1922 The Use of a New Hemostatic Powder in Refractory Pseudocyst Wall Bleeding

Abstract

INTRODUCTION: Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding. CASE DESCRIPTION/METHODS: 84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place. DISCUSSION: To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.