A STICKY SITUATION

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Patients with cirrhosis regularly undergo endoscopy for management of portal hypertensive complications. Little is known about the pulmonary complications of such procedures. Here, we present an acute pulmonary complication post gastric variceal gluing. CASE PRESENTATION: A 61-year-old female with type 2 diabetes, hypertension, and Child Pugh A cirrhosis secondary to non-alcoholic steatohepatitis presented with a two-day history of right-sided shoulder and sub-diaphragmatic pain, 3 days after elective injection of a gastric varix with Glubran and Lipidol. She described the pain as being sharp and pleuritic. She denied shortness of breath, hemoptysis, or constitutional symptoms. She had a temperature of 36.7 degrees Celsius, heart rate of 83 beats/min, blood pressure of 136/81, respiratory rate of 18/min, and an oxygen saturation of 91% on room air. Her physical exam was unremarkable. She was tender to palpation of the right sub-diaphragmatic area. Stigmata of chronic liver disease were not noted. Her investigations revealed normal electrolytes, creatinine, hemoglobin and white blood cell count. Her platelets were 111, INR 1.2, ALT 27 U/L, Bilirubin 38 umol/L, GGT 43 U/L, and the D-dimer was 1.82 mg/L. Her chest x-ray showed several new nodular densities in both lungs. Computed tomography pulmonary angiogram reported diffuse pulmonary arterial calcification; it was later addended to reveal a large caliber variceal gastrorenal shunt and high density filling defects consistent with severe burden of embolized glue throughout the segmental and subsegmental pulmonary vasculature bilaterally. DISCUSSION: The use of glue is commonly used in endoscopic therapeutics to prevent and treat gastrointestinal bleeding [1,2]. It has an associated 0.5%-4.3% risk of embolization [1], which can result in cardiopulmonary collapse [2]. Embolization is believed to occur through travel through gastrorenal and splenorenal veins into the inferior vena cava, with eventual deposition into the pulmonary circulation [2]. Large, high-flow portosystemic shunts and glue injections of more than 1 mL are predicted risk factors for pulmonary embolization [3]. The differential diagnosis for our patient included septic emboli, pulmonary embolus, malignancy, or pulmonary hypertension associated with vessel calcification. Initial management included administration of Cefazolin for a possible infection, followed by watchful waiting as the patient was hemodynamically stable. A secondary review of her imaging by Radiology further confirmed the findings of embolized glue. CONCLUSIONS: Pulmonary embolization of glue is an uncommon endoscopic complication of variceal treatment that has been linked to complications such as cardiopulmonary collapse and septic emboli [2]. It is important that clinicians keep this on the differential diagnosis when evaluating patients with chest pain or hemodynamic instability after gluing of varices. Reference #1: Al-Hillawi L, Wong T, Tritto G, Berry PA. Pitfalls in histoacryl glue injection therapy for oesophageal, gastric and ectopic varices: A review. World J Gastrointest Surg. 2016;8(11):729–734. doi:10.4240/wjgs.v8.i11.729 Reference #2: Hameed F, Pepperell J, Sidney J. A rare complication of endoscopic intervention. Breathe. 2018;14(2):e40-e42. doi:10.1183/20734735.019017 Reference #3: Jindal A, Philips CA. Pulmonary Glue Embolization after Endoscopic Treatment of Bleeding Sigmoid Colon Varices. ACG Case Rep J. 2017;4:e52. Published 2017 Apr 12. doi:10.14309/crj.2017.52 DISCLOSURES: No relevant relationships by Jennifer Landry, source=Web Response No relevant relationships by Dana Saleh, source=Web Response