1
|
Wehbe H, Gutta A, Gromski MA. Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon. Gastrointest Endosc Clin N Am 2024; 34:363-381. [PMID: 38395489 DOI: 10.1016/j.giec.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.
Collapse
Affiliation(s)
- Hisham Wehbe
- Department of Internal Medicine, Indiana University School of Medicine, 550 University Boulevard, UH 3533, Indianapolis, IN 46202, USA
| | - Aditya Gutta
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA
| | - Mark A Gromski
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100 Indianapolis, IN 46202, USA.
| |
Collapse
|
2
|
Choi JH, Cho IR, Lee SH, Kim JS, Park N, Lee MW, Jang DK, Paik WH, Ahn DW, Ryu JK, Kim YT, Kim E, Lee J. Efficacy and safety of novel hemostatic gel in endoscopic sphincterotomy or endoscopic papillectomy: A multicenter, randomized controlled clinical trial. Dig Liver Dis 2023; 55:527-533. [PMID: 36737314 DOI: 10.1016/j.dld.2023.01.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopists often experience obstacles with traditional hemostasis using the side-viewing duodenoscope for bleeding after endoscopic sphincterotomy (EST) or endoscopic papillectomy (EP). AIMS In this randomized controlled trial, we evaluated the efficacy and safety of a novel hemostatic gel for post-EST or post-EP bleeding. METHODS A randomized trial was conducted from November 2020 to December 2021 at two tertiary centers in South Korea. Patients who experienced bleeding immediately after EST or EP were enrolled in the study, and primary hemostasis was achieved with either the novel hemostatic gel or epinephrine spray. RESULTS A total of 84 patients were enrolled in this study, and 41 patients were finally analyzed in each group. Hemostatic gel was significantly superior to epinephrine spray for successful primary hemostasis (100% vs. 85.4%; P = 0.026). ). In terms of delayed bleeding, no significant difference was observed between the hemostatic gel and epinephrine spray (2.4% vs. 7.3%; P = 0.329). The mean procedural time was significantly higher for the hemostatic gel than epinephrine spray (3.23 ± 1.94 vs. 1.76 ± 0.99 min; P < 0.001), and no differences were observed in the adverse events. CONCLUSIONS The novel hemostatic gel is expected to achieve satisfactory results with easier hemostasis for immediate bleeding after EST or EP. (Registered in Clinical Research Information Service: KCT0005607).
Collapse
Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - In Rae Cho
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
| | - Joo Seong Kim
- Department of Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Namyoung Park
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Min Woo Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Eunji Kim
- CG Bio Co., Ltd., Seoul, Republic of Korea
| | | |
Collapse
|
3
|
Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023; 118:208-231. [PMID: 36735555 DOI: 10.14309/ajg.0000000000002130] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.
Collapse
|
4
|
Valladares-Pasquel AG, Lanz-Zubiría L, Hernández Guerrero AI. Modification of the endoscopic hemostatic powder application technique. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2022; 8:47-49. [PMID: 36820253 PMCID: PMC9938313 DOI: 10.1016/j.vgie.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Video 1Modification of the endoscopic hemostatic powder application technique.
Collapse
Affiliation(s)
- Alvaro G. Valladares-Pasquel
- Department of Gastrointestinal Endoscopy, Instituto Nacional de Cancerología, Mexico City, Mexico,Gastroenterology Department, Medica Sur, Mexico City, Mexico
| | | | | |
Collapse
|
5
|
Jiang SX, Chahal D, Ali-Mohamad N, Kastrup C, Donnellan F. Hemostatic powders for gastrointestinal bleeding: a review of old, new, and emerging agents in a rapidly advancing field. Endosc Int Open 2022; 10:E1136-E1146. [PMID: 36238531 PMCID: PMC9552790 DOI: 10.1055/a-1836-8962] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/20/2022] [Indexed: 10/26/2022] Open
Abstract
Background and study aims Hemostatic powders are increasingly used to address limitations in conventional endoscopic techniques for gastrointestinal bleeding. Various agents exist with different compositions, characteristics, efficacy, and adverse events (AEs). We sought to review existing hemostatic powders, from preclinical to established agents. Methods A literature review on hemostatic powders for gastrointestinal bleeding was undertaken through a MEDLINE search from 2000-2021 and hand searching of articles. Relevant literature was critically appraised and reviewed for mechanism of action, hemostasis and rebleeding rate, factors associated with hemostatic failure, and AEs. Results The most established agents are TC-325 (Hemospray), EndoClot, and Ankaferd Blood Stopper (ABS). These agents have been successfully applied to a variety of upper and lower gastrointestinal bleeding etiologies, in the form of primary, combination, salvage, and bridging therapy. Few AEs have been reported, including visceral perforation, venous embolism, and self-limited abdominal pain. Newer agents include CEGP-003 and UI-EWD, which have shown results similar to those for the older agents in initial clinical studies. All aforementioned powders have high immediate hemostasis rates, particularly in scenarios not amenable to conventional endoscopic methods, but are limited by significant rates of rebleeding. Other treatments include TDM-621 (PuraStat) consisting of a liquid hemostatic agent newly applied to endoscopy and self-propelling thrombin powder (CounterFlow Powder), a preclinical but promising agent. Conclusions Rapid development of hemostatic powders and growing clinical expertise has established these agents as a valuable strategy in gastrointestinal bleeding. Further research will continue to refine the efficacy and applicability of these agents.
Collapse
Affiliation(s)
- Shirley X. Jiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daljeet Chahal
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, United States
| | - Nabil Ali-Mohamad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada,Blood Research Institute, Versiti, Milwaukee, Wisconsin, United States
| | - Fergal Donnellan
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| |
Collapse
|
6
|
Cha B, Lee D, Shin J, Park JS, Kwon GS, Kim H. Hemostatic efficacy and safety of the hemostatic powder UI-EWD in patients with lower gastrointestinal bleeding. BMC Gastroenterol 2022; 22:170. [PMID: 35392821 PMCID: PMC8991611 DOI: 10.1186/s12876-022-02247-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
Background and aims Acute lower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. Recently, a novel endoscopic hemostatic powder (UI-EWD/Nexpowder™, Nextbiomedical, Incheon, South Korea) was developed and applied for the control of LGIB. The aim of this study was to evaluate the hemostatic efficacy and long-term safety of UI-EWD in LGIB. Patients and methods We conducted a retrospective cohort study of LGIB at a single tertiary center in south Korea. One hundred and sixty-seven consecutive patients with LGIB who were initially successful in endoscopic hemostasis were included and divided into the conventional treatment group (n = 112) and the UI-EWD therapy group (n = 55; 38 patients with conventional treatment and 17 patients with UI-EWD alone). The success rate of hemostasis, adverse events related to UI-EWD, and re-bleeding rate were evaluated. Results The incidence of endoscopic hemostasis applied to the hepatic flexure (7.3% vs. 0%, p = 0.011) and larger than 4 cm (25.5% vs. 8.0%, p = 0.002) were significantly higher in the UI-EWD group than in the conventional therapy group. The cumulative rebleeding rate within 28 days in the UI-EWD group was 5.5% (3/55), which was significantly lower than that in the conventional treatment group (17.0% [19/112]; p = 0.039). No UI-EWD-related adverse events were recorded. Conclusion Based on our results, application of UI-EWD in LGIB showed promising results for the prevention of re-bleeding, especially in locations where it is difficult to approach or cases with more bleeding. There were no significant complications, such as perforation or embolism. In particular, UI-EWD should be considered first for anatomical or technical impediments to endoscopic access in LGIB.
Collapse
Affiliation(s)
- Boram Cha
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Donghyun Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Jongbeom Shin
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea.
| | - Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Gye-Suk Kwon
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| | - Hyungkil Kim
- Digestive Disease Center, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, South Korea
| |
Collapse
|
7
|
Man Z, Sidi L, Xubo Y, Jin Z, Xin H. An in situ catechol functionalized ε-polylysine/polyacrylamide hydrogel formed by hydrogen bonding recombination with high mechanical property for hemostasis. Int J Biol Macromol 2021; 191:714-726. [PMID: 34571130 DOI: 10.1016/j.ijbiomac.2021.09.100] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
In situ hydrogel has attracted widely attention in hemostasis due to its ability to match irregular defects, but its application is limited by insufficient mechanical strength and long gelation time. Although some specifical in situ chemically cross-linked hydrogels could be fast formed and exhibit high mechanical strength, they unable to absorb blood. Hence their applications were further limited in emergency hemostasis usage. In this study, a robust hydrogel formed by hydration of powders was developed using multiple hydrogen bonds crosslinking. Here, catechol groups modified ε-polylysine (PL-CAT) and polyacrylamide (PAAM) were used to construct the PL-CAT/PAAM hydrogel. This hydrogel could be formed within 7 s to adhere and seal bleeding sites. The catechol groups endowed the hydrogel outstanding adhesive strength, which was 3.5 times of fibrin glue. Besides, the mechanical performance of in-situ PL-CAT/PAAM hydrogel was explored and the results showed that the hydrogel exhibited high compressive strength (0.47 MPa at 85% strain). Most importantly, the blood loss of wound treated with PL-CAT/PAAM hydrogel powders was 1/7 of untreated group, indicating the hydrogel's excellent hemostatic effect. And the cytotoxicity studies indicated that the PL-CAT/PAAM hydrogel had low toxicity. To summarize, this hydrogel could be a potential hemostatic material in emergency situations.
Collapse
Affiliation(s)
- Zhang Man
- Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300072, China; School of Materials Science and Engineering, Tianjin University, Tianjin 300072, China
| | - Li Sidi
- College of Chemistry and Chemical Engineering, Yantai University, Yantai 264005, Shandong Province, China
| | - Yuan Xubo
- Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300072, China; School of Materials Science and Engineering, Tianjin University, Tianjin 300072, China
| | - Zhao Jin
- Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300072, China; School of Materials Science and Engineering, Tianjin University, Tianjin 300072, China.
| | - Hou Xin
- Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300072, China; School of Materials Science and Engineering, Tianjin University, Tianjin 300072, China.
| |
Collapse
|
8
|
Guo XF, Yu XA, Hu JC, Lin DZ, Deng JX, Su ML, Li J, Liu W, Zhang JW, Zhong QH. Endoscopic management of delayed bleeding after polypectomy of small colorectal polyps: two or more clips may be safe. Gastroenterol Rep (Oxf) 2021; 10:goab051. [PMID: 35382164 PMCID: PMC8972999 DOI: 10.1093/gastro/goab051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/14/2022] Open
Abstract
Background The resection of small colorectal polyps (≤10 mm) is routine for endoscopists. However, the management of one of its main complications, namely delayed (within 14 days) postpolypectomy bleeding (DPPB), has not been clearly demonstrated. We aimed to assess the role of coloscopy in the management of DPPB from small colorectal polyps and identify the associated factors for initial hemostatic success. Methods We conducted a retrospective study of 69 patients who developed DPPB after the removal of colorectal polyps of ≤10 mm and underwent hemostatic colonoscopy at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between April 2013 and June 2021. Demographics, clinical variables, and colonoscopic features were collected independently. We applied univariate and multivariate analyses to assess factors associated with initial hemostatic success. Results General colonoscopy without oral bowel preparation was successfully performed in all the patients, with a median duration of 23.9 (12.5–37.9) minutes. Among 69 patients, 62 (89.9%) achieved hemostasis after initial hemostatic colonoscopy and 7 (10.1%) rebled 2.7 ± 1.1 days after initial colonoscopic hemostasis and had rebleeding successfully controlled by one additional colonoscopy. No colonoscopy-related adverse events occurred. Multivariate analysis showed that management with at least two clips was the only independent prognostic factor for initial hemostatic success (odds ratio, 0.17; 95% confidence interval, 0.03–0.91; P = 0.04). All the patients who had at least two clips placed at the initial hemostatic colonoscopy required no further hemostatic intervention. Conclusions Colonoscopy is a safe, effective, and not too time-consuming approach for the management of patients with DPPB of small colorectal polyps and management with the placement of at least two hemoclips may be beneficial.
Collapse
Affiliation(s)
- Xue-Feng Guo
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xiang-An Yu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jian-Cong Hu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - De-Zheng Lin
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Xin Deng
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Ming-Li Su
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Juan Li
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wei Liu
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jia-Wei Zhang
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qing-Hua Zhong
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Corresponding author. Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Er Heng Road, Guangzhou, Guangdong 510655, P. R. China. Tel: +86-20-38254166; Fax: +86-20-38254166;
| |
Collapse
|
9
|
Facciorusso A, Bertini M, Bertoni M, Tartaglia N, Pacilli M, Pavone G, Ambrosi A, Sacco R. Efficacy of hemostatic powders in lower gastrointestinal bleeding: Clinical series and literature review. Dig Liver Dis 2021; 53:1327-1333. [PMID: 34120857 DOI: 10.1016/j.dld.2021.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited evidence on the efficacy of hemostatic powders in the management of lower gastrointestinal bleeding. AIMS to revise our series of patients with lower gastrointestinal bleeding treated with hemostatic powders and to provide a pooled estimate of their efficacy based on the current literature. METHODS Sixty-five patients underwent topical endoscopic application of hemostatic powder between 2016 and 2020. The primary endpoint was treatment success, with 7- and 30-day rebleeding rate, adverse events and mortality as secondary outcomes. Literature review was based on computerized bibliographic search on the main databases through December 2020. Pooled effects were calculated using a random-effects model. RESULTS Overall, the powder was applied as monotherapy in 37 patients (56.9%), as combination therapy in 15 patients (23.4%), and as rescue therapy in 13 cases (19.9%). Hemostasis was achieved in 100% of patients. Rebleeding rate at 7- and 30-day was 7.7% and 9.2%, respectively. A total of 10 studies with 259 patients were included in the meta-analysis. Immediate hemostasis was achieved in 96.3% (93.4%-99.2%) patients, whereas pooled 7- and 30-day rebleeding rates were 9.6% (4.5%-14.6%) and 12.9% (7.2%-18.5%), respectively. CONCLUSION Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy.
| | - Marco Bertini
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Michele Bertoni
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Nicola Tartaglia
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Mario Pacilli
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Giovanna Pavone
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Antonio Ambrosi
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Rodolfo Sacco
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| |
Collapse
|
10
|
Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
Collapse
Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
11
|
Facciorusso A, Bertini M, Bertoni M, Tartaglia N, Pacilli M, Ramai D, Mohan BP, Chandan S, Ambrosi A, Sacco R. Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1283-E1290. [PMID: 34447877 PMCID: PMC8383089 DOI: 10.1055/a-1495-4764] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/14/2021] [Indexed: 12/16/2022] Open
Abstract
Background and study aims There is limited evidence on the effectiveness of hemostatic powders in the management of lower gastrointestinal bleeding (LGIB). We aimed to provide a pooled estimate of their effectiveness and safety based on the current literature. Patients and methods Literature review was based on computerized bibliographic search of the main databases through to December 2020. Immediate hemostasis, rebleeding rate, adverse events, and mortality were the outcomes of the analysis. Pooled effects were calculated using a random-effects model. Results A total of 9 studies with 194 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95 % of patients (95 % confidence interval [CI] 91.6 %-98.5 %), with no difference based on treatment strategy or bleeding etiology. Pooled 7- and 30-day rebleeding rates were 10.9 % (95 %CI 4.2 %-17.6 %) and 14.3 % (95 %CI 7.3 %-21.2 %), respectively. Need for embolization and surgery were 1.7 % (95 %CI 0 %-3.5 %) and 2.4 % (95 %CI 0.3 %-4.6 %), respectively. Overall, two patients (1.9 %, 95 %CI 0 %-3.8 %) experienced mild abdominal pain after powder application, and three bleeding-related deaths (2.3 %, 95 %CI 0.2 %-4.3 %) were registered in the included studies. Conclusion Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Marco Bertini
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Michele Bertoni
- Gastrointestinal Endoscopy Unit, Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Nicola Tartaglia
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Mario Pacilli
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, Brooklyn Hospital Medical Center, Brooklyn, New York, United States
| | - Babu P. Mohan
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, United States
| | - Saurabh Chandan
- Gastroenterology Unit, CHI Health Creighton University Medical Center, Omaha, Nebraska, United States
| | - Antonio Ambrosi
- General Surgery Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Rodolfo Sacco
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, Italy
| |
Collapse
|
12
|
Bestari MB, Joewono IR, Girawan D, Argatio JT, Abdurachman SA. Hemospray® during Emergency Endoscopy: Indonesia's First Experience from 37 Patients. Case Rep Gastroenterol 2020; 14:70-79. [PMID: 32110203 PMCID: PMC7036561 DOI: 10.1159/000505775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 01/06/2020] [Indexed: 01/14/2023] Open
Abstract
Gastrointestinal bleeding (GIB) is one of the main indications for performing endoscopy; this condition can be life threatening. In some cases, emergency endoscopy (EE) is necessary to identify the source and stop the bleeding. Recently, hemostatic powder was introduced, one of which was Hemospray® (Cook Medical, Winston-Salem, NC, USA), which showed promising results for rapid hemostasis in primary treatment and salvage when conventional methods fails. Samples were taken retrospectively for a duration of 3 years since Hemospray was first introduced in Indonesia, from January 2016 to January 2019. The total number of EEs that used Hemospray were 37 procedures for 37 patients; 21 (56.8%) were males and 16 (43.2%) were females, while the average age was 67.8 years. Hemospray was used for upper GIB in 30 cases (81.1%) and for lower GIB in 7 (18.9%). Hemospray was used as monotherapy for 24 patients (64.9%) and as secondary modality for 13 (35.1%). The primary treatment was argon plasma coagulation in 8 cases (21.6%), adrenaline in 4 (10.8%), and Histoacryl® in 1 (2.7%). The mortality rate was 37.8% (n = 14); most deaths occurred within 30 days after the EE was performed, and none of the deaths was related to endoscopy or GIB. Hemospray was able to achieve hemostasis in all cases. Furthermore, there was no event of rebleeding. When conventional modalities alone were inadequate, the combination with Hemospray appeared to be able to control the bleeding. One of the main advantages of Hemospray is the ease in reaching difficult areas, and it require less skill compared to conventional modalities.
Collapse
Affiliation(s)
- Muhammad Begawan Bestari
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
| | - Ignatius Ronaldi Joewono
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Dolvy Girawan
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
| | | | - Siti Aminah Abdurachman
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Upper gastrointestinal bleeding (UGIB) is a common and life-threatening condition in the United States and worldwide. RECENT FINDINGS There have been several exciting recent advances in the endoscopic management of UGIB. One such advance is the recent approval of Hemospray by US Food and Drug Administration in May 2018. Another one is the emerging role of video capsule endoscopy as a triage and localization tool for UGIB patients. Finally, the development of new reversal agents for antithrombotic medications is an important advance in the management of life-threatening upper gastrointestinal bleed. SUMMARY In this article, we will broadly review the management of nonvariceal UGIB, focusing primarily on the data addressing these new advances.
Collapse
|
14
|
Hemostatic spray powder TC-325 for GI bleeding in a nationwide study: survival and predictors of failure via competing risks analysis. Gastrointest Endosc 2019; 90:581-590.e6. [PMID: 31220444 DOI: 10.1016/j.gie.2019.06.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS TC-325 (Hemospray, Cook Medical, Winston-Salem, NC) is an inorganic hemostatic powder recently approved by the U.S. Food and Drug Administration. This study aimed to examine the effectiveness, safety, and predictors of TC-325 failure in a large real-life cohort. METHODS This was a retrospective study conducted at 21 Spanish centers. All patients treated with TC-325 until September 2018 were included. The primary outcome was treatment failure, defined as failed intraprocedural hemostasis or recurrent bleeding within the first 30 postprocedural days. Secondary outcomes included safety and survival. Risk and predictors of failure were assessed via competing-risk models. RESULTS The cohort comprised 261 patients, of whom 219 (83.9%) presented with upper gastrointestinal bleeding (GIB). The most common causes were peptic ulcer (28%), malignancy (18.4%), and therapeutic endoscopy-related GIB (17.6%). TC-325 was used as rescue therapy in 191 (73.2%) patients. The rate of intraprocedural hemostasis was 93.5% (95% confidence interval [CI], 90%-96%). Risks of TC-325 failure at postprocedural days 3, 7, and 30 were 21.1%, 24.6%, and 27.4%, respectively. On multivariate analysis, spurting bleeding (P = .004), use of vasoactive drugs (P = .02), and hypotension (P = .008) were independent predictors of failure. Overall 30-day survival was 81.9% (95% CI, 76%-86%) and intraprocedural hemostasis was associated with a better prognosis (adjusted hazard ratio, 0.29; P = .006). Two severe adverse events were noted. CONCLUSION TC-325 was safe and effective for intraprocedural hemostasis in more than 90% of patients, regardless of the cause or site of bleeding and its use as rescue therapy. In this high-risk cohort treated with TC-325, the 30-day failure rate exceeded 25% and was highest with spurting bleeding or hemodynamic instability.
Collapse
|
15
|
Gutta A, Gromski MA. Endoscopic Management of Post-Polypectomy Bleeding. Clin Endosc 2019; 53:302-310. [PMID: 31525836 PMCID: PMC7280838 DOI: 10.5946/ce.2019.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022] Open
Abstract
Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.
Collapse
Affiliation(s)
- Aditya Gutta
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|