The Use of Hemospray® in Refractory Post-Polypectomy Bleeding From a Large Antral Polyp

Abstract

SymbolIntroduction: The management of refractory upper gastrointestinal bleeding (UGIB) despite exhaustive use of conventional techniques is a challenge. A novel technology that has recently emerged is Hemospray® (Cook Medical), which is licensed in Canada and Europe for the management of non-variceal upper gastrointestinal bleeding. We present a case of Hemospray® in the treatment of refractory UGIB after removal of a large antral polyp.SymbolCase Report: A 77-year-old man with a past medical history of systolic heart failure requiring a HeartMate II left ventricular assist device presented to our emergency room with one week of melena. Esophagogastroduodenoscopy (EGD) showed an actively oozing 2 cm sessile polyp in the antrum. Initial hemostasis was attempted using 7 mL of epinephrine (1:10,000) and the polyp was removed with hot snare polypectomy. The post-polypectomy site was treated with argon plasma coagulation (APC) and three hemostatic clips. At discharge, he had no further episodes of bleeding and both his aspirin and warfarin were held. After 35 days post-discharge, his warfarin was restarted. However, 10 days later he had two episodes of melena. His EGD showed the post-polypectomy site with active oozing and no visible vessel. This site was injected with 3ml of epinephrine (1:10,000) and a hemostatic clip was applied. Four days later, he developed an acute episode of melena. Repeat EGD demonstrated blood in the gastric antrum with previous clip still in place and a fresh clot with active oozing at the polypectomy site. Cauterization was performed and five hemostatic clips were placed to achieve hemostasis. He was eventually discharged after his hemoglobin stabilized and no further evidence of active bleeding. Fourteen days after discharge, he returned with weakness, hemoglobin drop and melena. Again, his EGD showed an adherent clot and active oozing at the polypectomy site. One Ovesco® “bear trap” clip was placed at the polypectomy site but there was continual oozing. He received numerous rounds of APC but the bleeding persisted. Given that he failed conventional endoscopic therapies and was not a candidate for interventional radiology treatment, Hemospray was attempted. After Hemospray® was applied to the polypectomy site, there was no further evidence of active bleeding or oozing. He was monitored for several days and eventually discharged with stable hemoglobin and no additional episodes of bleeding. Conclusion: This case highlights the novel application of Hemospray® and its effectiveness in achieving acute hemostasis in a patient with refractory post-polypectomy bleeding from a large antral polyp. To date, there have only been 15 cases of its use in the United States.