Endoscopic hemostasis of spurting colonic diverticular bleeding using the combination of self-assembling peptide solution and endoscopic band ligation

Self-assembling peptides (PuraStat; 3-D Matrix, Tokyo, Japan) are novel synthetic self-assembling peptides that are licensed for use as a hemostat [1]. The matrix forms an extracellular scaffold that is activated by the change in pH on contact with blood and generates a stable mechanical barrier over the bleeding site, thereby facilitating intrinsic in vivo hemostasis [2]. Self-assembling peptides are mainly used to induce hemostasis of oozing bleeding in endoscopic procedures [3]; their usefulness in colorectal diverticular bleeding has yet to be investigated. In this study, we report a case in which the combination of self-assembling peptide solution and endoscopic band ligation (EBL) were effective for endoscopic hemostasis of spurting bleeding from a colonic diverticulum ([Video 1]).

Video 1 Endoscopic hemostasis of spurting bleeding from a colonic diverticulum is achieved using the combination of self-assembling peptide solution and endoscopic band ligation.

The patient was a 66-year-old woman who had hypertension and a history of diverticular bleeding 20 years previously. She presented to our emergency room with massive bloody stools, a hemoglobin of 104 g/L, progressive anemia, and pallor, and underwent emergency colonoscopy. During this examination, we observed spurting bleeding from a diverticulum at the hepatic flexure ([Fig. 1 a]). We identified the diverticulum as the source of the bleeding in the red dichromatic imaging (RDI) mode and marked its vicinity with a clip. Next, 3 mL of the self-assembling peptide solution was injected into the diverticulum using a dispersal tube ([Fig. 1 b]). After the injection, the spurting bleeding gradually subsided and hemostasis was temporarily achieved ([Fig. 1 c]). We removed the scope, placed a band onto it, and reinserted it, with the diverticulum confirmed as the source of bleeding by locating the clip. Complete hemostasis was achieved via EBL ([Fig. 1 d]).The patient resumed eating the day after hemostasis had been achieved and was discharged 5 days later without any evidence of further bleeding or progression of anemia.

Fig. 1 Endoscopic images showing: a spurting bleeding from a diverticulum at the hepatic flexure; b self-assembling peptide solution being injected into the diverticulum using a dispersal tube under red dichromatic imaging (RDI) mode observation; c hemostasis temporarily achieved after the injection, as shown in the RDI mode; d the appearance following endoscopic band ligation, which successfully achieved complete hemostasis.

In this case, the self-assembling peptide solution temporarily stopped the spurting bleeding, making it easier to identify the bleeding point. Furthermore, the temporary hemostasis ensured a stable visual field, thereby permitting safe EBL to be performed.

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Publication History

Article published online:
09 February 2023

• References

• 1 Uraoka T, Ochiai Y, Fujimoto A. et al. A novel fully synthetic and self-assembled peptide solution for endoscopic submucosal dissection-induced ulcer in the stomach. Gastrointest Endosc 2016; 83: 1259-1264
• 2 Subramaniam S, Kandiah K, Chedgy F. et al. A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial. Endoscopy 2021; 53: 27-35
• 3 Yamamoto K, Sofuni A, Mukai S. et al. Use of a novel self-assembling hemostatic gel as a complementary therapeutic tool for endoscopic sphincterotomy-related bleeding. J Hepatobiliary Pancreat Sci 2022; 29: e81-e83