ECTOPIC VARICEAL BLEEDING TREATED WITH HEMOSPRAY AS SALVAGE THERAPY: 2 CASE STUDIES

Aims:

Ectopic varices are portosystemic shunts out of the common gastro-oesophageal varices alongside the gastrointestinal tract, and although rare the rate of bleeding is 4 fold higher comparing to common varices. Likewise, treatment strategies have shown poorer outcomes than gastro-oesophageal. No cases have been reported in literature of the use of haemospray in ectopic varices.

Methods:

We present two cases of use of hemospray as a salvage therapy and their outcomes.

Results:

Case 1: 56 Year old female Alcoholic liver disease Child-Pugh C presented with a 4 day history of melena hypovolaemic shock.

Gastroscopy showed fresh blood in duodenum. Deeper D3 intubation showed a duodenal varix with a fibrin plug, treated with 10 ml of thrombin injection, still oozing so haemospray applied with good result. The patient rebled in less than 48 hours. TIPS was performed, with cessation of bleeding.

Case 2: 56 year old female with exact same background was admitted with increased jaundice. While admitted she had several episodes of rectal bleeding plus 4 point hemoglobin drop secondary to large rectal varices. Endoscopic thrombin injection x 5 seemed to stop the bleeding. 24 hours later another frank rectal haemorrhage observed. In new sigmoidoscopy, a persistent fibrin plug started bleeding. 19 ml thrombin applied but still minimal oozing which effectively stopped after hemospray.

Patient hb improved to baseline, however continued to drink and had further episode of bleeding in 3 months, resolved after TIPS insertion.

Conclusions:

In the 2 cases described, the salvage use of haemospray as a combined method was effective to provide inmediate hemostasis but did not contribute to achieve a definitive treatment as the underlying cause was still untreated.

Hemospray could potentially play a key role in contributing to stabilize the patient's haemodynamics, facilitating the treatment of reversible decompensating factors as well as a bridge towards definitive treatment.