Haemostatic powder spray safely stops acute upper GI bleeds in children

The use of a powder agent, either as monotherapy or in combination with other conventional therapy, appears to be safe and effective for endoscopic haemostasis in children with acute upper gastrointestinal (GI) bleeding (UGIB), according to real-world data from Singapore.

Retrospective analysis of data from 23 paediatric patients (mean age 8 years, 56.5 percent boys) who were treated at KK Women's and Children's Hospital for acute UGIB showed that all of them achieved bleeding control following the application of haemostatic powder spray (100 percent). [JPGN Rep 2024;5:250-255]

Only three patients (13 percent) experienced rebleeding, which occurred within 72 hours in two and later in one. These patients had gastric ulcers, one with fungal gastropathy and underlying acute lymphoblastic leukaemia, one with underlying pancytopenia, and another with myelodysplastic syndrome and haematopoietic stem cell transplantation. In addition, significant thrombocytopenia was observed, ranging from 12 × 10⁹/L to 74 × 10⁹/L.

“An underlying haematologic disorder with significant thrombocytopenia … could be the key risk factor leading to reoccurrence of UGIB [in the cohort]. In our experience, the reapplication of [haemostatic powder spray] in conjunction with other conventional techniques … eventually [led to] haemostasis with no further rebleeds,” the investigators noted.

As for safety, all patients tolerated haemostatic powder spray applications with no adverse events.

“Topical haemostatic powders have emerged as a valuable tool due to its ease of use, applicability across various bleeding pathologies, and its potential to treat large areas in which the exact location of bleeding is unknown,” the investigators said.

“The findings of our audit support the use of [haemostatic powder spray] in the management of UGIB in children… Due to its ease of use, [the powder agent allows] for wider and more timely access to life-saving endoscopic therapy,” they added.

Of the paediatric patients included in the study, three had GI disorders, three had haematological diseases, one had metabolic disorder, one had neurological disease, and one had cardiac disease. UGIB was due to gastric ulcer in nine patients, erosive pangastritis in 10, duodenal ulcer in three, and oesophageal ulcer in one.

Twenty-one patients had haematemesis at presentation, with two having melaena only and seven having haemodynamic instability. Mean haemoglobin was 10.82 g/dL, and five patients had a haemoglobin drop of more than 2 g/dL.

Haemostatic powder was used as monotherapy in 16 patients. Five patients received fluid bolus for resuscitation, and 19 required blood transfusion. All patients received intravenous proton pump inhibitor (omeprazole 1 mg/kg/dose three times a day or esomeprazole 0.1 mg/kg/h continuous infusion) and enteral sucralfate before endoscopy, as part of institutional practice. Four patients received octreotide at 3 µg/kg/h due to bleeding severity.

Haemostatic powder as monotherapy

While guidelines generally discourage the use of haemostatic powder spray as a monotherapy, recent studies have shown promising results. In adult patients with peptic ulcers, haemostatic powder was found to be noninferior to conventional dual therapy in terms of achieving haemostasis and reducing rebleeding rates. Taking these data in consideration, the new American College of Gastroenterology guidelines make a conditional recommendation for the use of haemostatic powder as initial treatment for actively bleeding ulcers. [Endoscopy 2015;47:a1-a46; Ann Intern Med 2022;175:171-178; Gastrointest Endosc 2022;96:28-35.e1; Am J Gastroenterol 2021;116:899-917]

“In paediatric patients, monotherapy with haemostatic powder has been shown to be as effective as conventional approaches in the management of children with UGIB with no adverse events encountered. Similarly, the findings of our audit also support the efficacy and success of [the powder spray] as a monotherapy,” they added. [J Pediatr Gastroenterol Nutr 2018;67:e47-e50]

Beyond the use of haemostatic powder spray as monotherapy or in combination with other approaches, its feasibility in general may be limited by the size of endoscope, as a paediatric gastroscope will not allow therapeutic procedures to be performed, as the investigators pointed out.

“Notably, our youngest patient was a 4-month-old with a diagnosis of eosinophilic gastritis, with no rebleeding observed. Haemostatic powder spray was applied on the 4-month-old infant using a standard endoscope with an outer diametre of 8.9 mm and a working channel of 2.8 mm. This supports the use of haemostatic powder in young children, with the youngest of 2 days old recorded in [a] prospective study,” they continued. [J Pediatr Gastroenterol Nutr 2018;67:e47-e50]

Meanwhile, concerns of adverse events involve abdominal pain attributed to visceral distension from the carbon dioxide propellant and viscus perforation following use of haemostatic powder spray, “though in many cases it is difficult to discern whether the cause was [the powder], endoscope trauma, or friable tissue from the underlying condition,” the investigators noted. [Endosc Int Open 2022;10:E1136-E1146]

The real-world data presented in this retrospective study add to the growing literature on the efficacy and safety of haemostatic powder spray use in the paediatric population, they said, adding, however, that further research is necessary to confirm if the powder agent can be used as monotherapy, especially in children with actively spurting bleeding ulcers.