Refractory Bleeding Research Articles

S1092 Long Term Outcomes of TIPS for Patients With Refractory Variceal Bleeding and Ascites: “A Real World Experience” From a Single Large Center

S1092 Long Term Outcomes of TIPS for Patients With Refractory Variceal Bleeding and Ascites: “A Real World Experience” From a Single Large Center

Salvage endovascular embolization of the left pulmonary artery for recurrent pseudoaneurysm

BackgroundPulmonary pseudoaneurysm (PPA) is a potentially lethal complication of lung resection with a high risk of recurrence after endovascular coiling.Case presentationWe report a case in which recurrent hemoptysis due to PPA after left lower lobe sleeve resection was treated by endovascular embolization of the left main pulmonary artery as a salvage treatment. The first hemoptysis was managed by endovascular coil embolization with extracorporeal membrane oxygenation, but refractory hemorrhage occurred 3 months later due to penetration of the endovascular coil into the bronchial anastomosis site. Because left completion pneumonectomy was considered too high risk, the left main pulmonary artery was palliatively embolized using an Amplatzer vascular plug (St. Jude Medical, MN, USA) to totally disrupt the left pulmonary arterial flow.ConclusionsTotal embolization of the left main pulmonary artery for repeated PPA rupture may be useful as a palliative treatment in patients unable to tolerate pneumonectomy.

Techniques and Outcomes of Transjugular Intrahepatic Portosystemic Shunting in Infants with Budd-Chiari Syndrome

PurposeTo describe the technical aspects, feasibility, and outcomes in children with Budd-Chiari syndrome (BCS) undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation during infancy. Materials and MethodsA retrospective review of infants with BCS undergoing TIPS creation between January 2012 and December 2018 was performed. Eight infants (5 males) underwent TIPS creation (7 for refractory ascites and 1 for refractory variceal bleeding) during the study period. The median age at TIPS creation was 10.5 months (range, 8–16 months). The median elapsed time between presentation and TIPS creation was 6.5 months (range, 0–13 months). The median weight and median pediatric end-stage liver disease score of the infants at the time of TIPS creation were 6.7 kg (range, 5.4–10 kg) and 13 kg (range, 8–18 kg), respectively. ResultsTIPS creation was successful in all patients. There were no immediate postprocedural complications. An 18-gauge hollow needle was manually curved, through which a 21-gauge Chiba needle was inserted to access the portal vein. All patients received 1 or 2 overlapping bare metal stents. One patient was lost to follow-up after the procedure. The median follow-up duration was 32 months (range, 14–51 months). Four of 7 infants needed reintervention. Two children died during the follow-up period. Two children successfully underwent living donor liver transplant, whereas the remaining 3 children were asymptomatic at the follow-up. ConclusionsTIPS creation was found to be safe and efficacious in improving portal hypertension and growth in these children, although, with a higher rate of reinterventions, possibly due to the use of small, bare metal stents.

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-Apropensity score matched analysis.

BackgroundTranscatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over‐the‐scope clips (OTSC) have shown superiority to standard endoscopic treatment.ObjectiveTo compare OTSC treatment to TAE in refractory peptic ulcer bleeding.Patients and MethodsIn this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.ResultsPatients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re‐therapy (12.9% vs. 1.5%; p = 0.042) and in‐hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04–8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in‐hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11–27.43]; p = 0.048) stayed significant.ConclusionsOTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in‐hospital mortality.

Recombinant Factor VIIa in Pediatric Cardiac Surgery

ObjectivesRecombinant activated factor VIIa (rVIIa) is used off-label for refractory bleeding after cardiac surgery. This study reviewed the indications, usage rates, and complications of rVIIa. DesignA retrospective case-control observational study. SettingA single quaternary pediatric hospital. ParticipantsAll children undergoing cardiac surgery with cardiopulmonary bypass over a three-year period. InterventionsAdministration of rVIIa as rescue therapy for refractory bleeding after weaning from cardiopulmonary bypass. Measurements and Main ResultsOnethousand, five hundred fifteen cardiopulmonary bypass procedures were reviewed. Patients receiving rVIIa were each matched to two control patients by age, procedure type, and bypass time. Data collected included weight, crossclamp time, anticoagulant and antifibrinolytic dose, return to the operating room for bleeding, thrombotic events, and extracorporeal membrane oxygenation (ECMO) circuit interventions.Forty-two patients received rVIIa (2.8%). Major systemic thrombotic complications were observed in 19% (controls 12.5%) of patients; 80% of recombinant factor VIIa patients requiring postoperative ECMO had interventions for circuit thrombosis (controls 31.25%); 4.76% of rVIIa recipients required reexploration for intractable bleeding (controls 1.39%). ConclusionsThis study added to understanding regarding the use of recombinant factor VIIa in pediatric cardiac surgery and reported increased thrombotic complications, especially for children who progress to ECMO. Prospective studies to better understand the pathophysiology of coagulopathy and hemorrhage in pediatric cardiac surgery and the role of hemostatic agents, such as rVIIa, are required.

Multimodal treatment of refractory haemorrhage from haemosuccus pancreaticus.

Multimodal treatment of refractory haemorrhage from haemosuccus pancreaticus.

Safety and Efficacy of Recombinant Factor VIIa (NovoSeven) Use during ECMO Support in Patients after Cardiac Surgery

Background: Acute postoperative bleeding in cardiac surgical patients is a major cause of morbidity and mortality. Substitution of coagulatory factors may not always provide optimal hemostasis and off label, use of recombinant FVIIa has been proposed. When on ECMO, extra care must be taken during coagulatory substitution as clotting of the system may cause cardiovascular complications and possible ECMO failure, leading to death. In this paper, we examined the safety and efficacy of rFVIIa during ECMO support in postoperative cardio-surgical patients. Methods: We retrospectively examined all patients receiving rFVIIa postoperatively from December 2005 and January 2020. Clinical characteristics, demographics, bleeding, thrombotic complications, mortality, and rFVIIa administration were analyzed. Results: A total of 74 patients received rFVIIa postoperatively due to uncontrollable bleeding after cardiac surgery on our ICU. Of these patients, 23 patients were on ECMO treatment. Twelve patients received rFVIIa during, but not prior to the initiation of ECMO therapy. Six patients (50%) were male; mean age was 46 years (30-72 years). Eleven patients (91.7%) were on venoarterial ECMO, one patient was on central ECMO (8.3%). Dose of administered rFVIIa was corrected for body weight; mean dosage was 82μg/kg. We saw a significant reduction in need for red packed cells, fresh frozen plasma and thrombocyte transfusion after rFVIIa administration. There was no impact on the functionality of the ECMO system, especially regarding the oxygenator after rFVIIa administration. One patient suffered a stroke due thromboembolism (8.3%). One patient developed late thromboembolism in the leg (8.3%), and two cases of pulmonary embolism (16.7%) were recorded. Overall survival was 25% and there was no significant difference in survival between ECMO and non-ECMO patients. Weaning from ECMO could be achieved successfully in 41.7% of our patients. Conclusion: Recombinant Factor VIIa is an effective agent in reducing blood loss during ongoing ECMO therapy in patients with refractory bleeding. Although no direct relation between rFVIIa application and thromboembolic events could be established, its use should be done with the utmost care and in selected patients. However, rFVIIa therapy did not impact ECMO function in our cohort.

Combination of Model for End-Stage Liver Disease and Lactate Predicts Death in Patients Treated With Salvage Transjugular Intrahepatic Portosystemic Shunt for Refractory Variceal Bleeding.

Data about the prognosis of salvage transjugular intrahepatic portosystemic shunt (TIPS) using covered stents for refractory variceal bleeding caused by portal hypertension are scarce. We aimed to assess survival and to identify predictors of mortality in these patients. One hundred sixty-four patients with cirrhosis from five centers treated with salvage TIPS between 2007 and 2017 were retrospectively divided into a derivation cohort (83 patients) and a validation cohort (81 patients). Comparisons were performed using the Mann-Whitney and Fischer's exact test. Six-week overall survival (OS) was correlated with variables on the day of the TIPS using Kaplan-Meier curves with log-rank test and univariate/multivariate analyses using the Cox model. Eighty-three patients were included in the derivation cohort (male, 78%; age, 55years, alcohol-associated cirrhosis, 88%; Model for End-Stage Liver Disease [MELD], 19 [15-27]; arterial lactate, 3.7mmol/L [2.0-8.3]). Six-week OS rate was 58%. At multivariate analysis, the MELD score (OR, 1.064; 95% CI, 1.005-1.126; P=0.028) and arterial lactate (OR, 1.063; 95% CI, 1.013-1.114; P=0.032) were associated with 6-week OS. Six-week OS rates were 100% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15 and 5% in patients with lactate ≥12mmol/L and/or MELD score≥30. The 81 patients of the validation cohort had similar MELD and arterial lactate level but lower creatinine level (94vs 106µmol/L, P=0.008); 6-week OS was 67%. Six-week OS rates were 86% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15 and 10% for patients with lactate ≥12mmol/L and/or MELD score≥30. In the overall cohort, rebleeding rate was 15.8% at 6weeks, and the acute-on-chronic liver failure grade (OR, 1.699; 95% CI, 1.056-1.663; P=0.040) was independently associated with rebleeding. After salvage TIPS, 6-week mortality remains high and can be predicted by MELD score and lactate. Survival rate at 6weeks was >85% in patients with arterial lactate ≤2.5mmol/L and MELD score≤15, while mortality was >90% for lactate ≥12mmol/L and/or MELD score≥30.

Iron Deficiency and the Small bowel​.

This article reviews iron deficiency anemia (IDA) and suspected small bowel bleeding (SSBB) from initial consultation through laboratory evaluation, endoscopic evaluation, and therapeutic options. Recent guidelines on management of SSBB, IDA, video capsule endoscopy (VCE), and device-assisted enteroscopy (DAE) are reviewed. The advantages and limitations of VCE, DAE, and imaging are discussed. Medical treatment for refractory small bowel bleeding is discussed. Evaluation of IDA starts with a detailed history and physical exam. Additional lab work can establish the diagnosis of IDA and evaluate for associated conditions. If initial endoscopic tests are unrevealing, SSBB should be ruled out. Further investigation can be performed using video capsule endoscopy (VCE), device-assisted enteroscopy (DAE), and imaging. The mainstay of medical treatment of IDA secondary to SSBB is iron supplementation. Additional treatment is tailored to the pathology and may include medical, endoscopic and surgical options.

Factor VIII inhibitor bypass activity (FEIBA) for the reduction of transfusion in cardiac surgery: a randomized, double-blind, placebo-controlled, pilot trial

BackgroundUncontrolled bleeding after cardiac surgery can be life-threatening. Factor eight inhibitor bypassing activity (FEIBA) is a prothrombin complex concentrate empirically used as rescue therapy for correction of refractory bleeding diathesis post-cardiopulmonary bypass (CPB). FEIBA used as rescue therapy for bleeding diathesis after CPB has been associated with a low incidence of complications and a reduction in transfusion requirement and re-exploration. The feasibility and efficacy of early administration of FEIBA after the termination of CPB have not been studied in a prospective randomized trial.MethodsWe designed a small randomized, double-blinded, placebo-controlled pilot trial to determine the feasibility of a larger trial testing the hypothesis that FEIBA decreases transfusion requirements after CPB. The study was designed to evaluate the feasibility of a larger pivotal trial to determine the effectiveness of FEIBA in reducing the total volume of blood products transfused perioperatively, and its safety profile. Study participants were adult patients undergoing elective major aortic cardiovascular surgery at a tertiary referral hospital, who were equally randomized to receive a single dose of either FEIBA or matched placebo intraoperatively at the end of CPB.ResultsTwenty patients were screened and 12 were randomized and included in the analysis. Protocol adherence was high, and all patients received the study drug per intention-to-treat except one patient. There were no protocol deviations or events of unblinding, and adverse events were not different between groups. Patients in the FEIBA group were older and more likely to be female and had higher BMI, lower hematocrit, and longer hypothermic circulatory arrest. There were no differences in post-randomization blood product transfusions (difference FEIBA vs. placebo −899 mL; 95% CI −5206 to 3409) or in the administration of open-label FEIBA.ConclusionsThis pilot trial confirmed the adequacy of the trial design that involved the early, blinded administration of FEIBA, by demonstrating excellent protocol adherence. We conclude that a larger trial establishing the effectiveness of early prothrombin complex concentrate administration to reduce the use of blood products in the setting of high-risk cardiac surgery is feasible.Trial registrationClinicalTrials.gov, NCT02577614. Registered 16 October 2015

Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review

Abstract Objectives Sinistral portal hypertension (SPH) is caused by increased pressure on the left portal system secondary to splenic vein stenosis or occlusion and may lead to gastric varices. The definitive management of SPH is splenectomy, but this is associated with significant mortality and morbidity in the acute setting. In this systematic review, we investigated the efficacy and safety of splenic artery embolisation (SAE) in managing refractory variceal bleeding in patients with SPH. Methods A comprehensive literature search was conducted using MEDLINE and Embase databases. A qualitative analysis was chosen due to heterogeneity of the studies. Results Our search yielded 339 articles, 278 of which were unique. After initial screening, 16 articles relevant to our search remained for full text review. Of these, 7 were included in the systematic review. All 7 papers were observational, 6 were retrospective. Between them they described 29 SAE procedures to control variceal bleeding. The technical success rate was 100% and there were no cases of rebleeding during follow up. The most common complication was post-embolisation syndrome. Four major complications occurred, two resulting in death. These deaths were the only 30-day mortalities recorded and were in patients with extensive comorbidities. Conclusions Although there is a distinct lack of randomized controlled studies comparing SAE to other treatment modalities, it appears to be safe and effective in treating hemorrhage secondary to SPH.

Splenectomy in a Severe Case of Acquired Factor X Deficiency Secondary to Amyloidosis: Case Discussion and Review of the Literature

Amyloidosis is a protein deposition disorder wherein amyloid fibrils affect soft tissues and visceral organs. One subtype is light-chain (AL) amyloidosis, which is characterized by amyloidogenic immunoglobulins produced generally by clonal plasma cells. Kidney and heart are the most commonly involved organs by AL amyloidosis while liver and sensory/autonomic nervous system can be clinically prominent. In a minority, acquired Factor X (FX) deficiency (related to amyloid binding this factor) can provoke a profound bleeding diathesis.We present a 62-year-old black male who was referred to our institution in May 2016 by a community hematologist after diagnoses of FX deficiency and monoclonal gammopathy. The patient initially presented with ecchymosis, hemearthroses, and blood per rectum. Workup revealed a hemoglobin 7.7g/dL, platelets 62x10³/µL and prolonged PT (35.4s) and aPTT (53.9s). Echocardiogram revealed concentric LV ‘hypertrophy’ and grade 2 diastolic dysfunction. Abdominal ultrasound identified an enlarged spleen of 18 cm. Fibrinogen level was 295mg/dL, PT and PTT mixing studies normalized, and FX activity was measured at 0.02U/mL (normal 0.2-0.4U/mL). Bone marrow biopsy showed plasma cell myeloma involving 50% of the marrow. He was started on therapy with cyclophosphamide, bortezomib, and dexamethasone.Unfortunately, the patient had no measurable response after 3 cycles of therapy at which time he presented with severe and progressive hemarthrosis, mucocutaneous bleeding, symptomatic anemia, thrombocytopenia, and elevations in PT/PTT. He received transfusions with fresh frozen plasma (FFP) around the clock, aminocaproic acid, and supportive transfusion of packed RBC and platelets. Due to active mucosal bleeding, the patient was administered vitamin K and transfused FFP every 4 hours. His coagulation parameters did not improve. Interestingly, despite his mixing studies correcting “in vitro,” he failed to demonstrate any “in vivo” correction despite FFP transfusion and three plasmapheresis treatments. Given his refractory bleeding, the surgical service was consulted regarding the prospect of a splenectomy. In an effort to optimize the patient for surgery, he received prothrombin complex concentrate (PCC) without significant improvement (Table 1). Ultimately, the patient underwent splenectomy (estimated blood loss 200cc) and was managed intra-operatively with FFP and aminocaproic acid infusion. His coagulation studies and platelet count improved immediately post-operatively (Table 1), and repeat FX level the following day demonstrated a normal value of 0.48 U/mL. Surgical pathology of the spleen was consistent with extensive deposition of amyloid (lambda subtype). To date, the patient has had a complete normalization of coagulation studies and FX levels and is clinically responding to daratumumab therapy.The incidence of coagulopathy in AL amyloidosis has been estimated to approach one third of all patients, largely due to acquired coagulation factor deficiency, and most commonly FX. Splenomegaly is present in fewer than 15% of patients with AL amyloidosis, however it is much more frequent in patients with acquired FX deficiency. Amyloid deposition in the spleen is thought to bind FX as well as sequesters platelets leading to potentially life threatening bleeding. Our review of the literature identified five previously reported cases of acquired FX deficiency secondary to AL amyloidosis which completely reversed after splenectomy (Kapoor et. al. American Journal of Hematology 2006), but our patient's presentation was particularly severe. Previous reports have also described the improvement of acquired FX deficiency in AL amyloidosis patients with high-dose melphalan (Choufani et. al. Blood 2001), although it is unclear what degree of clinically significant bleeding these patients were experiencing. Splenectomy is frequently reserved as last-line management in these patients, when more conservative measures such as FFP and plasmapheresis are not effective. This is due to the short half-life of the infused FX (Furie et. al. NEJM 1977), as well as its expedited clearance in the spleen, where it is bound to amyloid. While some cases using recombinant Factor VIIa and PCC have worked, they are more often ineffective. In patients with severe bleeding, splenectomy can produce rapid improvement as evidenced here. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Implementation and Impact of a Multidisciplinary Coagulation Factor Stewardship Program

Introduction: Coagulation factor products are costly and can cause adverse outcomes when used inappropriately. Active stewardship may reduce the risk of inappropriate use, increase the likelihood of safe and effective use, and help control costs. Such goals may be met when these products are dispensed from an inpatient pharmacy. After multidisciplinary discussions of unmet clinical needs and pharmacoeconomic concerns, coagulation factor product guidelines for use were established at our institution and a multidisciplinary stewardship program was implemented.Objective: The purpose of this quality improvement initiative was to implement a multidisciplinary coagulation factor stewardship program and ascertain its impact on the use of coagulation factor products after dispensing them from inpatient pharmacy instead of the blood bank.Methods: We compared the utilization of 4-Factor prothrombin complex concentrate (4F-PCC) and recombinant factor VIIa (rVIIa) from the period of 7/1/16 to 5/31/17, 6 months prior to and 6 months after implementation of the stewardship program. Prior to implementation, pharmacists, hematologists, surgeons, anesthesiologists, and intensivists met to develop hospital-wide guidelines and order sets for 4F-PCC and rVIIa. The guidelines include indications for which 4F-PCC can be dispensed without hematology consultation and the requirement for hematology consultation for approval of requests outside of these guidelines. The Pharmacy & Therapeutics Committee approved all guidelines, order sets and the hematology service stewardship. Data about approval, administration, cost, and outcomes were obtained retrospectively for the 6 months prior and prospectively for the 6 months after implementation of the stewardship program.Results: Pre-implementation, 30 patients received 4F-PCC and 7 received rFVIIa. Warfarin reversal prior to emergent surgery (n=18, 60%) was the most common indication for 4F-PCC, followed by warfarin reversal for major bleeding (n=9, 30%) and direct oral anticoagulant (DOAC) reversal (n=3, 10%). Vitamin K was administered to 78% of the patients requiring warfarin reversal. The indications for rFVIIa included FVII deficiency (n=3, 42%), hemophilia with inhibitors (n=2, 29%), and refractory major bleeding (n=2, 29%). Of all patients, 7 (19%) died before discharge, but not within 72 hours and 1 (3%) had a thrombotic event within 72 hours. The cost of 4F-PCC and rFVIIa during the 6 months preceding the stewardship program was $261,880.After stewardship was implemented, 34 patients received 4F-PCC and 3 received rFVIIa. Indications for 4F-PCC included warfarin reversal prior to emergent surgery (n=21, 62%), warfarin reversal for major bleeding (n=5, 15%), DOAC reversal (n=4, 12%), and peri-operative management of other coagulopathies (n=4, 12%). Vitamin K was administered to 88% of patients requiring warfarin reversal. The pharmacy dispensed the products according to institutional guidelines in 88% of cases, and without hematology consultation when it should have been obtained in 12% of cases. Hematology was consulted for stewardship in 6 cases; 2 were approved and 4 were denied for disseminated intravascular coagulation (DIC) (n=2), factor V deficiency without active bleeding (n=1), and surgical bleeding (n=1). Of all patients, 10 (24%) died before discharge, including the 2 with DIC who were denied product. Three (7%) died within 72 hours and 2 (5%) had thrombotic events within 72 hours. The cost for 4F-PCC and rFVIIa was $160,144 after stewardship was implemented.Conclusions: Dispensing 4F-PCC and rFVIIa from the inpatient pharmacy with stewardship has resulted in similar utilization and efficacy as existed in the pre-implementation period but with cost savings of $101,000 during the first 6 months of stewardship. Furthermore, implementation of a multidisciplinary coagulation factor stewardship program with standardized institutional guidelines, streamlined dispensing from the inpatient pharmacy, as well as use of expert hematologic consultation when indicated, has enhanced the culture of safety in our institution. The experience has also enriched the training of hematology fellows, residents and pharmacists. DisclosuresFongemie:Bristol Myers Squibb: Speakers Bureau. Comenzo:Janssen: Consultancy, Research Funding; Prothena: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Karyopharm: Research Funding.

Aortic Valve Stenosis, a Precipitating Factor of Recurrent Bleed in Colonic Angiodysplasia: A Literature Review.

Angiodysplasia (also known as angioectasia) is a lesion characterized by abnormal, dilated small blood vessels in the mucosa and submucosal layers of the GI tract. With the estimated low incidence of active GI bleeding from these lesions, angiodysplasia can be challenging to diagnose. The presence of aortic stenosis has increased the recognition rate of angiodysplasia, especially in the elderly. Despite the associations between aortic stenosis and angiodysplasia (Heyde's syndrome) revealed in several studies, the etiology of Heyde syndrome is still debatable, which has led to the proposition of several hypotheses that are reviewed in this article. This activity will help review the meaning of Heyde's syndrome, epidemiology, proposed pathophysiology, diagnosis, and management by surveying articles published between 1955 and 2021 on PubMed. We used search terms such as "colonic angiodysplasia," "arteriovenous malformation," "Heyde syndrome," "refractory gastrointestinal bleed," "aortic valve stenosis," and "acquired von Willebrand disease." Findings revealed an association between aortic stenosis and lower gastrointestinal (GI) bleed.

Endoscopic hemostatic spray for uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection: a report of 2 cases.

Background and AimsThere is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed.MethodsWe present 2 patient cases of ESD and EMR used to treat a gastric adenoma (case 1) and 2 gastric hyperplastic masses (case 2) with refractory bleeding after use of multiple other treatment modalities. Both patients were not surgical candidates because of their medical comorbidities.ResultsBleeding was eventually controlled with the use of endoscopic hemostasis spray after attempts were made using SB Knife Jr tip, Coagrasper Hemostatic Forceps, Argon Photocoagulation, and scope tamponade.ConclusionsIn very specific cases, endoscopic hemostasis spray may have some utility for refractory bleeding after dissection of gastric lesions. After using this spray, it became technically challenging to suture endoscopically because of the mud-like quality of the hemostasis material.

腹部大動脈瘤による播種性血管内凝固症候群 (DIC) により止血に難渋した舌咬創の1例

腹部大動脈瘤による播種性血管内凝固症候群 (DIC) により止血に難渋した舌咬創の1例

PuraStat in gastrointestinal bleeding: results of a prospective multicentre observational pilot study

BackgroundA recently developed haemostatic peptide gel for endoscopic application has been introduced to improve the management of gastrointestinal bleeding. The aim of this pilot study was to evaluate the feasibility, safety, efficacy and indication profiles of PuraStat in a clinical setting.MethodsIn this prospective observational multicentre pilot study, patients with acute non-variceal gastrointestinal bleeding (upper and lower) were included. Primary and secondary application of PuraStat was evaluated. Haemoglobin, prothrombin time, platelets and transfusion behaviour were documented before and after haemostasis. The efficacy of PuraStat was assessed during the procedure, at 3 days and 1 week after application.Results111 patients with acute gastrointestinal bleeding were recruited into the study. 70 percent (78/111) of the patients had upper gastrointestinal bleeding and 30% (33/111) had lower gastrointestinal bleeding. After primary application of PuraStat, initial haemostatic success was achieved in 94% of patients (74/79, 95% CI 88–99%), and in 75% of the patients when used as a secondary haemostatic product, following failure of established techniques (24/32, 95% CI 59–91%). The therapeutic success rates (absence of rebleeding) after 3 and 7 days were 91% and 87% after primary use, and 87% and 81% in all study patients. Overall rebleeding rate at 30 day follow-up was 16% (18/111). In the 5 patients who finally required surgery (4.5%), PuraStat allowed temporary haemostasis and stabilisation.ConclusionsPuraStat expanded the therapeutic toolbox available for an effective treatment of gastrointestinal bleeding sources. It could be safely applied and administered without complications as a primary or secondary therapy. PuraStat may additionally serve as a bridge to surgery in order to achieve temporary haemostasis in case of refractory severe bleeding, possibly playing a role in preventing immediate emergency surgery.

Successful hemostasis for refractory colonic diverticulum bleeding by clipping with polyglycolic acid sheets.

Video 1Endoscopic clipping with polyglycolic acid sheets for colonic diverticulum bleeding.

Concomitant use of combined hormonal contraceptives and antifibrinolytic agents for the management of heavy menstrual bleeding: A practice pattern survey

IntroductionConcomitant antifibrinolytic agents and combined hormonal contraceptives (CHC) have been anecdotally used to manage refractory heavy menstrual bleeding (HMB). Yet, there remains uncertainty among clinicians regarding the safety of this therapeutic option as concomitant CHC is listed as a contraindication to tranexamic acid use in the United States. AimTo describe current treatment practices and physician-reported safety and effectiveness of concomitant antifibrinolytics and CHCs. MethodsWe surveyed clinician members of the Hemostasis and Thrombosis Research Society and the Foundation of Women and Girls with Blood Disorders using a web-based survey. We also shared the survey link on Twitter. ResultsOf the 224 respondents who completed the survey, 214 treated women of reproductive age with HMB. Of the 214 respondents, 138 (64%) had treated at least 1 woman with concomitant antifibrinolytic agents and CHCs in the past 12 months. Over half of these respondents (n = 77, 57%) reported that at least 50% of women had resolution of refractory HMB. One respondent reported an arterial or venous thrombotic event that occurred in 1 woman. ConclusionWe found that the use of concomitant CHCs and antifibrinolytic agent for refractory HMB is prevalent, appears to be efficacious and is relatively safe. Further research is warranted.

Biliary Self-Expandable Metal Stent Could Be Recommended as a First Treatment Modality for Immediate Refractory Post-Endoscopic Retrograde Cholangiopancreatography Bleeding.

Background/AimsRecent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding. MethodsPatients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis. ResultsA total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min. ConclusionsTemporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.