Gastric Variceal Hemorrhage: Successful Treatment with Combination Endoscopic Cyanoacrylate Injection and Retrograde-balloon Tranvenous Embolization

Abstract

Purpose: CASE REPORT: This is a case of a 52 year old Hispanic man with cryptogenic cirrhosis presenting to the EC with his 2rd Gastric Variceal Bleed. Previous CT scan showed portal vein thrombosis which precluded him from having a TIPS procedure. Due to ongoing bleeding, he was brought to the IR suite for an emergent balloon-occluded retrograde transvenous embolization (BRTE). Complete hemostasis was not achieved; therefore we performed a rescue EGD while the patient was still on the table in the IR suite. The BRTE had slowed the flow of blood through the varices, allowing better visualization of the offending varix. At this point the varix was injected with cyanoacrylate. Immediate hemostasis was achieved and the patient was discharged from the hospital 2 days after the procedure. On follow up 3 months later there was total obliteration of the gastric varices. The patient has been followed in clinic over the last 12 months with no additional bleeding episodes. DISSCUSION: Variceal bleeding is one of the most serious complications associated with portal hypertension and chronic liver disease. Gastric variceal (GV) bleeding is associated with a poorer prognosis than esophageal variceal bleeding, more blood loss, and a higher mortality rate. TIPS (Transjugular intrahepatic portosystemic shunts) has been the first line therapy for GV bleeding. Recent studies have shown, however, that endoscopic therapy with tissue adhesives, liquids that rapidly polymerize upon contact with endothelium and blood, is as effective as TIPS for controlling bleeding and preventing recurrence of bleeding, with fewer long-term complications. Another approach is balloon-occluded retrograde transvenous obliteration (BRTO), an Interventional Radiology technique involving transvenous injection of tissue adhesives. Studies thus far investigating the efficacy of BRTO as compared to TIPS for GV bleeding have been promising and more studies are necessary to determine the role this procedure will play for controlling GV bleeding, particularly in the setting of GV hemorrhage. Simultaneously performing endoscopic injection with BRTO has also been described and studies suggest the simultaneous approach results in bleeding control rates greater than 90%. The simultaneous procedure successfully induces thrombosis in gastric varices, leading to shrinkage and resolution of the varices, with a relapse rate from 0-10%. Our successful case introduces an additional strategy in the treatment of GV; initial BRTO followed shortly by EGD with endoscopic cyanoacrylate injection. This strategy may be more effective than either modality alone or the simultaneous injection strategy and deserves more rigorous investigation.