Endoscopic Ultrasound-Guided Sclerosant and Coil Embolization of Bleeding Gastric Varices

Abstract

The use of an Endoscopic Ultrasound (EUS) as a diagnostic tool has been in known since long, however its therapeutic use is limited. There is data for use of Cyanoacrylate Glue (CYA) as a temporary measure to control bleeding in Gastric Varices (GV) followed by either Transjugular Intrahepatic Portosystemic Shunt (TIPS) or Balloon-occluded Retrograde Transvenous Obliteration (BRTO). A 44 year old Asian male with history of Hepatitis B virus cirrhosis complicated by infiltrative Hepatocellular Cancer (HCC) causing portal vein thrombosis (PVT) came to the EC with melena and BRBPR associated with dizziness and HR of 107 beats/min and BP of 91/53 mmHg. His initial Hb was 6.5 gm/dL. GI was consulted for an emergent upper endoscopy which showed no esophageal varices (EV) but the stomach showed large blood clots which prevented identification of bleeding source. Thus the procedure was converted to an emergent EUS, which showed bleeding GV. CYA was unavailable at the institution and considering hemodynamic instability, a decision was made to emergently inject 3% sodium tetradecyl sulfate (STS) sclerosing agent (SA) under EUS Doppler guidance. A repeat Doppler confirmed decrease in blood flow to GV. Patient was sent to ICU for supportive management. An interventional radiology consult, deemed patient a poor candidate for TIPS and BRTO due to PVT and advanced cirrhosis. Thus, two deep GV were injected with two tornado 4mm x 30mm coils followed by 3mL of 3% STS injection. Successful hemostasis was confirmed with absent blood flow within the varix. A week later, his Hb improved to 9.6 gm/dl with no further GI bleed. The prevalence of GV is around 15% in patients with portal hypertension and cirrhosis. Up to 30% of all GV hemorrhages tend to be severe with higher rates of re-bleeding and mortality than EV. When CYA or SA are used solely, it has higher rates of systemic embolization and re-bleeding hence tornado coil embolization helps prolong the hemostasis and minimize complications. The data shows SA tend to cause higher ulcer formation at site of injection and re-bleeding then CYA. However, CYA is not available at all centers and patient who are poor candidates for TIPS/BRTO alternative therapies must be employed in emergent situations. EUS-guided coil embolization is a novel approach to achieve prolonged hemostasis. To our knowledge, this is the first case demonstrating the utility of SA followed by coil embolization in a patient with actively bleeding GV. Watch the video: https://goo.gl/rss1Jz