1931 The Use of Hemostat Spray in Refractory Rectal Cancer Bleeding

Abstract

INTRODUCTION: We present a case of a patient with a history of T4b N0 M0 rectal cancer with diverting colostomy followed by radiation and chemotherapy. He presented with hemodynamically significant rectal bleeding. CASE DESCRIPTION/METHODS: A large four centimeter external fungating mass with fresh blood and clots noted on digital rectal exam. Patient had a similar episode of bleeding earlier for which he underwent IR embolization. The patient presented with 200–300 ml of bright red blood per rectum associated with tachycardia and hypotension, leading to ICU admission. The initial hemoglobin was noted to be 5 g/dl. He received 2 units of packed red blood cells (PRBC) with subsequent rise in hemoglobin to 7.8 g/dl. significant hematochezia continued, requiring an additional 2 units of PRBC. Endoscopic examination of rectum revealed that the cancer had circumferentially infiltrated the wall the entire remnant rectum. The rectum lacked distensibility. The floor and lateral surface of the rectum was covered in well-organized clots, fresh bleeding was noted along the walls of the rectum which looked pale, and necrotic (Figure 1). The heavy clot burden was removed with a combination of cold snare dissection and the use of a Roth net. The rectal mucosa was washed with water and two actively bleeding vessels on the floor of the rectum as well as friable tissue with active bleeding along the lateral walls were noted (Figure 2). To avoid contact with water in the instrument channel, the instrument channel of the colonoscope was flushed with 150 cc of air before Cook Hemospray catheter was introduced. Care was taken to avoid contact with the catheter and pools of blood or water in the rectum. We opted to disconnect the suction during the process of application. The Cook Hemospray device was then used with a spray catheter to apply a total of 25 sprays. Profusely bleeding sites were first prioritized after which the oozing friable mucosa were sprayed. The individual puffs of hemostat powder coalesced to achieve an even layer of powder over the entire surface of the rectal mucosa. This initial application achieved complete hemostasis from the vessels and the mucosa. We opted not to wash the powder 2 minutes after application. The final grayish white appearance resembled the lunar surface (Figure 3). DISCUSSION: Patient was downgraded from the ICU with a post procedure Hgb of 9.8 g/dl and no evidence of rectal bleeding or a drop in the hemoglobin for 72 hours post procedure, not needing additional PRBC transfusions.