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We read with considerable interest the recent report by Ibrahim et al 1 on the use of haemostatic powder in addition to standard of care management for oesophageal variceal bleeding. The authors have performed a randomised controlled trial of early (<2 hours) application of haemostatic powder compared with ‘early’ elective endoscopy (performed at 12–24 hours) and found a significant improvement in the primary outcome, which was clinical haemostasis in the first 24 hours and endoscopic haemostasis at early elective endoscopy. The authors suggest that this very early control of bleeding could translate into improved survival, which was significantly better in the powder group although the trial was not powered for this outcome. The authors highlight that despite guidelines suggesting that endoscopy should take place as soon as possible after resuscitation and always within 12–24 hours, this target is often not achieved, primarily due to the lack of availability of endoscopists experienced in the control of variceal bleeding.2–4 The authors suggest that the use of powder, which is technically easier to apply, could address this issue and allow earlier control of bleeding as a temporising therapy pending definitive endoscopic therapy.
All attempts to improve quality and reduce variation in endoscopy for variceal bleeding are to be encouraged; however, there are a number of issues in the current report that invite comment. The first concerns the definition of clinical haemostasis. The authors define clinical haemostasis as a systolic blood pressure (BP) of >80 mm Hg and a heart rate of <100 beats per minute. There are problems with this definition as although the current Baveno consensus criteria lack a strict definition of haemodynamic shock, other studies have used systolic BP <90 mm Hg5 or <100 mm Hg6 as an indicator of failure to control bleeding. The selection of a systolic BP of >80 mm Hg may be too low to define clinical haemostasis, a notion that is confirmed by the finding in the current study that of the 30 patients fulfilling this definition all had evidence of active bleeding at the first endoscopy.
Second, the reported 5-day treatment failure rate (38%) and 6-week mortality (30%) in the control arm are high compared with other studies using the current standard of care. For instance, Conejo et al 7 reported a 6-week mortality of 17.2% in a cohort of 523 patients, whereas Seo et al 6 report a 5-day failure rate of 16% in a cohort of patients undergoing endoscopy and vasoactive therapy with octreotide. While the current study was not powered to show differences in survival, the unexpectedly high mortality especially in Child-Pugh C patients (90%) suggests that the proposed strategy of delayed endoscopy in those patients deemed to have clinical haemostasis according to the proposed definition could potentially be detrimental.
Novel techniques to control variceal bleeding such as haemostatic powder and self-expanding metal stents may have a role to play in the acute management of variceal bleeding and require further evaluation.8 However, we should not lose sight of the fact that the current standard of care applied according to published guidelines is very effective, and concerted efforts should be made to ensure that all hospitals accepting patients with variceal bleeding have access to timely endoscopy by experienced operators.
Contributors JM and JO’B conceived, drafted and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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