Treatment Of Bleeding Gastric Varices Research Articles

Endoscopic cyanoacrylate injection for the treatment of bleeding gastric varices: the first Iranian series.

Gastric varices are a major cause of gastrointestinal bleeding and death in patients with portal hypertension. N-butyl-2-cyanoacrylate injection is a new method for controlling bleeding gastric varices. This study aims to investigate the prognosis and complications of cyanoacrylate therapy for bleeding gastric varices. We conducted a prospective study between May 2009 and January 2010 at our center affiliated with the Shiraz University of Medical Sciences, Shiraz, Iran. All patients with gastric variceal bleeding were enrolled in the study. N-butyl-2-cyanoacrylate injection was performed for treatment of the bleeding, and patients underwent monthly endoscopies to determine the outcomes. There were 13 patients with portal hypertension and gastric variceal bleeding included in the study. Initial hemostasis was obtained in all patients but more than one injection was needed in seven patients. Two patients developed re-bleeding and two died of advanced cirrhosis and other accompanying diseases. No major complications were observed after treatment with N-butyl-2-cyanoacrylate. This method can be safely used in treatment of gastric variceal bleeding.

Combined endoscopic-interventional radiologic approach for the treatment of bleeding gastric varices in the setting of a large splenorenal shunt

Endoscopic cyanoacrylate (glue) injection is an effective therapy for bleeding gastric varices (GV) but may result in life-threatening embolic complications. The risk of glue-related embolism is heightened if a large gastro/splenorenal shunt (SRS) is present.1 Techniques that minimize the risk of glue embolization via the SRS would significantly enhance the safety of the procedure.

Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: A randomized controlled trial

Gastric variceal obturation (GVO) therapy is the current treatment of choice for gastric variceal bleeding (GVB). However, the efficacy of non-selective β-blockers (NSBB) in the secondary prevention of GVB is still debatable. This study aimed at evaluating the efficacy of additional NSBB to repeated GVO in the secondary prevention of GVB. From April 2007 to March 2011, 95 patients with GVB after primary hemostasis using GVO were enrolled. Repeated GVO were performed until GV eradication. Forty-eight and 47 patients were randomized into the GVO alone group (Group A) and the GVO+NSBB group (Group B), respectively. Primary outcomes in terms of re-bleeding and overall survival were analyzed by multivariate analysis. After a mean follow-up of 18.10 months in group A, 26 patients bled and 20 died. In group B, 22 patients bled and 22 died after a mean follow-up of 20.29 months. The overall re-bleeding and survival rates analyzed by the Kaplan-Meier method were not different between the two groups (p=0.336 and 0.936, respectively). The model of end-stage liver disease (MELD) score and main portal vein thrombosis (MPT) were independent determinants of re-bleeding while MPT and re-bleeding were independent factors of mortality by time-dependent Cox-regression model. Asthenia was the most common adverse event and was higher in group B (p<0.001). Adding NSBB therapy to repeated GVO provides no benefit for the secondary prevention of bleeding and mortality in patients with GVB.

Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study

Background/AimsThis study evaluated the clinical outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hemorrhage from gastric varices (GV) in Korean patients with liver cirrhosis (LC).MethodsWe retrospectively analyzed data from 183 LC patients who underwent BRTO for GV bleeding in 6 university-based hospitals between January 2001 and December 2010.ResultsOf the 183 enrolled patients, 49 patients had Child-Pugh (CP) class A LC, 105 had CP class B, and 30 had CP class C at the time of BRTO. BRTO was successfully performed in 177 patients (96.7%). Procedure-related complications (e.g., pulmonary thromboembolism and renal infarction) occurred in eight patients (4.4%). Among 151 patients who underwent follow-up examinations of GV, 79 patients (52.3%) achieved eradication of GV, and 110 patients (72.8%) exhibited marked shrinkage of the treated GV to grade 0 or I. Meanwhile, new-appearance or aggravation of esophageal varices (EV) occurred in 54 out of 136 patients who underwent follow-up endoscopy (41.2%). During the 36.0±29.2 months (mean±SD) of follow-up, 39 patients rebled (hemorrhage from GV in 7, EV in 18, nonvariceal origin in 4, and unknown in 10 patients). The estimated 3-year rebleeding-free rate was 74.8%, and multivariate analysis showed that CP class C was associated with rebleeding (odds ratio, 2.404; 95% confidence-interval, 1.013-5.704; P=0.047).ConclusionsBRTO can be performed safely and effectively for the treatment of GV bleeding. However, aggravation of EV or bleeding from EV is not uncommon after BRTO; thus, periodic endoscopy to follow-up of EV with or without prophylactic treatment might be necessary in LC patients undergoing BRTO.

Tracheoesophageal Fistula in the Treatment of Gastric Variceal Hemorrhage with Sengstaken-Blakemore Tube

The Sengstaken-Blakemore tube (SB tube) is used to control esophageal or gastric variceal bleeding in emergencies, and various complications have been reported following its use. Tracheoesophageal fistula (TEF) is an extremely rare complication after SB tube insertion. We herein present a case of an 80-year-old female patient who experienced TEF after repeated insertion of the SB tube to control recurrent gastric variceal hemorrhage. (Korean J Helicobacter Up Gastrointest Res 2012;12:188-191)

•Successful endoscopic treatment of bleeding gastric varices with n-butyl-2-cyanoacrylate and lipiodol mixture injection

Amac: Bu calismadaki amacimiz kanayan veya daha once kanamis olan gastrik varislerde syanoacrilat ve lipi­odol karisiminin hemostazdaki etkisini saptamaktir. Gerec ve yontem: 2003-2010 tarihleri arasinda aktif kanayan veya kanama bulgusu olan ve iki hafta icinde endoskopi unitesine kabul edilen 15 hasta retrospektif olarak degerlendirildi. Syanoacrilat ve lipiodol karisimini gastrik varisli hastalarda basarili sekilde uyguladik ve tum hastalara endoskopik islem, varisler basarili sekilde teda­vi edilene kadar aylik peryotlarla tekrarlandi. Bulgular: Syanoacrilatli skleroterapi ile aktif kanayan 9 hastada baslangicta hemostaz saglandi. Tekrar kanama, 1 hastada 24 saat sonra diger hastada 2 ay sonra goruldu (2/15, %13,3). Takip suresince gastrik varis eradikasyonu 13 hastada (%86,7) basarildi. Bir hasta tekrar kanama­dan opere edildi diger hasta karaciger yetmezliginden oldu. Gastrik varis eradikasyonundan sonra 5 yillik yasam 14/15 (%93,3) idi. Sonuc: Bu calismada aktif kanayan ve kanama isareti olan gastrik varisli hastalarda syanoacrilat lipiodol kombi­nasyonu ile skleroterapinin etkili tedavisi gosterildi.

Sa1566 Efficacy and Safety of 2-Octyl-Cyanoacrylate Injection for the Treatment of Gastric Variceal Hemorrhage

Endoscopic injection of cyanoacrylate (glue) is effective for the treatment of gastric variceal hemorrhage (GVH). Although n-butyl-2 cyanoacrylate (Histoacryl®) is the most commonly used agent worldwide, it is not readily available in the U.S. As an alternative, our group has utilized 2-octyl cyanoacrylate (Dermabond®), an FDA-approved agent for wound closure. The off-label, intravariceal injection of 2-octyl cyanoacrylate (OCA) for GVH has been a treatment option at our institution since 2000. To assess the efficacy and safety of OCA injection for the treatment of GVH. The medical records of patients treated with OCA injection for GVH from 1/2000 to 7/2010 were reviewed retrospectively. Data were extracted for patient demographics, type of gastric varices (GV) according to Sarin classification, bleeding stigmata, OCA dose and number of sites injected per treatment session, initial hemostasis and rebleeding rates, procedure-related complications, and mortality. Undiluted OCA was injected at a rate of 1 ml/15 sec until bleeding cessation and/or hardening of the varix. Repeat endoscopy was performed at 4 wks to assess for variceal obliteration and treatment of any residual GV. Follow-up endoscopy was performed at 6-12 months thereafter. A total of 62 patients (40 men) were identified. Cirrhotic portal hypertension was the cause of GV in 70% of cases. GV were classified as GOV1 in 2%, GOV2 in 63% and IGV1 in 35% of cases. Active bleeding, stigmata of recent bleeding (e.g., fibrin plug) and presumed bleeding from large GV were noted in 24%, 53% and 23% of patients, respectively. The mean volume of OCA injected was 6.5 ml (range 2-16 ml) with a mean of 2 injection sites (range 1-6) per treatment session. In patients with actively bleeding GV (n=15), immediate hemostasis was achieved in 93% of cases following OCA injection. The overall rebleeding rate was 6%. In 2 patients, early (< 1 wk) recurrent massive GVH required rescue TIPS which failed to control bleeding in one patient who subsequently died. Late (> 1 wk) recurrent GVH occurred in 2 patients; one patient was successfully retreated with OCA injection and the other patient opted for comfort care in the setting of multiorgan failure. Glue-related pulmonary embolism occurred in 2 (3%) patients, which was fatal in one. The mean (SD) follow-up was 17 (15) months. Bleeding-related mortality was 6% and the overall mortality was 23%. Endoscopic injection of 2-octyl cyanoacrylate is a relatively safe and effective endoscopic treatment option for gastric variceal hemorrhage. The outcomes are comparable to those reported for endoscopic variceal injection using n-butyl-2 cyanoacrylate.

Comparison among Endoscopic Variceal Obliteration, Endoscopic Band Ligation, and Balloon-occluded Retrograde Transvenous Obliteration for Treatment of Gastric Variceal Bleeding

Endoscopic variceal obliteration (EVO), endoscopic variceal ligation (EVL), and balloon-occluded retrograde transvenous obliteration (BRTO) are used to manage gastric variceal bleeding. We compared the re-bleeding rates and survival times of these modalities. The study enrolled 103 patients with suspected gastric variceal bleeding between July 2001 and May 2009. For the management of gastric variceal bleeding, 52 patients underwent EVO; 36, EVL; and 15, BRTO. We evaluated their laboratory results and vital signs, and calculated the Child score, Child classification, and Model for End-stage Liver Disease score. Rebleeding was defined as new-onset hematemesis, hematochezia, melena, or endoscopically proven bleeding. Time-to-rebleeding and survival time were examined by Kaplan-Meyer analysis. A value of p<0.05 indicated statistical significance. There were no significant differences in baseline characteristics among the three groups. The overall follow-up period averaged 65.13 months. During follow-up, rebleeding occurred in 17 patients (11 EVO, 5 EVL, and 1 BRTO). The times-to-rebleeding were 63.59, 75.79, and 51.41 months for EVO, EVL, and BRTO, respectively, and did not differ significantly (p=0.515). The median survival times were 77.42, 70.14, and 42.79 months, respectively, and also were not different significantly (p=0.978). There were no significant differences in the time-to-rebleeding or survival time among EVO, EVL, and BRTO. Further prospective, large-scale studies are needed.

Long-term result of endoscopic Histoacryl®(N-butyl-2-cyanoacrylate) injection for treatment of gastric varices

To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl(®) for treatment of gastric variceal bleeding and prophylaxis. Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl(®) injections endoscopically. One hundred patients underwent endoscopic Histoacryl(®) injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure. According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl(®) per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl(®) injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%. Histoacryl(®) injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.

Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding

Variceal bleeding is an acute medical emergency with high mortality. Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding is more severe and more difficult to control. The optimal therapy for gastric variceal bleeding remains unclear although endoscopic injection of N-Butyl-2-Cyanoacrylate (Histoacryl) glue is often used. However, its long-term efficacy is poorly described. We studied the immediate and long-term effects of Histoacryl glue injection as treatment for bleeding gastric varices in a large UK hospital. Endoscopy records and case notes were used to identify patients receiving Histoacryl injection for gastric variceal bleeding over a 4-year period. Thirty-one patients received Histoacryl for gastric variceal bleeding. Seventy-four per cent patients had alcohol-related liver disease and 61% of cirrhotics were Childs Pugh grade B or C. Fifty-eight per cent were actively bleeding during the procedure with 100% haemostasis rates achieved. Two patients developed pyrexia within 24 h of injection settling with antibiotics. No other complications were encountered. Mean overall follow-up was 35 months, with mean follow-up of survivors 57 months. Forty-eight per cent patients had endoscopic ultrasound assessment of varices during follow-up with no effect on rebleeding rates. Thirteen per cent required subsequent transjugular intrahepatic portosystemic shunt placement. Gastric variceal rebleeding rate was 10% at 1 year and 16% in total. One- and two-year mortality was 23% and 35%, respectively. Endoscopic injection of Histoacryl glue appears to be a safe and effective treatment for gastric variceal bleeding. Further data are required to compare it with other therapies in this situation.

Evaluation of therapeutic effects and serious complications following endoscopic obliterative therapy with Histoacryl

Our aim was to evaluate the utility of endoscopic obliterative therapy with Histoacryl for gastric varices and to investigate the incidence of serious complications. Endoscopic obliterative therapy with Histoacryl was performed on 129 gastric variceal patients. Sixty-five patients had cardiofornical varices, and 64 had fundal varices. Forty-five of 129 patients were emergency cases and the other 84 patients were prophylactic cases. Endoscopic therapy was performed under fluoroscopy using 70% Histoacryl (Histoacryl diluted with 5% Lipiodol). Endoscopic hemostasis of gastric varices was successful in 45/45 (100%) emergency cases. The recurrence rate of gastric varices was 17/120 (14.2%) among patients whose variceal eradication was achieved. Additional treatment was successfully performed in all recurrent cases. The incidence of serious complications was 4/129 (3.1%), including two cases of splenic infarction, one case of pulmonary embolism, and one case of an inflammatory tumor of pancreatic tail. The two patients with splenic infarction improved with conservative medical treatment. The patient with pulmonary embolism showed no respiratory symptoms, and died of liver failure. The patient with the pancreatic tumor, which was diagnosed as an inflammatory tumor, was treated surgically. Endoscopic obliterative therapy with Histoacryl is a useful and relatively safe method for treatment of bleeding gastric varices. Nonetheless, careful attention must be paid to avoid potentially serious complications.

EUS-Guided Therapy of Bleeding Gastric Varices

Introduction: The treatment of gastric varices (GV) is challenging due to their large size and bleeding severity. Endoscopic cyanoacrylate (CYA) glue obliteration has demonstrated a higher hemostasis and lower rebleeding rate compared with ligation or sclerotherapy. Treatment delivery under endoscopic ultrasound (EUS) guidance may improve results and offers new treatment approaches. EUS enables precise treatment delivery into the varix lumen and feeding veins. Obliteration can be confirmed on Doppler study. Furthermore, ultrasound visualization is not impaired by blood in the stomach. Coils that are currently used for intravascular embolization treatments, can be delivered under EUS-guidance and offer a new approach that may be an alternative or complementary therapy to glue injection. Aim: To assess the feasibility, safety and outcomes of EUS guided therapy with tissue adhesives, coils or a combination of both for the treatment of bleeding gastric varices. Methods: Patients with GV bleeding (active bleeding or stigmata of prior bleeding) treated by EUS-guided therapy between October 2007 and November 2008 were identified in a prospectively collected database. A linear array echoendoscope was used to deliver treatment. A 22G needle was inserted under EUS guidance. Either CYA, coils (InterLock®, Boston Scientific) or a combination of both was used. After each intervention EUS was used to assess obliteration and determine the need of further intervention. Rebleeding was assessed by clinical follow-up. EUS was used to evaluate GV obliteration during surveillance. Results: Eleven GV were treated in 9 patients (4M: 5F;mean age 56). Five varices were active bleeding while the other six had stigmata of prior bleeding. CYA alone (mean volume: 2.3mL; range1-5mL) was injected in 6 varices. Coils alone (1coil per varix) were inserted in 3 varices. A combination of coils (1 or 2 coils per varix) and CYA (mean volume: 2mL; range: 1-3mL) was used in 2 varices. No complications, including symptoms or signs of embolization, were observed. No rebleeding has been reported on follow-up. EUS surveillance was available in 4 patients and showed complete obliteration of GV. Conclusions: Endoscopic treatment of gastric varices under EUS guidance may improve results due to improved targeting of therapy within the varix. The delivery of coils under EUS guidance is a novel approach with promising results. Further studies are warranted.

Portal-vein embolization after sclerotherapy treatment of bleeding gastric varices: report of a case with long-term follow-up

Portal-vein embolization after sclerotherapy treatment of bleeding gastric varices: report of a case with long-term follow-up

Endoscopic Treatment of Bleeding Gastric Varices Using Large Amount of N-Butyl-2-Cyanoacrylate Under Fluoroscopic Guidance

We propose the use of fluoroscopic guidance for endoscopic injection of n-butyl-2-cyanoacrylate to treat gastric variceal hemorrhage to achieve placement of the safest quantity of tissue adhesive. Ten patients with gastric varices were treated with n-butyl-2-cyanoacrylate endoscopic injection under fluoroscopic guidance for the purpose of hemostasis or prevention of recurrent bleeding. The glue was infused into the varices in the quantities needed to achieve complete obliteration of the gastric varices. The median quantity of tissue adhesive required in this series was 6.6 mL. The procedure was initially considered successful in all patients. There were no complications relating to the procedure. The mean duration of follow-up was 20 months. Injection of suitable quantities of cyanoacrylate under fluoroscopic guidance seems to be safe and effective for controlling hemorrhagic gastric varices.

Portal and splenic vein occlusion complicating Histoacryl injection therapy in bleeding gastric varices

Endoscopic injection therapy with n-butyl-2-cyanoacrylate (NBCA) (Histoacryl®, B. Braun, Melsungen, Germany) is an effective hemostatic treatment for gastric variceal bleeding [1]. In this report we describe a case of portal and splenic vein occlusion after injection therapy with NBCA.

Endoscopic Management of Gastric Varices: Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate in a North American Patient Population

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America. To assess the safety and efficacy of gastric variceal glue injection in a North American population. Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed. Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%. The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.

The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration

The purpose of our study was to evaluate the long-term outcome and complications of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients with hemorrhage from gastric fundal varices. Thirty-four consecutive patients with bleeding from gastric varices who were treated with B-RTO were enrolled in this study between December 1994 and September 2005 (urgent cases, n = 12; elective cases, n = 22). The long-term outcome, complications, and various liver functions were evaluated. Complete obliteration was achieved in 31 of 34 (91%) patients with an acute bleeding episode. In one of the remaining patients, there was a technical failure, and the other two had only partial obliteration. The two patients with partial obliteration did not obtain hemostasis. Thus, the rate of hemostasis was 94% (31/33). Gastric varices disappeared in all patients with complete obliteration during the treatment. The rate of gastric variceal eradication was 91%. Variceal rebleeding from esophageal varices occurred in three patients. The rate of rebleeding was 10% (3/31). Rebleeding from gastric varices was not observed after complete obliteration. None of the patients showed worsening of their Child-Pugh score. Although the 5-year cumulative worsening rate of esophageal varices was 52%, neither portal hypertensive gastropathy nor ectopic varices were observed. The patients with worsening esophageal varices were successfully treated with an endoscopic procedure. The 5-year survival rate was 68%. B-RTO is useful for treatment of bleeding gastric varices, achieving high eradication of gastric varices, a low rebleeding rate, and a fairly good prognosis with improved hepatic function.

Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate

Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices. Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary. Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27). This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.

Long-Term Outcome and Safety of Histoacryl Glue Sclerotherapy for Bleeding Gastric Varices

Prior to the introduction of N-butyl-2-cyanoacrylate (Histoacryl) glue, the prognosis of gastric variceal haemorrhage was poor. Long term efficacy and safety of Histoacryl has been established in several Asian studies but there is no comparable data in Western populations. We thus report our experience in using glue to manage gastric variceal haemorrhage.A retrospective review of records of patients seen with bleeding gastric varices treated with Histoacryl from 1994-2005 was undertaken. Histoacryl was injected as a 1:1 mixture with lipiodol using a 21-gauge sclerotherapy needle. Twenty-one patients were analysed. Median follow up was 30 months (11 days-88 months). Data collected included patient demographics, Child-Pugh (CP) score, cause of portal hypertension, variceal location and transfusion requirements. Primary haemostasis was defined as control of bleeding at the time of endoscopy. Early in the study, repeat sclerotherapy was only undertaken for re-bleeding; later, repeat treatments were performed to obliterate varices. The median age was 54 years (range 32-79). Seventeen patients had cirrhosis, 13 secondary to alcohol and HCV; 4 patients had extrahepatic portal hypertension. CP score at presentation was A in 3, B in 8 and C in 6. Three patients had portal vein and 2 others splenic vein thrombosis. All received octreotide at presentation. Seventeen patients were actively bleeding and 4 had evidence of recent bleeding. Median blood transfusion requirement was 9 units (range 0-37 units). Location of varices was fundal in 17 patients and proximal lesser curve in 4 with 17 having associated oesophageal varices. Primary haemostasis was achieved in 18 (86%). Of the others, 1 achieved haemostasis with re-treatment, 1 proceeded to surgery, and the final patient died. Early re-bleeding occurred in 5 (25%), with successful re-treatment in 4 (80%); the final patient required a TIPS. Median injected glue volume per session was 5 ml (2-9 ml). Complications included 3 patients with radiologic but not clinical evidence of distant glue embolisation (pulmonary vessels 2, iliac and adrenal vein 1). There was no treatment-related mortality. Survival at 30-days was 90%, and 71% at 1 year; most deaths liver related. During long term follow up, the only re-bleed was at 13 months in a patient with splenic vein thrombosis who had a curative splenectomy; there were no long term glue-related sequelae. Our results confirm that, in a Western population, Histoacryl sclerotherapy is an effective and safe treatment for bleeding gastric varices with results similar to Asian studies. It should be considered as first line treatment for gastric variceal bleeding.

Fatal multiple systemic embolisms after injection of cyanoacrylate in bleeding gastric varices of a patient who was noncirrhotic but with idiopathic portal hypertension

Acrylates are widely used in many countries for the treatment of bleeding gastric varices. 1 Ryan B.M. Stockburger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology. 2004; 126: 1175-1189 Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar N-butyl-2-cyanoacrylate has recently been removed from the market and substituted with N-butyl-2-cyanoacrylate plus methacryloxysulpholane (Glubran 2; GEM, Viareggio, Italy), which has proven to have the same profile of tissue and blood compatibility and low toxicity.