Hemostasis: Role of PuraStat® in the prevention and management of gastrointestinal bleeding

Table 1 Limitations and disadvantages of methods used in endoscoping therapy of gastrointestinal bleeding

Endoscopic therapy method		Limitations/disadvantages	Ref.
Injection therapy	Epinephrine	May cause systematic effects on the cardiovascular system including hemodynamic changes. Comparing injecting actively bleeding ulcers at endoscopy with epinephrine alone or in combination with absolute alcohol shows initial hemostasis in 97.5% with epinephrine and 94.9% in the combination group. No significant differences between the groups in rebleeding (9 vs 6), emergency surgery (12 vs 9), transfusion needs, hospital stay (5 days vs 4 days), mortality (94 vs 7), or ulcer healing at 4 weeks (50 days vs 46 days). Systematic changes including severe hypertension, and ventricular tachycardia, following epinephrine injection. Endoscopic injection of a small volume (3-11 mL) of diluted epinephrine caused a rise in the plasma epinephrine concentration by 4-5 times above the basal level. Hypertensive emergency and ventricular tachycardia were reported. Rebleeding has been reported (10%-20%)	Schlag et al[31], Chung et al[32], von Delius et al[33], Sung et al[34], Stevens et al[35]
	Normal saline	Less effective compared to injecting epinephrine. It is usually used in patients with coronary artery disease. It may act by producing primary tamponade. It has no vasospasm effect. Rebleeding usually occurs if used alone	Pinkas et al[23]
	Sclerosant (e.g., polidocanol, ethanolamine, ethanol)	Polidocanol is not commonly used. It has no benefits over epinephrine. The incidence of complications from sclerotherapy vs banding in patients with esophageal varices were: Esophageal stricture formation 25.6% vs 1.9%, ulcer bleed 25.4% vs 5.7%, esophageal perforation 2.2% vs 0%, and massive esophageal hematoma 16% vs 0%	Bataller et al[36], Schmitz et al[37]
Ablation therapy	Thermotherapy and electrotherapy	Higher rebleeding rates after the use of contact thermal therapy for gastrointestinal-related tumor bleeding, despite initial successful hemostasis	Ofosu et al[38]
	APC	Endoscopic APC for treating hemorrhagic radiation proctitis was successful (79%), patients had self-limiting early complications (18.7%), late complications of rectal stenosis (3.3%). Depth of injection is unpredictable and may fail to stop bleeding	Siow et al[39]
	Laser phototherapy	Is becoming obsolete. A higher risk of gastrointestinal perforation. Less effective in stopping bleeding compared to other methods	Kay et al[29]
Mechanical therapy	Endoscopic clipping band ligation	Requires highly skilled endoscopist. Applications of the clips can be difficult with massive bleeding. Sometimes clips dislodge prematurely causing recurrent bleeding	Ji et al[30]

APC: Argon plasma coagulation.