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Inside Tract - For bleeding ulcers: The great equalizer
For bleeding ulcers: The great equalizer
Date: November 15, 2011
Why does Murphy’s Law pull in the patients with really difficult bleeding ulcers after hours, just as the least experienced endoscopist is on call, assisted by the youngest nurse on the team?
A European physician posed that question in a journal recently, pointing out the weak link in otherwise good standard care for what can be a life-threatening condition.
Endoscopy has proved its worth for all varieties of upper GI “bleeds” that nature throws at it, says Patrick Okolo, who’s performed hundreds of the procedures. “But it’s clear that the technique is operator-dependent and can require great dexterity and skill,” he says. Large spurting vessels in the posterior duodenal wall, for example, or bleeding ulcers in upper reaches of the lesser gastric curvature can test any clinician’s mettle.
To compound things, Okolo says, “We’re seeing more patients on anticoagulants for heart disease. So more people have ulcers that bleed,” he adds, “and when they do, they bleed more profusely.”
It’s a problem that could worsen as baby boomers age.
This spring’s report in the journal Endoscopy, however, highlights what may be a strong alternative to usual care for bleeding ulcers. Okolo and a Hopkins team partnered with industry and gastroenterologists in Hong Kong* for the first clinical trial of a powder that, when sprayed on the ulcers, rapidly cut hemorrhage short.
Twenty patients with significant GI bleeding participated in the safety and efficacy trial of Hemospray, the directed, airborne nano-sized particles of a mineral compound dubbed TC-325 by its industry source.
The particle powder seals ulcers both by dehydrating surface blood and by boosting natural platelet-based clotting.
“We achieved bleeding control in 95 percent of patients,” says Okolo—all except one man with a pseudoaneurysm, something best handled surgically anyway. The trial followed promising studies in pigs. “We were impressed,” Okolo adds, “that even severe bleeds were staunched in the animals.”
The work began, he explains, after colleague Samuel Giday mused that Hopkins might try topical powder-based methods the U.S. military uses on the battlefield to treat wounds. “We thought they might be appropriate for arterial bleeding in the GI tract,” says Okolo.
“The challenge, though, was to adapt them for internal use.”
What’s resulted is an endoscopic setup in which a small, handheld carbon dioxide canister delivers bursts of Hemospray via a catheter aimed at, but not touching, the bleeding artery. Within two days, animal studies show, the inert covering sloughs off and leaves the gut naturally.
Key questions still remain, mostly concerning venous application. But for now, Okolo says, the technique looks user-friendly and requires that endoscopists display “only moderate dexterity.”
Call it the Great Equalizer.
* Clinicians at the Chinese University of Hong Kong also took part in the research.