Hemostatic Powders in Non-Variceal Upper Gastrointestinal Bleeding: The Open Questions

Abstract

Hemostatic powder (HP) is a relatively recent addition to the arsenal of hemostatic endoscopic procedures (HEPs) for gastrointestinal bleeding (GIB) due to benign and malignant lesions. Five types of HP are currently available: TC-325 (Hemospray™), EndoClot™, Ankaferd Blood Stopper®, and, more recently, UI-EWD (NexpowderTM) and CEGP-003 (CGBio™). HP acts as a mechanical barrier and/or promotes platelet activation and coagulation cascade. HP may be used in combination with or as rescue therapy in case of failure of conventional HEPs (CHEPs) and also as monotherapy in large, poorly accessible lesions with multiple bleeding sources. Although the literature on HP is abundant, randomized controlled trials are scant, and some questions remain open. While HP is highly effective in inducing immediate hemostasis in GIB, the rates of rebleeding reported in different studies are very variable, and conditions affecting the stability of hemostasis have not yet been fully elucidated. It is not established whether HP as monotherapy is appropriate in severe GIB, such as spurting peptic ulcers, or should be used only as rescue or adjunctive therapy. Finally, as it can be sprayed on large areas, HP could become the gold standard in malignancy-related GIB, which is often nonresponsive or not amenable to treatment with CHEPs as a result of multiple bleeding points and friable surfaces. This is a narrative review that provides an overview of currently available data and the open questions regarding the use of HP in the management of non-variceal upper GIB due to benign and malignant diseases.

Ideal strategy for nonvariceal upper gastrointestinal bleeding

“…Endoscopic hemostasis can be performed for Mallory-Weiss tears with major endoscopic stigmata of recent hemorrhage though there is inadequate evidence to recommend a specific modality [4]. As topical hemostatic agents can be applied across a large surface area, they have the potential to become the gold standard in treating GI bleeding due to malignancy [50]. Thermal and mechanical endoscopic therapy or combination therapy with epinephrine injection along with contact thermal or mechanical therapy can be used to achieve hemostasis for Dieulafoy lesions [4].…”

“…The use of topical hemostatic agents can be quite effective at inducing immediate hemostasis in UGIB secondary to malignant bleeding. As these agents can be applied across a large surface area and are relatively easy to use, they have the potential to become the gold standard in GI bleeding due to malignancy [50].…”

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

“…Additionally, efficacy in nonbleeding lesions is limited, as the powder primarily adheres to blood. Washing the lesion site or cleaning the lens post-spray is also not recommended, as it may wash away the powder[ 27 , 28 , 32 ].…”