Transesophageal endoscopic ultrasound-guided coil and cyanoacrylate treatment of challenging esophageal varices bleeding associated with CREST syndrome ulcerative esophagitis

Ligation is the recommended endoscopic treatment for acute esophageal variceal bleeding [1]. It can be challenging when associated with esophagitis. There is abundant evidence regarding the safety and efficacy of coil and glue embolization [2] [3] even in primary prophylaxis for gastric varices [4].

We report the case of a 43-year-old woman with CREST syndrome with scleroderma and sclerosing cholangitis with portal hypertension. She had hematemesis with oozing esophagitis twice in the past 3 months. We concluded ulcerative esophagitis due to CREST syndrome and esophageal motility dysfunction. She was admitted to our hospital for another hematemesis with hemorrhagic shock. After resuscitation, the initial gastroscopy showed active lower esophageal bleeding without any visible varices. An adrenaline injection and thermal treatment failed to control the bleeding and neither did band ligation owing to the difficult suction of sclerotic tissue. Thus the endoscopist decided to deploy a self-expandable metal SX-ELLA Danis stent (Ella-CS, Hradec Kralove, Czech Republic), which seemed to be effective. A computed tomography (CT) scan showed portal hypertension with a dilated left gastric vein associated with GOV 1 gastric varices along with a partial migration of the stent into the stomach ([Fig. 1]). An early transjugular intrahepatic portosystemic shunt (TIPS) was excluded owing to severe pre-existing pulmonary arterial hypertension. We decided to perform a new endoscopy.

Fig. 1 3 D Left gastric and portal vein reconstruction.

After stent removal, we still found active venous bleeding without any visible varices. Endoscopic ultrasound (EUS) allowed following the dilated vein from the portal vein to the variceal network. We performed an EUS-guided deployment of three Nester embolization coils and injected 1.0 ml of cyanoacrylate (CYA) glue with an Olympus Easyshot 19G needle ([Video 1]). Doppler ultrasound confirmed decreased flow in the varix without bleeding, and a CT scan 24 hours later showed effective embolization ([Fig. 2]).

Video 1 Transesophageal endoscopic ultrasound-guided coil and cyanoacrylate treatment of a challenging esophageal varices bleed associated with CREST syndrome ulcerative esophagitis.

Fig. 2 3 D Venous reconstruction after embolization.

In this video, we report on a successful transesophageal EUS-guided coil and CYA treatment of challenging esophageal variceal bleeding associated with CREST syndrome esophagitis.

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Competing interests

J. Rivory is a consultant for Cook Medical.

• References

• 1 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 2 Robles-Medranda C, Nebel JA, Puga-Tejada M. et al. Cost-effectiveness of endoscopic ultrasound-guided coils plus cyanoacrylate injection compared to endoscopic cyanoacrylate injection in the management of gastric varices. World J Gastrointest Endosc 2021; 13: 13-23
• 3 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83: 1164-1172
• 4 Kouanda A, Binmoeller K, Hamerski C. et al. Safety and efficacy of EUS-guided coil and glue injection for the primary prophylaxis of gastric variceal hemorrhage. Gastrointest Endosc 2021; 94: 291-296

Publication History

Article published online:
06 May 2022