S4597 Endoscope Retention in Aftermath of Hemospray: A Unique Clinical Scenario

Introduction: Endoscopy is an essential tool in controlling upper gastrointestinal bleeding, permitting direct mapping and therapeutic intervention. Hemospray is a hemostatic powder that has shown strong potency in accomplishing hemostasis for gastrointestinal (GI) bleeds. It has been observed that Hemospray can attain around 90%-95% initial hemostasis in several situations. However, challenges can arise during endoscopic procedures, as presented in this case where the endoscope became lodged while applying hemospray, requiring the use of an innovative approach to assist in its removal. Case Description/Methods: A 43-year-old man presented with a 4-day history of vomiting and jaundice, along with 1 episode of blood-tinged vomitus. The patient reported binge drinking 8 cans of beer daily for the past 2 weeks. In the emergency department, the patient was noted to be hypotensive, tachycardiac and tachypneic. Laboratory tests were significant for thrombocytopenia, severe hyponatremia of 107 mmol/L, hypokalemia, elevated total bilirubin level of 13.5 mg/dL and elevated transaminases (aspartate aminotransferase 774 U/L, alanine transaminase 498 U/L and alkaline phosphatase level of 268 U/L). Shortly after admission, he experienced massive hematemesis, prompting transfusion, emergency endotracheal intubation and esophagogastroduodenoscopy (EGD) using a dual-channel endoscope. Endoscopic findings revealed a Mallory-Weiss tear at the distal esophagus. Hemostasis was achieved using hemostatic powder. However, difficulty was encountered in removing the dual-channel endoscope. The patient was administered rocuronium for paralysis and was turned from a supine to left lateral which aided in the successful retrieval of the endoscope after 3 minutes. A second-look EGD performed 24 hours later showed a healing Mallory-Weiss tear with an adherent clot and no evidence of active bleeding. Discussion: There are only a few case reports describing endoscope entrapment within the esophagus after Hemospray application to achieve hemostasis. In 1 report, the patient required admission to the intensive care unit for 48 hours before safe endoscope removal was possible. In another case, a bronchoscope was passed alongside the trapped endoscope, and the adhesions caused by the Hemospray were manipulated using a back-and-forth motion. Our case report offers an alternative management strategy, including paralysis and proper patient positioning, which resolved the issue within 3 minutes. We believe that documenting such case can contribute to a better understanding of the condition.