S2203 Off-Label Use of Hemospray in Bleeding Non-Cirrhotic Portal Hypertensive Gastric Varices: A Bridge to Definitive Therapy

Abstract

INTRODUCTION: With a mortality rate as high as 26%, acute gastric variceal bleeding remains an important medical emergency. Given the paucity of data, management of non-cirrhotic portal hypertension associated varices has been challenging. Current management relies on technically challenging and time consuming techniques to achieve early endoscopic hemostasis via injectable adhesives, fibrin and thrombin injections, mechanical banding, and application of sclerosants. Recent studies favor endoscopic use of topical hemostatic spray (TC-325) - a therapeutic with FDA approval in nonvariceal gastrointestinal bleeding and increasingly being used off-label in the management of gastric varices. Despite excellent short-term efficacy, hemostatic powders are limited by high rebleed rates and thus primarily serve as a bridge toward definitive therapy. CASE DESCRIPTION/METHODS: A 55-year-old gentleman with metastatic pancreatic cancer complicated by splenic vein thrombosis with isolated gastric varices, presented with epigastric pain, melena and evidence of hemodynamic compromise. Laboratory investigation revealed a hemoglobin of 6.6 g/dL. The patient was admitted to the MICU and treated with empiric antibiotics, IV fluids, pantoprazole and octreotide drips. After blood transfusion EGD was performed revealing multiple large isolated gastric varices (IGV-1) with red spots as well as active bleeding from a gastric fundus varix. The bleeding gastric varix was not amenable for band ligation or injection of sclerosants. Hemospray was generously applied to the bleeding culprit and surrounding varices, with successful hemostasis. The patient was not a candidate for splenectomy thus underwent splenic artery embolization by interventional radiology. He was continued on pantoprazole and octreotide drips for 72 hours, without evidence of rebleeding, and was discharged in stable condition. DISCUSSION: Options for treatment of bleeding isolated gastric varices are limited in the United States. Our case highlights the successful, off-label use of hemospray as a bridging intervention in non-cirrhotic gastric varices until definitive treatment with artery embolization could be performed. This contrasts with bleeding cirrhotic portal hypertensive varices that are managed with TIPS (Transjugular intrahepatic portosystemic shunt) or BRTO (Balloon-occluded retrograde transvenous obliteration). More studies are needed to validate the use of topical hemostatic powder (TC-325) in the management of non-cirrhotic gastric variceal bleeding.Figure 1.: Varix in the gastric fundus with active bleeding.Figure 2.: Gastric varices prior to administration of hemospray.Figure 3.: Gastric varices without active bleeding following administration of hemospray.