Fibrin Glue

In a large European multicenter trial of 854 patients (Rutgeerts et al, 1997) the recurrent bleeding rates were 15% in the group treated with repeated injection of fibrin glue (fibrinogen and thrombin) plus epinephrine, 19% in

TABLE 28-2. Sclerosants Available for Injection Therapy

Sclerosant

Dose

Method

Brand, Manufacturer

Polidocanol

Ethanolamine oleate 5%

W-butyl-2-cyanoacrylate

Sodium tetradecyl 3% sulfate

Absolute ethanol 98%

0.5 to 1.0 mL aliquots, 4 quadrant (max 5 mL of 1% solution) Needle primed with Lipiodol 0.5 mL + 0.5 mL Lipiodol

0.2 to 0.4 mL aliquots using a tuberculin syringe (maximum 2 mL)

Aethoxysklerol; Kreussler Pharma GmbH, Wiesbaden, Germany Histoacryl; Braun Melsungen, Germany Lipiodol; Byk Gulden, Konstanz, Germany the group treated with a single injection of fibrin glue plus epinephrine, and 23% in the group treated with injection of polidocanol plus epinephrine. The difference between the repeated injection of fibrin glue and polidocanol was statistically significant and there was a tendency towards less recurrent bleeding with repeated injection compared with single injection.

In Canada and the United States, fibrin glue kits are approved for surgery only and may not be used for injection into tissues or blood vessels due to the theoretical risk of thromboembolism. Other potential risks include anaphylaxis and transmission of viral infections. The latter may be eliminated in the future with recombinant fibrinogen and thrombin. A proposed advantage of fibrin glue in NVUGIB is less potential to injure tissues despite repeated use, although this has yet to be proved.

Commercially prepared fibrin glue kits include Beriplast P fibrin sealant (Centeon Pharma GmbH, Marburg, Germany [not available in Canada, USA]), Hemaseel (Hemacure, FL), and Tisseel Kit VH (Baxter, CA). The Tisseel Kit VH supplies human fibrinogen (made from pooled fresh frozen plasma) and bovine thrombin in separate vials. The fibrinogen is a freeze-dried powder that must be reconstituted by mixing it with a solution containing a fibrinolysis inhibitor (bovine aprotinin). The thrombin is also freeze-dried and must be reconstituted using a calcium chloride solution. The two reconstituted solutions are drawn into separate syringes.

To ensure that clot formation occurs only at the injection site Rutgeerts and colleagues (1997) used a special dual-lumen injector needle (eg, Endo-Flex GmbH, Voerde, Germany) to simultaneously apply the separate thrombin and fibrinogen solutions. Alternatively, the solutions may be delivered sequentially through a standard single lumen injector needle.

The US Food and Drug Administration restrictions and the aforementioned risks notwithstanding, widespread applicability of fibrin glue in the setting of acute UGI bleeding is open to question: the kits require refrigeration (2° to 8°C); the vials must be preheated to 37°C for approximately 10 minutes; mixing the solutions takes at least another 5 minutes; and the special dual-lumen injector needle ideally should be available for simultaneous application of the two solutions. The reconstituted solutions can be kept in their vials or syringes for up to 4 hours.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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