864 SUCCESSFUL EUS-GUIDED TREATMENT OF GASTRIC VARICES WITH COIL EMBOLIZATION AND INJECTION OF ABSORBABLE GELATIN SPONGE

Abstract

Gastric varices occur in 15-20% of patients with portal hypertension and are associated with significant gastrointestinal bleeding and high mortality. Endoscopic options are currently limited in patients with bleeding gastric varices. Here, we report our experience with endoscopic ultrasound-guided coil embolization and injection of absorbable gelatin sponge for the treatment of gastric varices. A 51 year old female with alcoholic cirrhosis, complicated by ascites, hepatic encephalopathy, and known type 1 gastric varices, presents to the hospital with hematemesis. She was deemed by interventional radiology to not be a suitable candidate for either transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO). It was therefore decided to offer EUS-guided treatment of her gastric varices. On EUS, four large collections of gastric varices were visualized, each with multiple individual compartments measuring 7-12 mm in short axis. Multiple varices were seen to directly contact the surface of the fundus. Using a 19 gauge EUS needle, a collection of gastric varices was punctured, followed by deployment of multiple 20 mm x 14 cm and 20 mm x 7 cm embolization coils. Following coil embolization, there was immediate obliteration of Doppler flow. After multiple coils were deployed, and contrast injections ruled out the presence of a gastrorenal shunt, additional injection was performed of absorbable gelatin sponge (prepared as a slurry) in order to further enhance variceal eradication. The process was then repeated until all four collections of gastric varices were eradicated. In total, eight vascular coils were deployed. The patient tolerated the procedure well and has not had recurrent bleeding on follow-up. EUS guided coil embolization and injection of absorbable gelatin sponge is a feasible and effective technique for the endoscopic management of symptomatic gastric varices in patients considered to be poor candidates for standard treatments such as TIPS and BRTO. This case highlights the advantages of coil embolization and absorbable gelatin sponge application, as well as the benefit of EUS guidance, over traditional direct cyanoacrylate injection for the endoscopic management of gastric varices.