S5286 Hemostatic Hydrogel in Gastric Variceal Management

Introduction: Gastric varices occur at a rate of 15%-20% and are often associated with higher bleeding rates and worse patient outcomes compared to esophageal varices. Treatment options include band ligation, cyanoacrylate injection, endoscopic ultrasound (EUS) guided coiling, or a combination therapy of coiling and cyanoacrylate (CYA). Here we use a hemostatic hydrogel, comprised of self-assembling peptides, in the treatment of gastric varices. Case Description: A 77-year-old woman with recent nonsteroidal anti-inflammatory drug overuse and cirrhosis without proper prior evaluation is admitted for 2 episodes of hematemesis and melenic stools. She was resuscitated with 2 units of packed red blood cells and CTA imaging showed no active bleeding. An esophagogastroduodenoscopy showed small non-bleeding grade 1 varices in the lower third esophagus and a larger type I isolated gastric varix with stigmata of recent hemorrhage. Initially, balloon-occluded retrograde transvenous obliteration (BRTO) was considered, however it was felt that the shunt was too small to intervene on. She underwent EUS which showed medium sized gastric varices with multiple collaterals but only 1 vessel in the submucosa measuring 7 mm in maximum diameter. The varix was punctured with a 19-gauge needle and an 8 mm coil was deployed in excellent position under direct visualization. Sclerosis was induced by a 3 mL intravariceal injection of hemostatic hydrogel with complete cessation of flow by doppler. After intervention, no further GI bleeding was noted in the days following. Discussion: There are several available treatment approaches to gastric varices, of which cyanoacrylate (CYA) injection is the most utilized. The most feared complication of CYA is systemic embolization either as a stroke or pulmonary embolus. Here, we presented the use of hemostatic hydrogel which consists of synthetic peptides with acidic properties that, once in contact with blood, are neutralized and form a fibrin-mesh. It is currently used for management of bleeding after endoscopic submucosal resection. By mimicking the human extracellular matrix, coagulation is induced and a physical seal is created with subsequent cessation of intravariceal blood flow. Some forms currently on the market utilize peptides such as the RADA16 peptide, which is a 16-amino acid chain naturally occurring in the body. Novel approaches such as this hemostatic hydrogel may provide a safer management technique compared to current standard of care after additional testing and comparison for validated use.