract. A Dieulafoy’s lesion is an aberrant vessel that does not reduce in caliber when it extends from the submucosa to the mucosa. Damage to this artery can cause severe and intermittent arterial bleeding from small vascular stumps that are difficult to visualize. Furthermore, these catastrophic bleeding episodes frequently result in hemodynamic instability and the need for transfusion of multiple blood products. Recently, uremic syndrome has been identified as a risk factor for gastric mucosal lesions. We present two clinical cases of acute digestive bleeding due to Dielafoy lesion with chronic kidney disease as the main cause, where two different therapies were performed endoscopically. We concluded with the results of our patients that the best therapy was the application of the hemostatic hemoclip on the injury vs the injection with adrenaline on the wound site. Uremia is identified as a risk factor for upper gastrointestinal bleeding in patients with pre-existing Dieulafoy’s lesion, as well as a higher incidence of new bleeding.

An Infant with Dieulafoy’s Lesion: A Case Report from the Philippines

This is a case of a 5-month-old infant who experienced repeated episodes of hematemesis and no known underlying health conditions. It was subsequently diagnosed as Dieulafoy’s lesion localized in the lesser curvature of the stomach. Endoscopic diagnosis and treatment were done by angiographic embolization. Dieulafoy’s lesion is considered rare even for adult cases, much more for pediatric patients and usually underdiagnosed. Hence, patients presenting with gastrointestinal bleeding should be managed in a multidisciplinary approach. Spreading awareness about this lesion by including it in the considerations, may help improve early detection and treatment.

Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion

AIM： To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding. METHODS： Retrospective study of patients with gas- trointestinal bleeding secondary to Dieulafoy＇s lesion （DL） from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastro- intestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy de- scribed a lesion compatible with Dieulafoy. We exclud- ed patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures. RESULTS： Twenty-nine patients with DL were identi- fied. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach （51.7%）. The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial （spurting） bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was ap- plied to nine patients （31%）, eight of them with adren- aline and one with argon, while 69% of the patients received combined treatment. Six patients （20.7%） presented with recurrent bleeding at a median of 4 d after endoscopy （interquartile range = 97.75）. Within these six patients, the new endoscopic treatment ob- tained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding （50% vs 33.3% for other type of bleeding） rP = 0.024, odds ratio （OR） = 8.5, 95% CI = 1.13-63.87]. The use of combined en- doscopic treatment prevented the recurrence of bleed- ing （10% vs 44.4% of single treatment） （P = 0.034, OR = 0.14, 95% CI = 0.19-0.99）. CONCLUSION： Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial （spurting） bleeding are associated with a high rate of bleeding recurrence.

Clinical and endoscopic analysis of gastric Dieulafoy’s lesion

AIM:To investigate the incidence,location,clinical presentation,diagnosis and effectiveness of endoscopic treatment of gastric Dieulafoy's lesion(DL)in China. METHODS:All patients who received emergency upper gastrointestinal(GI)endoscopy due to gastric DL from February 2000 to August 2008 at GI endoscopy center of Renmin Hospital of Wuhan University were included in this study.The clinical presentation,medical history,location and characteristics of DL methods and effectiveness of therapy of patients with DL were retrospectively analysed by chart reviews.Long-term follow-up data were collected at outpatient clinics or telephone interviews. RESULTS:Fifteen patients were diagnosized with DL,which account for 1.04%of the source of bleed- ing in acute non-variceal upper GI bleeding.Common comorbidities were found in one patient with hypertension and diabetic mellitus.Hemoclip or combined therapy with hemoclip produced primary hemostasis in 92.8%(13/14) of patients. CONCLUSION:DL is uncommon but life-threatening in China.Hemoclip proved to be safe and effective in controlling bleeding from DL.

Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy’s lesion

AIM： To investigate the endoscopic hemostasis for gastrointestinal bleeding due to Dieulafoy＇s lesion. METHODS： One hundred and seven patients with gastrointestinal bleeding due to Dieulafoy＇s lesion were treated with three endoscopic hemostasis methods： aethoxysklerol injection （46 cases）, endoscopic hemoclip hemostasis （31 cases）, and a combination of hemoclip hemostasis with aethoxysklerol injection （30 cases）. RESULTS： The rates of successful hemostasis using the three methods were 71.7% （33/46）, 77.4% （24/31） and 96.7% （29/30）, respectively, with significant differences between the methods （P 〈 0.05）. Among those who had unsuccessful treatment with aethoxysklerol injection, 13 were treated with hemoclip hemostasis and 4 underwent surgical operation; 9 cases were successful in the injection therapy. Among the cases with unsuccessful treatment with hemoclip hemostasis,7 were treated with injection of aethoxysklerol and 3 cases underwent surgical operation; 4 cases were successful in the treatment with hemoclip hemostasis. Only 1 case had unsuccessful treatment with a combined therapy of hemoclip hemostasis and aeth- oxysklerol injection, and surgery was then performed. No serious complications of perforation occurred in the patients whose bleeding was treated with the endoscopic hemostasis, and no releeding was found during a 1-year follow-up. CONCLUSION： The combined therapy of hemoclip hemostasis with aethoxysklerol injection is the most effective method for gastrointestinal bleeding due to Dieulafoy＇s lesion.

Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy's lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy's lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy's lesion by mini-loop ligation.

Florid reactive periostitis ossificans of the humerus: Case report and differential diagnosis of periosteal lesions of long bones

A case of florid reactive periostitis ossificans(RPO) arising in a long bone is presented. This is a rare bone proliferation with a pronounced periosteal reaction. Less than 100 cases have been described in the literature with far fewer outside the bones of the hand, feet, fingers, and toes. Although the etiology is unknown, a relationship to preceding trauma is suggested. The imaging and histologic features show an overlap with other bone lesions including bizarre parosteal osteochondromatous proliferation, subungual exostosis, and malignant surface tumors of bone and cartilage which include, periosteal and parosteal osteosarcoma. It is important to recognize the clinical presentation and diagnostic features of RPO as a benign entity so that it is not mistaken for a more aggressive neoplasm. We present a case of a right distal humeral lesion that on histopathological review revealed florid RPO. This diagnosis was not suspected on imaging studies, but was made on open biopsy of the mass. The patient remains disease free, years postoperatively. In addition to presenting this unique case report, we review the pertinent literature, and offer a differential diagnosis and treatment strategy for its management.

Endoscopic management of Dieulafoy's lesion using Isoamyl-2-cyanoacrylate

Dieulafoy's lesion (DL) is a rare but important cause of obscure gastrointestinal bleeding that may be over-looked during diagnostic endoscopy. Mortality rates are similar to those of other causes for gastrointestinal bleeding. Diagnosis by upper endoscopy is the modal-ity of choice during acute bleeding. In the absence of active bleeding, the lesion resembles a raised nipple or visible vessel. There are no guidelines regarding effective selective therapy for DL, when diagnosed, en-doscopist experience is the major determinant of the treatment strategy. Following our strategy, an expert endoscopist with a skilled assistant should have a high rate of successful DL diagnosis when an obscured gas-trointestinal lesion is suspected. Cyanoacryltes com-pounds have been used successfully in management of Gastric varices and DLs. To our knowledge, there have been no previous reports regarding use of isoamyl-2-cyanoacrylate (AMCRYLATE ; Concord Drugs Ltd.,Hyderabad, India) as an effective therapy for gastric DL without serious complications. In our case study, Isoamyl-2-cyanoacrylate (AMCRYLATE) was effective and safe for treating DL. Surgical wedge resection of the lesion should be considered as a therapeutic option if endoscopic therapy fails.

Actively bleeding Dieulafoy's lesion of the small bowel identified by capsule endoscopy and treated by push enteroscopy

Dieulafoy＇s lesion is an unusual cause of recurrent GI bleeding. This report describes a case of actively bleeding Dieulafoy＇s lesion of the small bowel in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of push enteroscopy. The case illustrates that capsule endoscopy and enteroscopy are highly complementary in patients with small bowel diseases.

Clinical presentation and endoscopic management of Dieulafoy's lesions in an urban community hospital

AIM:To identify rates of occurrence,common clinical and endoscopic features,and to review the outcome of endoscopic management of Dieulafoy's lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting. METHODS:Endoscopic data from esophagogastroduo denoscopies (EGDs),done at Wyckoff Heights Medical Center,Brooklyn,NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy's lesions. Demographic data,medical history,examination findings,lab data,endoscopic findings and details of therapy for patients treated for Dieulafoy's lesions were reviewed retrospectively. RESULTS:Dieulafoy's lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding,while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding,prevalence of Dieulafoy's lesions approached 10 percent. The most common location of the lesion was the body of stomach (7),followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection,in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.CONCLUSION:Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy,especially in patients with multiple co-morbid conditions,can be very effective and life saving.

S100 PROTEIN-POSITIVE DENDRITIC CELLS AND THE SIGNIFICANCE OF THEIR DENSITY IN GASTRIC PRECANCEROUS LESIONS

Quantitative analysis of dendritic cells (DC’s) was carried out in tissue specimens of normalgastric mucosa (n=15),gastric ulcer (n=19),chronic atrophic gastritis (n=28),and gastriccarcinoma (n=65) by ABC immunostaining with S100 protein antibody.Significant increasein DC number were observed in chronic atrophic gastritis with type Ⅲ intestinal metaplasiaand/or grade Ⅱ,Ⅲ dysplasia.The result suggests that DC’s are potentially capable opresenting neoantigens associated with malignant transformation at the precancerous stagewhen malignant morphological changes have not yet taken place.Combined with routinediagnostic methods,the serial monitoring of DC density in gastric mucosa may be usefulin the follow-up of premalignant lesions in the stomach and the diagnosis of early gastriccarcinoma.

Bleeding Dieulafoy's-like lesions of the gut identified by capsule endoscopy

Dieulafoy's-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

Endoscopic lysis of bladder scar associated with Hunner’s lesions:A new technique

Objective:Five to ten percent of interstitial cystitis/bladder pain syndrome(IC/BPS)patients have Hunner’s lesions(HL),areas of non-specific inflammation and scarring.The poor quality of life of patients with HL is entwined in associated pain and loss of bladder capacity.Although the decrease in bladder capacity is usually dependent on pain,it may also be dependent upon scarring and associated compliance changes produced by the inflammatory process.This report reviews the potential role of endoscopic scar lysis using the holmium laser in the management of these patients whose only other therapeutic option is urinary diversion.Methods:Two patients with HL and“end stage”bladders who underwent holmium laser division of bladder wall scar/tethering were identified.Clinical data were reviewed with emphasis on safety and efficacy.Results:Both patients selected for this procedure underwent holmium laser lysis of known scar tissue in an effort to increase bladder capacity and improve symptoms of urinary frequency and pain with bladder filling.The median age of patients who underwent the procedure was 63(59-67)years.Incisions were made with the holmium laser at frequencies of 3e10 Hz of 300e700 J along the region of scarring.All procedures were performed by the same practitioner.There was an increase in bladder capacity by 58.3%(50.0%-66.7%).During a mean follow-up of 4.2 years,there appeared to be a significant improvement with an increase in interval time between voids and a decrease in pain with bladder filling.Conclusion:Patients with IC/BPS may be severely debilitated by a clinically significant decrease in their bladder capacity,especially in the face of HL.The use of the holmium laser to incise regions of scar and bladder wall tethering may produce a clinically significant and durable increase in bladder capacity.The use of this technique as a means of treating bladder scarring poses an excellent adjunct to existing treatment strategies.

Bizarre Parosteal Osteochondromatous Proliferation-Like Lesion Originating in Soft Tissue: Report of a Case

Many tumors are unique to the organs from which they arise. Over the last 20 years, however, most tumors that were thought to be primary in soft tissues (derived from the primitive mesenchyme) and thought not to have counterparts in bone, were found to, in fact, rarely arise as unique lesions from bone. Some examples include synovial sarcoma, rhabdomyosarcoma and leiomyosarcoma, to name but three. We now have begun to see the reverse with lesions that were initially thought to be unique to bone arising in soft tissue. While this has been well reported with osteosarcoma and Ewing's sarcoma, it has never been reported with Bizarre Parosteal Osteochondromatous Proliferation (BPOP), also known as Nora's lesion. This study explores the first reported case of a soft tissue lesion, with clinical, radiological and histopathological characteristics of BPOP.

Elaboration and validation of Crohn's disease anoperineal lesions consensual definitions

To establish consensual definitions of anoperineal lesions of Crohn’s (APLOC) disease and assess interobserver agreement on their diagnosis between experts. METHODSA database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Française de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss’s kappa test or descriptive statistics. RESULTSTerms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration (entity, depth, extension), anal skin tags (entity, inflammatory activity, ulcerated aspect), fistula (complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions (abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association’s guidelines definitions. The diagnosis of ulceration (κ = 0.70), fistulae (κ = 0.75), inflammatory activity of external fistula openings (86.6% agreement), abscesses (84.6% agreement) and erythema (100% agreement) achieved a substantial degree of interobserver reproducibility. CONCLUSIONThis study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions.

Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy's lesions”-a case report and literature review

A Dieulafoy's lesion is a dilated,aberrant,submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion.It can be located anywhere in the gastrointestinal tract.We describe a case of massive gastrointestinal bleeding from Dieulafoy's lesions in the duodenum.Etiology and precipitating events of a Dieulafoy's lesion are not well known.Bleeding can range from being self-limited to massive life- threatening.Endoscopic hemostasis can be achieved with a combination of therapeutic modalities.The endoscopic management includes sclerosant injection,heater probe,laser therapy,electrocautery,cyanoacrylate glue,banding,and clipping.Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection.Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis,angiographic embolization or surgical wedge resection of the lesions.We present a 63-yearold Caucasian male with active bleeding from the two small bowel Dieulafoy's lesions,which was successfully controlled with epinephrine injection and clip applications.

Prevalence of precancerous lesions and conditions in India: A systematic review and meta-analysis

BACKGROUND Smoking and chewing tobacco are associated with numerous oral mucosal lesions and conditions,often leading to cancer progression.AIM To investigate the prevalence of precancerous lesions and conditions among the Indian population.METHODS Systematic search was conducted for population or community-based observational epidemiological studies in PubMed,EMBASE,Web of Science,IndMED,Google Scholar,reports of the WHO South-East Asia Region,MOHFW India reports,Science Citation Index,WHO Index Medicus of the South-East Asian Region,Reference Citation Analysis(https://www.referencecitationanalysis.com/)and Open Grey from the earliest available up to 31st January 2022.The effect size was calculated for the prevalence of precancerous lesions and conditions.RESULTS One hundred sixty-two estimates from 130 studies yielded 52 high,71 moderate,and seven low-quality studies from 823845.Point estimate based on crosssectional studies for leukoplakia was 4.3%(95%CI:4.0-4.6),oral submucous fibrosis was 2.7%(95%CI:2.5-3.0),palatal lesions in reverse smokers and nicotine palatine were 5.8%(95%CI:4.4-7.2),and Erythroplakia was 1.2%(95%CI:0.7-1.7),and lichen planus was 1.1%(95%CI:0.9-1.2).Amongst hospital-based studies,the pooled prevalence for Leukoplakia was 6.7%(95%CI:6.0-7.3),oral submucous fibrosis was 4.5%(95%CI:4.2-4.9),lichen planus was 7.5%(95%CI:5.3-9.6),and erythroplakia was 2.5%(95%CI:0.4-4.5),and palatal lesions in reverse smokers and nicotine palatini were 11.5%(95%CI:8.0-15.0).CONCLUSION Precancerous lesions and conditions are prevailing problems among the Indian population.It is mainly due to tobacco use,the smokeless form of tobacco.The meta-analysis indicates that hospital-based studies have a higher effect size of 6.7%than community-based studies.Patients who have already developed this condition may be advised to reduce their exposure to the risk factor to prevent the condition from progressing further.

Angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

Angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.

Cecum Dieulafoy＇s Lesion Presenting with Recurrent Lower Gastrointestinal Bleeding： Case Report

Introduction： Gastrointestinal Dieulafoy＇s lesion is a rare entity, of unknown etiology, and corresponds to an arterial malformation at the submucosal space that can be a source of life-threatening hemorrhage. We report a case of a Cecum Dieulafoy＇s bleeding lesion that was managed endoscopically with a favorable outcome. Case report： Female, 70-year-old, diagnosed with type 2 diabetes, hypothyroidism, and chronic heart failure associated with rheumatic mitral stenosis, submitted to biological valve replacement in 2006 and with permanent atrial fibrillation using vitamin K antagonist anticoagulant for thrombosis prophylaxis. Her background includes a stroke in 2004 without any permanent disability. In 2016, the patient experienced voluptuous and painless lower gastrointestinal bleeding with severe acute anemia, requiring hospital admission, fluid resuscitation and blood transfusion. Urgent colonoscopy revealed a small reddish vascular malformation at the cecum with oozing active bleeding, about 3 mm in size. Initially argon plasma coagulation was performed with satisfactory and immediate hemostasis. One week later, she recurred with hematochezia. The lesion at the cecum was reassessed and it was possible to notice a large caliber vessel surrounded by a normal appearance mucosa, compatible with Dieulafoy＇s lesion and it was treated with an endoscopic clip placement with a good long-term response. Conclusion： Endoscopy is the method of choice for diagnosis of Dieulafuy＇s lesion and may provide efficient treatment with mechanical hemostasis such as endoclip placement with a high success rate.