Diagnosis and treatment of recurrent upper gastrointestinal bleed with endoscopic ultrasound (gastric varix with splenic artery aneurysm)

Abstract

Background:Endoscopic ultrasound (EUS)-guided vascular therapy is evolving. Herein, we report a case of recurrent gastrointestinal bleed which was incriminated to gastric varix, but EUS picked up 3 cm splenic artery pseudoaneurysm which was treated by EUS-guided coil and glue.Case Report:A 33-year-old male, chronic alcoholic, presented with hematemesis in August 2015, for which three units of blood were transfused and upper gastrointestinal (UGI) showed esophageal varices with gastric varix, for which endoscopic sclerotherapy and glue injection were done, respectively. The patient remained asymptomatic for the next 18 months, when in January 2017, he presented with melena over 1 month requiring 10 units of blood transfusion. Patient underwent repeat UGI with endoscopic sclerotherapy and glue injection for esophageal and gastric varix. Ultrasound showed splenic vein thrombosis with collaterals around the splenic hilum. After 1 month in February 2017, he again had hematemesis and melena, for which after resuscitation, he was referred to SGPGI. The patient was diagnosed as having splenic vein thrombosis with gastric varix. Since patient had undergone multiple session of glue injection, he was planned for EUS-guided therapy of gastric varix. However, on EUS, a large 3 cm splenic artery pseudoaneurysm was picked up which was missed by prior imaging. Pseudoaneurysm was confirmed on computed tomography (CT) angiogram. The patient underwent endoscopic glue therapy for residual gastric varix and EUS guided-coil and glue in splenic artery. Obliteration after EUS therapy was confirmed by repeat EUS and CT angiogram after 2 weeks which showed no splenic artery aneurysm and patient had no symptoms.