Benefit of haemostatic spray in variceal bleeding: early application of spray or early application of guidelines?

We read with considerable interest the recent report by Ibrahim et al1 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...

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