Treatment of gastric body variceal bleeding caused by splenic vein thrombosis using color Doppler endoscopic ultrasonography.

Abstract

Watch a video of this article. A 58-year-old man with a history of alcoholic liver cirrhosis and pancreatitis was admitted for the treatment of gastric body varices (Lg-b)1 on the greater curvature caused by left-sided portal hypertension (LSPH) with splenic venous thrombosis. The supplying vein was the short gastric vein, and drainage veins were the left gastric vein and gastrorenal shunt (Fig. 1a,b, Video S1). We performed balloon-occluded retrograde transvenous obliteration (BRTO), but the Lg-b did not disappear. Seven days after BRTO, Lg-b bleeding occurred. Temporary hemostasis was obtained by endoscopic variceal ligation and 75% N-butyl-2-cyanoacrylate (NBCA) injection. However, the remaining Lg-b were indistinguishable from the gastric mucosal folds (Fig. 1c,d). We hence performed color Doppler endoscopic ultrasonography (CDEUS; GF-UCT260, Olympus Medical Systems, Tokyo, Japan) with water supplied. This enabled visualization of the bloodstream of the Lg-b and gastric-antrum varices (Lg-a) and distinguished risky Lg-b from the gastric folds (and the thrombotic Lg-b) (Fig. 2a). We changed the endoscope (GIF-H290) and succeeded in intravariceal injection of 5% ethanolamine oleate (EO; 17 mL) using a 21-gauge needle on endoscopic injection sclerotherapy. After a 5% glucose solution flush, 2 mL of 75% NBCA was injected, and the needle was flushed with 5% glucose solution again (glucose sandwich method) to avoid NBCA polymerization in the needle. Bleeding did not occur even after needle removal. One month after the treatment, we additionally performed scheduled intravariceal injection (13 mL of EO and 2 mL of 75% NBCA) by glucose sandwich method (Fig. 2b,c). The Lg-b and Lg-a completely disappeared, and part of the varices was replaced by NBCA without any liver dysfunction or complications on computed tomography (Fig. 2d). LSPH is a rare type of portal hypertension.2-5 This is the first report showing the usefulness of endoscopic treatment for Lg-b using CDEUS and combination injection of EO plus NBCA. Authors declare no conflict of interest for this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.