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TC-325 application leading to transient obstruction of a post-sphincterotomy biliary orifice.

TC-325 (Hemospray, Cook Medical Inc., Bloomington, Indiana, USA), a novel endoscopic hemostatic powder has been approved in many countries for nonvariceal gastrointestinal bleeding. It consists of a proprietary inorganic powder, which, when put in contact with moisture, becomes coherent and adhesive, creating a mechanical barrier and effecting hemostasis. Preliminary results in benign and malignant upper and lower gastrointestinal bleeding are promising [1–4]. Optimal indications and technical limitations are still being characterized [5]. We recently treated a patient presenting with hematemesis 12 hours after choledocholithiasis removal, in whom endoscopy confirmed oozing from the sphincterotomy site. Hemostasis occurred immediately following application of 5g (1/4 canister) Hemospray; however, resulting arrest of bile flow and caking of the orifice with the powder were noted. Biliary patency was quickly restored with vigorous water irrigation and prodding open of the papillotomy orifice with a sphincterotome tip; prolonged hemostasis was achieved with epinephrine injection. Subsequent follow-up at 4 months after the procedure did not reveal any clinical stigmata of gastrointestinal bleeding (●" Fig.1). TC-325 appears highly effective in achieving initial hemostasis [1–5], yet technical difficulties related to the first-generation delivery system have included blockage of the10-Fr catheter or the accessorychannel of theendoscope if there ispremature contact with moisture. Initial flushing of the accessory channel with air using a syringe before introduction of the catheter is thus recommended. Additional limitations include kinking of the delivery system’s soft catheter sheath when the endoscope is looped or positioned over a duodenoscope elevator. Recently, 7-Fr and 10-Fr catheters have been marketed as part of a secondgeneration delivery system. TC-325 powder application so far appears quite safe, withno reportedbowelobstructionor systemic embolization [1–5]. Here we have reported transient biliary obstruction following successful use of Hemospray in post-sphincterotomy hemorrhage. Caution should therefore be taken when applying hemostatic powders near small orifices adjacent to the bowel lumen.