P0469 - An Unconventional Treatment Modality for Persistent Hematochezia in the Setting of Radiation Proctitis

Sean Sullivan, DO¹, Alexander G. Pop, MD¹, Ashley Davis, MD², Michael Goldberg, DO¹, Richard Kalman, MD^2
1Einstein Healthcare Network, Philadelphia, PA; ²Albert Einstein Medical Center, Philadelphia, PA

Introduction: Chronic radiation proctitis results from progressive epithelial atrophy and fibrosis associated with obliterative endarteritis and chronic mucosal ischemia. Symptoms may occur any time between 9 months to 30 years after radiation exposure. The most common manifestation is radiation-associated vascular ectasia (RAVE) resulting in bleeding and iron deficiency. Endoscopy remains the mainstay of diagnosis for RAVE; often showing edematous, erythematous mucosa with ulceration or sloughing with the hallmark feature being vascular ectasias. Treatment includes argon plasma coagulation (APC), bipolar electrocoagulation (BiCAP)and clips. The use of hemostatic powder such as Hemospray^TM has been studied mainly in cases of upper gastrointestinal bleeding but there is little data on its efficacy in the management of bleeding due to RAVE.

Case Description/Methods: We present a case of a 69-year-old man with a medical history of prostate cancer treated with radiation and brachytherapy 3 years prior, radiation proctitis with recurrent episodes of lower gastrointestinal bleeding, and cryptogenic cirrhosis presenting with hematochezia. Vital signs were stable, and hemoglobin was 8 g/dL. Rectal exam yielded hematochezia. During his hospital course he continued to have hematochezia that worsened after initiation of dual anti-platelet therapy (DAPT) for percutaneous coronary intervention with stent placement. He underwent colonoscopy and multiple flexible sigmoidoscopies revealing RAVE that was initially treated with APC, then by BiCAP, and ultimately clips without resolution. Given the continued bleeding, the decision was made to use Hemospray^TM in an effort to decrease blood loss during the 2 weeks the patient required DAPT. Utilization of this treatment resulted in the patient requiring fewer blood transfusions.

Discussion: Hemostatic powders were recently approved for endoscopic use in the US. They act by binding to actively bleeding sites and absorbing water and blood, then adhering to the bleeding site to act as a bandage over the hemorrhagic lesion. Most of the original studies involved nonvariceal upper GI bleeding, but there are few cases of it being used for bleeding due to RAVE. One disadvantage is that it washes out after 12-24 hours, so it may not be well adapted to treating lesions with risk of delayed rebleeding. In this case however, after conventional methods failed, it was a promising tool for treating bleeding secondary to RAVE especially in a case complicated by the need for DAPT.


Figure: Rectum before and after application of HemosprayTM


Disclosures:
Sean Sullivan indicated no relevant financial relationships.
Alexander Pop indicated no relevant financial relationships.
Ashley Davis indicated no relevant financial relationships.
Michael Goldberg indicated no relevant financial relationships.
Richard Kalman indicated no relevant financial relationships.


Sean Sullivan, DO¹, Alexander G. Pop, MD¹, Ashley Davis, MD², Michael Goldberg, DO¹, Richard Kalman, MD². P0469 - An Unconventional Treatment Modality for Persistent Hematochezia in the Setting of Radiation Proctitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.