Topical haemostatic powder as a novel endoscopic therapy for severe colonic diverticular bleeding

Abstract

Background: Although most diverticular bleeding resolve spontaneously, up to 30% can bleed torrentially, necessitating angioembolization, endoscopic or surgical intervention. Non-contact endoscopic therapies, such as topical haemostatic powders, do not require precise targeting and are attractive because identification of specific culprit diverticulum is difficult. While their use in non-variceal upper gastrointestinal bleeding is well established, its role in lower gastrointestinal bleeding remains unclear. We used topical Hemospray in a novel setting of severe diverticular bleeding, evaluating its efficacy in achieving haemostasis, reducing re-bleeding and the need for re-intervention. Methods: Consecutive patients from a tertiary colorectal unit who underwent colonoscopy and Hemospray for severe diverticular bleeding from November 2016 to October 2017 were included. Hemospray was endoscopically applied to colonic segments with major stigmata of recent haemorrhage. Results: Ten patients had a median time to colonoscopy of 22 h (range: 8-54) from admission. Median of 3.5 units (range: 0-10) of packed cells were transfused pre-endoscopy. All achieved immediate haemostasis without further haemodynamic instability or re-bleeding. No endoscopic, radiological or surgical re-intervention was required. Patients were fit for discharge within a median of 3 days (range: 2-7) following Hemospray. There were no morbidities, mortalities or readmissions for diverticular bleeding after a median follow-up of 9.5 months (range: 3-16).Conclusion: This feasibility study shows that topical haemostatic powders can offer a safe and effective therapeutic endoscopic option in severe diverticular bleeding with high haemostatic rate. Prospective controlled trials are required to establish its efficacy compared to conventional therapy. © 2018 Royal Australasian College of Surgeons ANZ J Surg 89 (2019) E56-E60 ANZJSurg.com © 2018 Royal Australasian College of Surgeons E60Ng et al.

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…In a multicenter prospective study, the EndoClot polysaccharide hemostatic system (EndoClot Plus Inc., Santa Clara, California, USA) was used to treat diverticular bleeding; successful hemostasis was achieved in 83 % of the patients, while the remaining two cases (17 %) rebled secondary to malignancy and a cecal ischemic ulcer [105]. A systematic review by Chen et al [106] and two small studies [107,108] also described encouraging results for Hemospray (Cook Medical, Bloomington, Indiana, USA) in cases of actively bleeding LGIB lesions.…”

Experience with the use of a hemostatic powder in 152 patients undergoing urgent endoscopy for gastrointestinal bleeding

“…In the two other cases (gastric ulcerations with minor stigmata of recent hemorrhage), using Hemospray ® was not appropriate. Studies have described the use of Hemospray ® in various causes of lower GIB, with high rates of immediate hemostasis (10,23,24). Interesting results have been published in severe diverticular bleeding with immediate hemostasis in a series of ten patients, with no recurrence (24).…”

Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis

“…As shown in ▶ Fig. 1, out of 974 studies initially identified, and after exclusion of papers not fulfilling the inclusion criteria, 9 potentially relevant studies [9][10][11][12][13][14][15][16][17] with 194 patients were included. The main characteristics of the included studies are reported in ▶ Table 1.…”

“…All studies were Western series, except for a single small retrospective cohort from Singapore [13].…”

“…Of note, none of the recruited patients received hemostatic powder treatment for the prevention of post-polypectomy bleeding, instead treatment was applied only in the case of active bleeding. A single series included only patients with diverticular bleeding [13], whereas cancer was overall the cause of lower GI hemorrhage in 12 patients (6.2 %).…”