Clinical Outcomes of Endoscopic Cyanoacrylate Injection Sclerotherapy With Post-Injection Audible Doppler Ultrasonography

Abstract

Introduction: Acute gastric variceal hemorrhage (GVH) causes significant mortality and morbidity, and patients who suffer re-bleeding have a five-fold increase in mortality rates. The sites in the stomach at which they develop make endoscopic band ligation (EBL) difficult, and their thicker mucosa and larger diameter make EBL more likely to fail to occlude the vessel. When compared to esophageal varices, gastric varices have higher rates of morbidity and mortality from hemorrhage. Several studies have shown the safety and efficacy of n-butyl 2-cyanoacrylate (CA) injection into varices. The technique employed at our institution involves CA injection followed by ultrasound doppler to confirm the cessation of variceal blood flow. We designed our study to determine if throughscope audible doppler assessment (ADA) for hemostasis after injection improves clinical outcomes for acute GVH. Methods: We retrospectively identified 75 patients who had documented gastric varices, underwent CA injection with ADA, and had at least two weeks of follow up. We included patients treated for either acute GVH or hemorrhage prophylaxis followed by ADA. We analyzed the survival and re-bleeding rates with patient characteristics, which included variceal etiology, cirrhosis etiology, initial MELD scores, and laboratory assessments at time of readmission and/or re-bleeding, and compared our data with known studies of both GVH and hemorrhage prophylaxis treated by CA injection without subsequent ADA. Results: 53 (70.7%) of the total 75 patients underwent CA injection with ADA for acute GVH. 13.7% (±5.3%) of these patients had re-bleeding within 88 days after bleeding was controlled in the first CA injection and 26.9% (±7.6%) had re-bleeding within one year. The remaining 22 (29.3%) patients had undergone CA injection with ADA for hemorrhage prophylaxis. 12.3% (±8.3%) of these patients had re-bleeding within one year after prophylaxis, the difference from acute GVH was statistically significant (p=.041) and is illustrated in Figure 1.Figure 1Conclusion: When compared to recent studies, CA injection with ADA for patients with acute GVH may be superior to CA injection alone for long term re-bleeding risk, but not seem to be significantly superior to standard CA injection for early follow up. The addition of ADA for patients undergoing CA injection for hemorrhage prophylaxis does not appear to significantly affect re-bleeding rates when compared to standard CA injection.