Successful Hemospray treatment for recurrent diclofenac-induced severe diffuse lower gastrointestinal bleeding avoiding the need for colectomy.

Endoscopic hemostasis is difficult to obtain in diffuse bleeding from broad lesions in the colon. Hemospray (Cook Medical, Limerick, Ireland) is a mineral-based granular powder that absorbs water and activates the clotting cascade [1]. It is approved for nonvariceal upper gastrointestinal bleeding [2] but, other than in Canada, it is not approved for use in the lower gastrointestinal tract. In the case reported here, Hemospray was used as a “last-resort” therapeutic option to avoid an emergency colectomy. A 66-year-old woman with no previous history of gastrointestinal bleeding presentedwith a severe episode of lower gastrointestinal bleeding (drop in hemoglobin from 13.1g/dL to 7.9g/dL) 6 days after total hip replacement. Her medication included nonsteroidal anti-inflammatory drugs (NSAIDs) in the form of diclofenac 50mg three times daily and a proton pump inhibitor (PPI). Colonoscopy revealed a blood-filled lower gastrointestinal tract with diffuse active bleeding in the right hemicolon and cecum from multiple broad, superficial ulcers (●" Fig.1a). The endoscopic appearance was compatible with ischemic or NSAID-associated colonopathy. Because there was a lack of reasonable alternative endoscopic therapies, we used Hemospray in the cecum and ascending colon with the aim of avoiding the need for the patient to undergo an emergency hemicolectomy. Bleeding was controlled immediately (●" Fig.1b). Recurrent colorectal bleeding occurred 2 days later. Repeat colonoscopy showed surprisingly well-healed fibrin-covered ulcers and mucosal inflammation in the cecum (●" Fig.1c) and ascending colon. However, diffuse active bleeding was found from multiple superficial ulcers in the transverse colon that had not been present 2 days earlier (●" Fig.1d). We decided to treat again with Hemospray.