Post written by Stuart K. Amateau, MD, PhD, from the Division of Gastroenterology and Hepatology, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA.

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States and occasionally patients exhibit refractory bleeding despite standard endoscopic therapy. Although used internationally for the last 5 years, the U.S. FDA only recently approved a hemostatic spray device for clinical use in non-variceal gastrointestinal bleeding. Despite its efficacy, not all endoscopy units have access to this device, at times due to cost. In this case series, we demonstrate successful treatment of active ulcer and necrotic cavity bleeding utilizing an absorbable and affordable hemostatic powder (Arista™) dispersed through a system constructed from readily available accessory components.

While this case series demonstrates a specific technique for endoscopic management of challenging and or refractory bleeding, the critical message involves viewing our field’s technical limitations as hurdles rather than boundaries. Frequently, minimal framework exists to facilitate collaboration and communication with specialties outside of our own. Our organization’s infrastructure affords us a unique advantage of working side by side with our surgeons in the operating room, often collaboratively and in tandem, in an attempt to maximize care. We observed our colleagues’ use of an alternative hemostatic powder, and the challenge was then narrowed to the construction of a deployment system. The powder’s supplied application device had both length and caliber limitations, both of which were addressed by use of the 9F outer sheath of a widely popular stent instruction system. Indeed, challenges remained, including distal catheter occlusion and optimization of application; however, these were readily addressed by initial trial and error and subsequent minor technical adjustments.

Providing state of the art care to improve and extend the lives of our patients remains central to everything we do as gastroenterologists. While we must recognize our personal limitations, we should continue to actively pursue alternative, creative options to expand our ability to manage endoscopic disease, asking ourselves ‘how can we do this?’ rather than telling ourselves ‘it can’t be done!’

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