Endoscopic Ultrasound-Guided Gastric Remnant Access for Massive Upper Gastrointestinal Bleeding in Roux-en-Y Anatomy

This case reports a novel and successful attempt at identifying and treating massive upper gastrointestinal bleeding in an unstable patient with Roux-en-Y anatomy via endoscopic ultrasound-directed transgastric intervention and over-the-scope clip placement. The remnant stomach was located under endoscopic ultrasound and accessed via gastrogastrostomy, which was created via lumen-apposing metal stent placement. The lesion was identified, and hemostasis was achieved with epinephrine injection and over-the-scope clip deployment. The patient made a full recovery with a healed lesion at outpatient follow-up. This method can pave the way for future improvement in minimally invasive treatment modalities for patients with altered gastrointestinal anatomy.