The Use of N-2-Butyl Cyanoacrylate As a Rescue Therapy for Re-Bleeding and Uncontrollable Bleeding from Esophageal Varices

Abstract

Introduction: Bleeding esophageal varices endoscopic management has a risk of failure to control acute bleeding in 10% to 20%. The risk of bleeding from mucosal ulceration after endoscopic therapy is around 20%. The decision to perform additional endoscopic therapy must be individualized, because there are no controlled trials that provide hard data on the value of these modalities in the setting of early re-bleeding. The value of endoscopic clips, snares, and/or injection of thrombin versus cyanoacrylate in this setting is not known. Objectives and Aim: To assess the use of N-2-butyl cyanoacrylate as a rescue therapy for uncontrollable bleeding and re-bleeding from esophageal varices. Materials and Methods: This prospective study included 112 patients with esophageal varices and were classified into 2 groups; group I included 53 patients with uncontrollable bleeding from esophageal varices after injection sclerotherapy (with ethanolamine oleate) or band ligation. Group II included 59 patients with re-bleeding from esophageal varices due to post injection or post banding mucosal ulceration. All cases in both groups were managed by intravariceal injection of N-2-butyl cyanoacrylate. Results: In group I; all 53 patients had stoppage of bleeding with the intravariceal injection of N-2-butyl cyanoacrylate. All 53 cases had large varices (GIII-GIV), Hepatocellular carcinoma (HCC) was found in 19(35.9%) patients from which 11(20.8%) without portal vein thrombosis (PVT) and 8(15.1%) with PVT. Secondary re-bleeding occurred in 3(5.66%) patients all with HCC and PVT (2 died and 1 was managed conservatively). In group II, from 59 patients; 4(6.8%) cases had extensive bleeding due to post band ligation mucosal ulceration (3 of them had HCC & PVT) and were very difficult to manage due to obscured endoscopic field except for 1 patient in which N-2-butyl cyanoacrylate was injected below the level of the ulcer and was unable to stop the bleeding due to extensive ulceration, all 4(6.8%) patients died, 55(93.22%) patients were managed by injection of N-2-butyl cyanoacrylate and control of bleeding during endoscopy from which 6(10.2%) patients had another re-bleeding attack and was fatal (4 of which had PVT & HCC). The remaining 49(83.1%) patients had no further bleeding till the next session of endoscopy which was usually carried after 2 weeks. Conclusion: The use of N-2-butyl cyanoacrylate injection in esophageal varices as a rescue therapy in cases of uncontrolled bleeding or re-bleeding is an effective and safe endoscopic technique with less morbidity and mortality than other rescue modalities.