A 78-year-old woman, on rivaroxaban medication because of atrial fibrillation, was
referred to our department with upper gastrointestinal bleeding. Emergency esophagogastroduodenoscopy
(EGD) revealed multiple duodenal diverticula with oozing bleeding from inside a large
diverticulum near the papilla ([Fig. 1] and [Fig. 2]). Because of the location, clips were not applicable, hence injection of epinephrine
and later injection of fibrin glue were administered. In spite of these interventions,
signs of bleeding recurred. On the third day after admission, 10 g of Hemospray was
applied into the descending duodenum using a 10-Fr catheter ([Fig. 3] and [Fig. 4]). After several bursts of Hemospray, bleeding stopped. During control examination
1 day later, Hemospray had disappeared from the gastrointestinal tract, but bleeding
from the duodenal diverticulum had recurred. The remaining Hemospray was applied into
the diverticulum and bleeding subsided. An overview of hemoglobin level, endoscopic
interventions, and transfusions is shown in [Fig. 5]. Follow-up EGD 2 days later was unremarkable and the patient resumed an oral diet.
After discharge, no further bleeding occurred during a 30-day follow-up.
Fig. 1 Bleeding diverticulum in the descending duodenum of a 78-year-old woman on rivaroxaban
medication because of atrial fibrillation.
Fig. 2 Bleeding site (arrow) inside the diverticulum near the papilla.
Fig. 3 Application of Hemospray with a 10-Fr catheter (left) on the third day after admission.
Fig. 4 Ongoing bleeding (arrow) after the first Hemospray application. Bleeding subsided
after further Hemospray administration.
Fig. 5 Overview of hemoglobin level, endoscopic interventions, and transfusions. RCC, red
cell count.
Hemospray is an inorganic powder that has been shown to be effective in patients with
upper and lower gastrointestinal bleeding [1]
[2]
[3]. It is theoretically ideal to control diverticular bleeding because complete coverage
of the mucosal surface in the diverticulum can be achieved. In the literature, two
cases of Hemospray as primary therapy in duodenal diverticular bleeding have been
reported [2]
[3]. In both cases, Hemospray was unsuccessful and patients underwent rescue angiography.
Effective application of Hemospray into a diverticulum can be difficult, especially
if the diverticular orifice is small. In our case, full bleeding control was only
achieved after the second administration. Clinical experience with repeated Hemospray
applications is limited, however, in our patient this proved to be an effective treatment.
Anticoagulant therapy could have contributed to delayed bleeding control although
rivaroxaban had been stopped earlier.
In conclusion, Hemospray is a possible tool to achieve hemostasis in refractory diverticular
bleeding and might be an option to avoid surgery or angiographic interventions.
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