An 80-year-old man with alcoholic liver cirrhosis and obstructed jaundice due to a
large pancreatic pseudocyst was referred for endoscopic ultrasound (EUS)-guided cystogastrostomy.
A computed tomography scan of the abdomen confirmed a 20-cm pancreatic pseudocyst,
which was compressing the stomach and biliary tree, as well as a moderate amount of
ascites and portal thrombosis with signs of portal hypertension [1]. The platelet count was 70 000/mm3. EUS confirmed the large pseudocyst adhering to the stomach wall. Cystogastrostomy
was performed, and a double pigtail catheter (10 Fr, 10 cm) was placed across the
gastrocystic fistula.
After 10 hours, the patient complained of severe hematemesis with a significant drop
in hemoglobin. Emergency endoscopy revealed a large amount of blood and clots in the
gastric fundus, with active bleeding from a vessel in the margin of the gastric fistula
([Fig. 1]). The catheter was not visualized and the fistula appeared to be closed. Adrenalin
and fibrin glue were injected with an apparent cessation of bleeding; however, 4 hours
later, the patient experienced two episodes of hematemesis of large amount of fresh
blood. A second endoscopy was performed and confirmed the active bleeding. A decision
was made to apply Hemospray (Cook Medical, Winston Salem, North Carolina, USA), which
resulted in immediate hemostasis ([Fig. 2] and [Fig. 3], [Video 1]). The patient recovered well and no further episodes of bleeding occurred.
Fig. 1 Active bleeding from a vessel in the margin of the gastric fistula.
Fig. 2 Endoscopic treatment with Hemospray.
Fig. 3 Immediate hemostasis after Hemospray treatment.
Active bleeding from a vessel in the margin of the gastric fistula was treated by
application of Hemospray, which resulted in immediate hemostasis.
Hemospray acts by forming a barrier over the bleeding site and increasing local concentration
of clotting factors [1]. Its efficacy has been shown in peptic ulcer bleeding [2], in cancer-related gastrointestinal bleeding, and in patients undergoing antithrombotic
therapy [3]
[4]. These initial reports are very promising in terms of initial hemostasis and rates
of rebleeding, but are limited by the small number of published cases.
In the present case, Hemospray was used for very severe bleeding after cystogastrostomy
in a patient with liver cirrhosis and portal hypertension, and the need for additional
endoscopic or radiologic treatments was obviated simply by spraying the material onto
the bleeding vessel.
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