PHP a promising alternative to endoscopic clip for post-EST bleeding

In patients with postendoscopic sphincterotomy (post-EST) bleeding, polysaccharide hemostatic powder (PHP) demonstrates noninferiority to endoscopic clip in the management of post-EST bleeding and is easier to use, reports a study.

“It can be considered not only as an alternative to current treatment modalities but also as a salvage therapy when standard approaches fail,” the investigators said. “PHP is safe for patients and easy for clinicians to use.”

In this study, the investigators randomized 104 eligible patients with nonpulsatile post-EST bleeding to receive either PHP or endoscopic clips. The immediate hemostasis rate was the primary endpoint, while secondary ones included delayed bleeding rate, overall treatment success rate, mean hemostasis time, and other major complications.

All patients in the PHP group achieved the primary endpoint (100 percent) compared with 92.3 percent of those in the endoscopic clip group (risk difference, 7.7 percent, 95 percent confidence interval, 0.5‒15.0; p=0.022). Four patients who received endoscopic clip had immediate hemostasis failure. [Am J Gastroenterol 2026;121:233-241]

A shorter hemostasis time was noted in the PHP group (50.77 vs 62.81 s; p=0.011). None of the patients who received PHP, compared with one in the clip group (2.1 percent), experienced delayed bleeding.

“Previous studies on PHP for gastrointestinal bleeding also suggest a potential for reduced rebleeding,” the investigators said. [J Gastroenterol Hepatol 2018;33:1500-1506]

“A vitro study shows the gel formed after PHP application has strong adhesive properties and allow it to remain on the wound, sealing it, promoting mucosal healing, and therefore reducing delayed bleeding,” they added.

Moreover, the overall treatment success rate was higher in the PHP vs the endoscopic clip group (100 percent vs 90.4 percent; p=0.022). Adverse events did not differ between the two arms.

“PHP is a promising tool for managing post-EST bleeding,” the investigators said. “Its noncontact nature is particularly advantageous in cases with complex anatomy or unclear visual fields that may not be suitable for standard targeted therapies.”

Low cost

Apart from its efficacy and ease of use, PHP is also inexpensive. In China, PHP costs 113 RMB (16 USD) per application prereimbursement, which is much lower than 260 RMB (37 USD) for clips.

“In addition, as a class A reimbursable drug, PHP entails a lower patient copayment ratio compared with clips, which are categorized under Class B reimbursement,” the investigators said. “This cost advantage enhances the accessibility of PHP, particularly in resource-limited settings, helping it become a practical first-line option.”

Notably, clip slippage during retrograde cholangiopancreatography (ERCP), especially when applying endoscopic clips to arrest bleeding, poses a major concern. [Dig Dis Sci 2015;60:168-173]

In the current study, four patients had clip slippage during deployment. The clips were reapplied successfully, but this prolonged procedure and increased the cost of treatment, according to the investigators.

“[L]arger-scale studies are needed to validate [the effectiveness of PHP] across diverse endoscopic ERCP indications and in preventing delayed bleeding after EST,” they said.