Endoscopic Application of Tranexamic Acid and Sucralfate in Gastrointestinal Tumor Bleeding: A Randomized Controlled Trial

Background Gastrointestinal bleeding is a common disease among the population in Taiwan, with gastrointestinal tumor bleeding accounting for 3-5% of cases. The pathophysiology of gastrointestinal tumor bleeding is unique, involving fragile surface mucosa, abnormal vascular proliferation, and malformation, making endoscopic hemostasis challenging. Conventional endoscopic hemostasis methods such as hemostatic injections, clips, or thermal coagulation have suboptimal success rates below 80%, with recurrence rates exceeding 50%. Recent clinical trials have demonstrated that hemostatic powder spraying effectively enhances hemostasis for gastrointestinal ulcers and reduces recurrence rates. Our previous research repurposed tranexamic acid in a powder form to enhance hemostasis for peptic ulcer and applied sucralfate powder to prevent postpolypectomy wound bleeding. Study aim Our research team combines previous experience by using tranexamic acid and sucralfate drug powders to spray onto bleeding gastrointestinal tumors to achieve hemostatic effects. Additionally, tumor-derived exosomes are associated with tumor angiogenesis and growth, so we hypothesize that gastrointestinal tumor bleeding may be linked to VEGF and miR-21 expression within gastrointestinal tumor exosomes. Study method This study is a clinical randomized controlled trial conducted at National Cheng Kung University Hospital. We will recruit 60 patients with gastrointestinal tumor bleeding undergoing endoscopic hemostasis. Patients in the experimental treatment group will receive additional topical administration of 1.5 g of tranexamic acid and 3 g of sucralfate drug powder. Immediate hemostasis and 30-day bleeding recurrence will be observed. Enrolled patients will also provide blood and tumor specimens for exosome analysis, evaluating the predictive effect of extracted tumor exosomes' VEGF and miR-21 on bleeding risk. This study will explore the association between specific tumor exosome expression levels and bleeding, serving as a basis for bleeding risk assessment and innovative therapies.

Upper gastrointestinal (GI) cancer bleeding is a challenging scenario in clinical practice, including esophageal cancer, gastric cancer, and duodenal cancer. Upper GI cancer bleeds because the growing tumor erodes into the gastrointestinal lining and blood vessels, creating ulcers or damaging capillaries. Certain risk factors contribute to upper GI tumor bleeding, including advanced tumor stage, male gender, older age, usage of certain medications (NSAIDs, anticoagulants, antiplatelets), and comorbidities like thrombocytopenia, coagulopathy, and chronic kidney disease. Furthermore, angiogenesis in upper GI tumors increased the fragility of new tumor blood vessels, leading to slow oozing or severe hemorrhage. Upper GI cancer exosomes play a significant role in gastric cancer progression, influencing metastasis, drug resistance, and the tumor microenvironment. Exosomes contain and transport a wide range of DNA, mRNA, and miRNA molecules. Tumor-derived exosomes carry pro-angiogenic factors like vascular endothelial growth factor (VEGF) and miR-21, enhancing vessel permeability and clot instability in bleeding sites. In tumors, VEGF drives pathological angiogenesis, enabling tumor growth, invasion, and metastasis by forming leaky vessels. VEGF is transported via exosomes, leading to GI tumor bleeding risks. High serum VEGF also correlates with poor prognosis in gastric cancers. MiR-21 acts as an oncomiR in tumors, overexpressed across many cancers to promote proliferation, invasion, and metastasis by targeting tumor suppressor genes. In gastric cancers, elevated miR-21 correlates with advanced stages, angiogenesis, and bleeding risks through vessel instability. Gastrointestinal tumor bleeding represents approximately 3-5% of all gastrointestinal bleeding cases, posing significant clinical challenges due to its unique pathophysiology and treatment complexity. The management of such bleeding is particularly difficult because malignant lesions have distinct characteristics compared to benign etiologies of bleeding. Gastrointestinal tumors often exhibit invasive growth patterns, causing disruption of the normal tissue architecture. They frequently develop multiple ulcerations on their surface, which serve as persistent bleeding sites. Additionally, local blood vessels within or adjacent to the tumor can be damaged or fragile, further complicating hemostasis. In this situation, conventional endoscopic treatment, such as epinephrine injection, clipping, or heat coagulation for tumor bleeding, is challenging and less effective. Cohort studies have reported initial endoscopic hemostasis rates ranging from 31% to 86%, with rebleeding rates between 28% and 80% when using conventional endoscopic hemostatic methods. Hemostatic powder spray, introduced in clinical practice since around 2011, represents a novel endoscopic technique for managing active GI bleeding. The hemostatic powder is delivered through a spraying system under endoscopic visualization. When Покажи пълното описание...

Inclusion Criteria: * patients aged ≥ 18 years who accept endoscopy for upper GI tumor bleeding Exclusion Criteria: * patients with no need for endoscopic hemostasis, allergy to sucralfate, tranexamic acid, pregnancy, and patients with hollow organ perforation