Endoscopic Management of Gastric Varices; Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate

Abstract

Background: Bleeding from gastric varices is an important cause of morbidity and mortality in patients with portal hypertension. Injection of glue directly into gastric varices can achieve hemostasis in acutely bleeding lesions as well as prevent rebleeding of varices. Aims: The aim of the present was to describe the clinical characteristics and outcomes of patients undergoing gastric variceal gluing in a well defined Canadian patient population. Methods: This descriptive epidemiological study involves a retrospective chart review of patients undergoing glue injection of gastric varices in the Calgary Health Region (CHR) from 2000-2005. Results: Twenty-nine patients (16 male, 13 female) underwent a total of 40 separate gluing procedures. The mean age was 52 years. Cirrhosis was present in 20 patients and extrahepatic portal vein obstruction in 7. Seventeen had prior known esophageal or gastric varices. At endoscopy, 75% had esophagogastric varices and 25% had isolated gastric varices. Ten also had portal hypertensive gastropathy. Of all gluing procedures, 78% (31 of 40) presented with upper gastrointestinal bleeding prior to endoscopy, although only 12 had actively bleeding gastric varices at endoscopy. Of those, 92% (11 of 12) achieved immediate hemostasis; the other patient died from variceal hemorrhage. One patient had a non-bleeding varix that bled uncontrollably after glue injection requiring insertion of a Linton tube. Rebleeding within 48 hours of gluing was observed after 3 procedures (8%). Two of these episodes were successfully treated with repeat glue injections. At follow-up endoscopy, gastric varices were eradicated in 23 patients (79%). Complications other than bleeding included superior mesenteric vein thrombosis in 1 patient, ulceration at the site of glue injection in 3, and damage to the endoscope in 2. No glue emboli were observed. Twenty-seven (93%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.5% (1 of 40). Conclusions: In the Calgary Health Region, glue injection with cyanoacrylate is safe and effective in the treatment of bleeding and recently bleeding gastric varices.