Award: Presidential Poster Award
Jason R. Stibbe, MD, MS1, Christie Blanton, MD2, John B. Rhodes, MD1, Catherine T. Hudson, MD, MPH1, Daniel Raines, MD, FACG1
1Louisiana State University Health Sciences Center, New Orleans, LA; 2Louisiana State University, New Orleans, LA
Introduction: Endoscopic application of hemostatic powder for the treatment of GI bleeding has now been well-described in the literature and utilized for multiple years in clinical practice. Its use as primary and salvage therapy in upper GI bleeding has been established following its approval for non-variceal GI bleeding. Successful use has even been reported in post-variceal banding ulcers, however in very small patient numbers with comparatively less data in acute, ulcerated, post- banding bleeding occurring with simultaneous gastric and esophageal varices.
Case Description/Methods: We present a case of a 57-year-old male with medical history including hepatitis C, cirrhosis, tobacco use, chronic kidney disease, duodenal ulcer, gastritis, ascites, esophageal varices, and diffuse/infiltrative hepatocellular carcinoma associated with tumor thrombus of the portal and hepatic veins who presented to the emergency department for new melenic stools. Hemoglobin was 12.4 g/dL on presentation, decreased to 10.2 g/dL by consultation at which time the melena progressed to hematochezia with an episode of hematemesis. The calculated MELD-sodium score was 19. Physical examination was pertinent for soft, distended abdomen without tenderness and no asterixis. IV ceftriaxone, pantoprazole, and octreotide were initiated. The patient received a single unit of packed red blood cells during hospitalization. EGD demonstrated large distal esophageal varices and an actively-spurting Type 1 (GOV1) gastroesophageal varix. Two bands were placed on esophageal varices and the gastric varix was banded to eradication with cessation of bleeding. Hematemesis recurred the following day and repeat EGD was performed for salvage therapy noting that prior evaluation deemed the patient non-candidate for liver transplant or TIPS procedure. Ulcerated varices were encountered at the prior banding sites with a large pool of coagulated blood in the stomach and hemostatic spray was successfully applied to each site. Hemoglobin remained stable after repeat hemostatic therapy without subsequent need for transfusion.
Discussion: Ordinarily, persistent bleeding following variceal banding in decompensated cirrhosis warrants TIPS consideration if a candidate and needed for rescue therapy. However, this case lends credence to the use of hemostatic spray in non-TIPS candidates for treatment of post-banding ulcerated variceal bleeding in both esophageal and gastric etiologies.
Citation: Jason R. Stibbe, MD, MS; Christie Blanton, MD; John B. Rhodes, MD; Catherine T. Hudson, MD, MPH; Daniel Raines, MD, FACG. P1361 - HEMOSTATIC SPRAY FOR SECONDARY HEMOSTASIS FOLLOWING ENDOSCOPIC VARICEAL BAND LIGATION. Program No. P1361. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.