Abstract
Background
Endoscopic assessment of gastric bleeding is essential for timely investigation and evaluation in attempting to resolve bleeds. Increasingly, endotherapy is used to stop bleeds to prevent the patient from progressing to surgery. The tools available for the endoscopist can be broadly broke into injection sclerotherapy, mechanical tamponade, thermal methods and Hemospray©. Each method has their own inherent advantages and disadvantages with indications for use.
Aims
Unfortunately, patients fail despite standard endotherapy and would then be subjected to surgical procedures. Fibrin glue injection has been selectively described in case reports to resolve recalcitrant bleeds. We have reviewed endotherapy cases by one surgeon where fibrin glue was used to resolve recalcitrant upper gastrointestinal bleeding in a variety of clinical presentations. The goal was to show that endotherapy application of fibrin glue can be used to resolve challenging GI bleeds.
Methods
A retrospective review was made from one surgeon records of endoscopic bleed resolution with fibrin glue from 2010 to 2018. Indications for the procedure were gastric bleeds in hospital, emergency department, or undergoing endoscopic procedures that resulted in a heavy bleed. Patients were categorized as high risk using the Rockall score and those with known ulcers ertr graded as Forest Ia. The patients were of a variety of ages, sex, and had differing co-morbid medical conditions. The fibrin product used was Tisseel which is a two-component fibrin sealant and was deployed using a standard endoscopic Injection sclerotherapy needle.
Results
In all but one of the patients, hemostasis had been reached by delivering fibrin glue by endoscopy. The patient that failed treatment had multiple co-morbidities and the bleeding source was a gastric bed of venous malformations. Patients were followed up with next day scoping to confirm bleed hemostasis. No adverse reactions were noted.
Conclusions
Studies have shown in the past that fibrin glue has worked in achieving hemostasis and had a lower rate of re-bleeding. There are several advantages to using the biological process of the clotting system. The fibrin mat will stay localized and not spread into the lesion. Fibrin injection also creates the natural meshwork of normal biological healing. This naturally compress the mat meshwork along the wound and promote hemostasis. Fibrin glue can also be re-applied in the case of a site re-bleed. Treating endoscopically can beneficial in that patients may not need to progress to the risks and recovery times of surgery. Utilizing the biological process of the body allows for natural repair and degradation of the clot. The procedure is well tolerated and had showed no side effects in this review. Our findings support the use of fibrin glue injection endotherapy as a last resort before surgical intervention.
Funding Agencies
None
A182 LAST RESORT – RESOLVING REFRACTORY UPPER GI BLEEDS WITH ENDOSCOPIC APPLICATION OF FIBRIN GLUE