Combined Endoscopic and Surgical Treatment of Severe Gastrointestinal Bleeding in a Patient with Heart Assist Device under Therapeutic Anticoagulation

Gastrointestinal (GI) bleeding is a common complication after heart assist device placement. Reasons for bleeding are multifactorial. Endoscopic therapy is the treatment of choice, whereas invasive procedures are avoided in these critically ill patients. We present the case of a 65-year-old male patient experiencing severe GI bleeding after left ventricular assist device (LVAD) and right ventricular assist device (RVAD) placement with therapeutic anticoagulation. Endoscopically, multiple gastric bleeding sources were found but could not be treated effectively due to a large blood clot. A combined endoscopic and surgical treatment was initiated, including gastrotomy for blood clot removal, surgical transgastric suturing, endoscopic over-the-scope clip (OTSC) placement and hemospray application. Postoperative endoscopic visualization showed effective bleeding control. The patient unfortunately died due to causes unrelated to the treatment. This case shows that a minimal invasive combination of endoscopic and surgical techniques can be an alternative treatment for severe upper GI bleeding in critically ill and anticoagulated patients.

Uso de Hemospray® en sangrado post-escleroterapia / Use of Hemospray® in post-sclerotherapy bleeding

Resumen: Introducción: Hemospray® es un nuevo dispositivo para hemostasia endoscópica utilizado para el sangrado gastrointestinal no variceal. Permite la hemostasia mediante la activación plaquetaria y el aumento de la concentración de factores de coagulación, así como la formación de una barrera mecánica sobre la pared de un vaso sangrante creando un tapón mecánico en el sitio de sangrado. Dentro de las principales indicaciones para su uso se encuentran lesiones de difícil acceso endoscópico, hemorragia gastrointestinal masiva, múltiples sitios de sangrado, modificación de la anatomía por terapia endoscópica previa, presencia de coagulopatía, dificultad para tener visualización directa o cuando es imposible tener contacto con la lesión sangrante. Sin embargo, su uso en niños aún no ha sido aprobado por la FDA. Existe un caso publicado de un paciente de 11 meses tratado exitosamente con Hemospray® por hemorragia gastrointestinal no variceal. Caso clínico: Se reporta el caso de una paciente de 2 años con falla hepática aguda y cirrosis biliar primaria con hipertensión portal y sangrado post-escleroterapia. Se analizó el caso para sustentar las nuevas terapias para el control del sangrado masivo en úlceras post-escleroterapia. Conclusiones: La aplicación demostró ser segura y sin efectos adversos. El uso de Hemospray® es una alternativa efectiva en el control del sangrado gastrointestinal.

Abstract: Background: Hemospray® is a new device for endoscopic hemostasis used for non-variceal gastrointestinal bleeding. It enables hemostasis and platelet activation by increasing the concentration of clotting factors and forming a mechanical barrier on the wall of a bleeding vessel creating a mechanical plug at the site of bleeding. Within the main indications for use are: injuries with difficult endoscopic access, massive gastrointestinal bleeding, multiple bleeding sites, modification of the anatomy by previous endoscopic therapy, presence of coagulopathy, difficulty in having direct visualization or when it is impossible to have contact with the bleeding lesion. However, its use in children has not been approved yet by the FDA. There is a case report of an 11-month-old patient successfully treated with Hemospray® for non-variceal gastrointestinal bleeding. Clinical case: We report the case of a 2-year-old female with acute liver failure and primary biliary cirrhosis with portal hypertension and bleeding after sclerotherapy. We analyzed the case to support new therapies for massive bleeding control in post-sclerotherapy esophageal ulcers. Conclusions: The application showed to be safe without side effects. Using Hemospray® is an effective alternative in controlling gastrointestinal bleeding.