The usefulness of endoscopic ultrasound (EUS) as a diagnostic tool is well known;
however, its therapeutic implications are upcoming. There are data for the use of
cyanoacrylate glue (CYA) as a temporary measure to control bleeding in gastric varices,
followed either by a transjugular intrahepatic portosystemic shunt (TIPS) procedure
or by balloon-occluded retrograde transvenous obliteration (BRTO).
A 44-year-old Asian man with hepatitis B virus cirrhosis complicated by hepatocellular
cancer causing portal vein thrombosis presented with melena and bright red blood
per rectum with associated dizziness, hemodynamic instability, and an initial hemoglobin
of 6.5 g/dL. He had a history of bleeding esophageal varices that had been banded
in the past, with prior EGD showing non bleeding gastric varices. An emergent repeat
esophagogastroduodenoscopy showed no residual esophageal varices and the stomach was
filled with blood clots and fresh blood that were preventing identification of the
bleeding source, but he had known prior gastric varices making that to be the most
likely source of bleeding. An emergent EUS showed multiple gastric varices with active
blood flow ([Fig. 1]). CYA was unavailable and, in view of the patient’s hemodynamic instability, a decision
was made to emergently inject 3 % sodium tetradecyl sulfate (STS), a sclerosing agent,
under EUS guidance. Doppler ultrasound confirmed a significant decrease in the blood
flow to the gastric varices.
Fig. 1 Endoscopic ultrasound Doppler showing the large gastric varices and blood flow to
these varices.
Following this an interventional radiology opinion was sought, but the patient was
deemed a poor candidate for TIPS and BRTO because of his portal vein thrombosis and
advanced cirrhosis. The following day, on repeat EUS, two deep gastric varices were
therefore identified and injected with two tornado 4-mm × 30-mm coils, followed by
a further 3 mL of 3 % STS ([Fig. 2]; [Video 1]). Successful hemostasis was confirmed with absent blood flow on follow-up Doppler
([Fig. 3]). A week later, the patient’s hemoglobin had improved to 9.6 g/dL with no further
bleeding episodes.
Fig. 2 Image during endoscopic ultrasound-guided injection of the sclerosing agent and coil
embolization of the gastric varices.
Video 1 Endoscopic ultrasound-guided sclerosant injection and coil embolization of bleeding
gastric varices.
Fig. 3 Repeat endoscopic ultrasound Doppler showing minimal to absent blood flow to the
varices following sclerosing agent injection and coil embolization.
The prevalence of gastric varices is around 15 % in patients with cirrhosis [1]. Up to 30 % of all gastric variceal bleeds are severe, with higher rates of rebleeding
and mortality. When CYA or a sclerosing agent are used on their own, they have high
rates of systemic embolization and rebleeding, therefore coil embolization helps prolong
hemostasis and minimize complications [2]. The data show that sclerosing agents can cause more ulcer formation at the injection
site and rebleeding than CYA. However, CYA is not available at all centers and, for
patients who are poor candidates for TIPS/BRTO, alternative therapies must be employed
in emergent situations. EUS-guided coil embolization is a novel approach to achieve
prolonged hemostasis. To our knowledge, this is the first case demonstrating the utility
of sclerosing agents followed by coil embolization in a patient with bleeding gastric
varices.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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