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

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.

Efficacy of hemostatic powders as monotherapy or rescue therapy in gastrointestinal bleeding related to neoplastic or non-neoplastic lesions.

BACKGROUND: Hemostatic powder (HP) in gastrointestinal bleeding (GIB) is mainly used as rescue therapy after failure of conventional hemostatic procedures (CHP). AIM: To define the best field of application and the efficacy of HP as first choice monotherapy or rescue therapy. METHODS: We compared the efficacy of HP monotherapy, HP rescue therapy, and CHP in the management of active GIB due to neoplastic and non-neoplastic lesions. RESULTS: A total of 108 patients, 43 treated with HP as either first choice or rescue therapy and 65 with CHP, were included in the study. The most frequent sources of bleeding were peptic ulcer and malignancy. Immediate hemostasis rates were: HP monotherapy = 100% in peptic ulcer and 100% in malignancy; HP rescue therapy = 93.2% in peptic ulcer and 85.7% in malignancy; CHP = 77.9% in peptic ulcer and 41.7 in malignancy. Definitive hemostasis rates were: HP monotherapy = 50% in peptic ulcer and 45.5% in malignancy; HP rescue therapy = 73.3% in peptic ulcer and 85.7% in malignancy; CHP = 69.1% in peptic ulcer and 33.3% in malignancy. No difference was found in terms of additional intervention between the three groups. CONCLUSIONS: HP is highly effective as monotherapy and rescue therapy in GIB. GIB related to malignancy may be the best field of application of HP, but confirmatory studies are necessary.

Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: Using propensity score matching.

BACKGROUND AND AIM: Recently, the application of hemostatic powder to the bleeding site has been used to treat active upper gastrointestinal bleeding (UGIB). We aimed to assess the effectiveness of the polysaccharide hemostatic powder (PHP) in patients with non-variceal UGIB. METHODS: We reviewed prospectively collected 40 patients with UGIB treated with PHP therapy between April 2016 and January 2017 (PHP group) and 303 patients with UGIB treated with conventional therapy between April 2012 and October 2014 (conventional therapy group). We compared the rate of successful hemostasis and the rebleeding between the two groups after as well as before propensity score matching using the Glasgow-Blatchford score and Forrest classification. RESULTS: Thirty patients treated with the PHP and 60 patients treated with conventional therapy were included in the matched groups. Baseline patient characteristics including comorbidities, vital signs, and bleeding scores were similar in the matched groups. The rate of immediate hemostasis and 7-day and 30-day rebleeding were also similar in the two groups before and after matching. In the subgroup analysis, no significant differences in immediate hemostasis or rebleeding rate were noted between PHP in monotherapy and PHP combined with a conventional hemostatic method. At 30 days after the therapy, there were no significant PHP-related complications or mortality. CONCLUSIONS: Given its safety, the PHP proved feasible for endoscopic treatment of UGIB, having similar effectiveness as that of conventional therapy. The PHP may become a promising hemostatic method for non-variceal UGIB.

Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review.

Despite the recent advances in endoscopic hemostatic techniques, the management of lower gastrointestinal bleeding could be sometimes challenging. Hemostatic powders such as Hemospray, EndoClot, and Ankaferd Blood Stopper have found their way into digestive endoscopy and are licenced in many countries especially for use in upper gastrointestinal bleeding. We reviewed the literature on the use of these hemostatic powders in different situations in lower gastrointestinal bleeding and looked at the success rate and rebleeding rate. Most of the data are derived from case reports, retrospective and prospective case series with absence of any randomized controlled trials. Hemostatic powders were used as primary or salvage therapy to control bleeding from polypectomy site, colonic tumors, diverticula, arteriovenous malformations, radiation proctitis, ischemic colitis, and surgical intestinal anastomosis. The rate of immediate control of bleeding is in the range of 88-100% with a recurrence rate of 3-13% except for radiation proctitis bleeding where rebleeding rate can be as high as 77%. Although there are many advantages for the use of local hemostatic agents in lower gastrointestinal bleeding, future randomized controlled trials comparing them with conventional methods are needed.

Efficacy of hemostatic powders in upper gastrointestinal bleeding: A systematic review and meta-analysis.

BACKGROUND: There is limited evidence on the efficacy of hemostatic powders in the management of upper gastrointestinal bleeding. AIMS: Provide a pooled estimate of the efficacy and safety profile of hemostatic powders in digestive endoscopy. METHODS: A computerized bibliographic search on the main databases was performed through December 2018. Pooled effects were calculated using a random-effects model. The primary outcome was immediate hemostasis rate. Secondary outcomes were rebleeding rate (either at 7 and 30 days), bleeding-related mortality, and all-cause mortality rate. RESULTS: A total of 24 studies, of which three were randomized-controlled trials, with 1063 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95.3% (93.3%-97.3%) of patients, with no difference based on treatment strategy, hemostatic agent used, bleeding etiology. Success rate was slightly lower in spurting bleeding (91.9%). Hemostatic powders showed similar efficacy as compared to conventional endoscopic therapy (odds ratio: 0.84, 0.06-11.47; p = 0.9). Thirty-day rebleeding rate was 16.9% (9.8%-24%) with no difference in comparison to other endoscopic treatments (odds ratio 1.59, 0.35-7.21; p = 0.55). All-cause and bleeding-related mortality rates were 7.6% (4%-10.8%) and 1.4% (0.5%-2.4%), respectively. CONCLUSION: Novel hemostatic powders represent a user-friendly and effective tool in the management of upper gastrointestinal bleeding.

Comparison of Hemospray® and Endoclot™ for the treatment of gastrointestinal bleeding.

BACKGROUND: Gastrointestinal (GI) bleeding is a common indication for endoscopy. For refractory cases, hemostatic powders (HP) represent "touch-free" agents. AIM: To analyze short term (ST-within 72 h-) and long-term (LT-within 30 d-) success for achieving hemostasis with HP and to directly compare the two agents Hemospray (HS) and Endoclot (EC). METHODS: HP was applied in 154 consecutive patients (mean age 67 years) with GI bleeding. Patients were followed up for 1 mo (mean follow-up: 3.2 mo). RESULTS: Majority of applications were in upper GI tract (89%) with following bleeding sources: peptic ulcer disease (35%), esophageal varices (7%), tumor bleeding (11.7%), reflux esophagitis (8.7%), diffuse bleeding and erosions (15.3%). Overall ST success was achieved in 125 patients (81%) and LT success in 81 patients (67%). Re-bleeding occurred in 27% of all patients. In 72 patients (47%), HP was applied as a salvage hemostatic therapy, here ST and LT success were 81% and 64%, with re-bleeding in 32%. As a primary hemostatic therapy, ST and LT success were 82% and 69%, with re-bleeding occurring in 22%. HS was more frequently applied for upper GI bleeding (P = 0.04). CONCLUSION: Both HP allow for effective hemostasis with no differences in ST, LT success and re-bleeding.