Treating Duodenal Varices with Cyanoacrylate Glue Injection

Abstract

Introduction: Treatment methods for some bleeding complications of portal hypertension such as portal hypertensive gastropathy (PHG), gastric antral vascular ectasias and duodenal varices are diverse and non-uniform. We present the case of a patient with a life threatening upper GI bleed secondary to a duodenal varix, who achieved adequate hemostasis with cyanoacrylate glue injection. Case presentation: A 46 year old female with history of active alcoholic liver disease was admitted with hemorrhagic shock due to a massive GI bleed. Initial resuscitation necessitated intubation, vasopressors and massive transfusion support. Initial EGD demonstrated small esophageal varices without stigmata, mild PHG and a nonbleeding gastric ulcer. Bleeding continued, therefore interventional radiology performed Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) with embolization of gastric and esophageal Hemodynamic instability continued and repeat EGD demonstrated a large, actively bleeding duodenal varix at the third portion of the duodenum. Cyanoacrylate glue was directly injected into the varix and hemostasis was achieved. The patient was discharged home within a few days. Surveillance EGD performed 2 months after discharge, while patient remained sober, revealed mild ulceration in the third portion of the duodenum at the site of glue injection, without presence of varices. After an episode of alcohol binge, she was readmitted with recurrent GI bleed. EGD revealed the previously injected duodenal varix actively bleeding. Endoscopic glue injection was again performed and hemostasis was achieved. Emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure was performed after which the patient was discharged in good condition, without known sequelae, complications or recurrent bleeding. Discussion: Although the successful use of cyanoacrylate glue injection to control bleeding duodenal varices has been reported in numerous cases, its use remains seldom, as gastroenterologists tend to prefer use of alternative methods in such instances. As described in our case and those previously reported, severe portal hypertension remains a risk factor for re-bleeding and complications. Our case demonstrates that adequate control of duodenal variceal bleeds can be achieved initially via cyanoacrylate glue injection but permanent treatment includes TIPS or transplant.