Application of endoscopic US-guided tissue adhesive injection as a rescue therapy for post-tissue adhesive variceal obturation–related gastric wall bleeding

Abstract

A 64-year-old woman with hepatitis C virus–related Child-Pugh class B cirrhosis first received cyanoacrylate injection for bleeding gastric varices in 2006 with apparently good variceal obturation (A). Five intermittent episodes of tarry stool passage occurred from 2008 to 2009. During these episodes, the bleeding always stopped after medical treatment. Endoscopic examination showed no active bleeding, and only a small ulcer-like mucosal depression over the previous cyanoacrylate injection site was ever found (B). No bleeding was found initially after the endoscopic examination for tarry stools in 2009; however, oozing from the small ulcer-like mucosal depression was observed during the procedure (C). A fistula-like communication between the gastric wall and the nearby collateral vessels was suspected at EUS, and EUS-guided cyanoacrylate injection of the paragastric collateral vessels was performed. The amount of cyanoacrylate injection required for obliteration of the injected vessel was determined under EUS control with power Doppler (about 2-4 mL of a histoacryl-lipiodol mixture) (D). EUS-guided cyanoacrylate injections were also administered to nearby collateral vessels because of rebleeding, and no further bleeding occurred after the third session. She died of pneumonia 5 months later.