A 77-year-old woman diagnosed with hepatitis B presented with
hematemesis. Esophagogastroduodenoscopy (EGD) showed esophageal varices with
signs of red color, and tumor-like gastric varices with a white nipple ([Fig. 1 a]). For suspected recent bleeding,
4 ml of a mixture of N-butyl-2-cyanoacrylate (Histoacryl) and Lipiodol
(1 : 1 ratio) was injected into the gastric varices. Follow-up
EGD 1 month later disclosed two ulcers on the esophageal varices at 36 and
34 cm, respectively, from the incisor. Pathology examination of the
removed protruding material at the center of the ulcer showed inflammatory
cells mixed with a cyanoacrylate substance ([Fig. 1 b, c]).
A 57-year-old woman diagnosed with hepatitis B-related liver
cirrhosis presented with massive tarry stool. EGD showed huge esophageal
varices with signs of red color and active gastric variceal bleeding. For
hemostasis, 4 ml cyanoacrylate mixture was injected. Recurrent gastric
variceal bleeding happened 1 week later, thus 6 ml cyanoacrylate mixture
was injected. However, tarry stool occurred again after 1 week, and EGD showed
oozing from the disrupted esophageal variceal mucosa with protruding foreign
materials ([Fig. 2]), which made ligation
difficult. Therefore 1 ml cyanoacrylate mixture was injected for
hemostasis.
Fig. 1 Cyanoacrylate polymer
migrates to the esophageal varices. a Before gastric
variceal obliteration (GVO), esophagogastroduodenoscopy (EGD) shows a fibrin
plug on the gastric varices (arrow). b EGD shows a
protrusion of cyanoacrylate polymer from disrupted esophageal varices (arrow).
c Microscopic findings reveal mixed inflammatory cells
and eosinophilic fibrin-like materials, consistent with cyanoacrylate
material.
Fig. 2 Esophagogastroduodenoscopy (EGD) shows
active esophageal variceal bleeding from the disrupted esophageal variceal
mucosa.
Endoscopic injection of cyanoacrylate to arrest gastric variceal
bleeding has been widely used and is now considered more effective than
sclerotherapy and band ligation [1]. However, despite the
efficacy of endoscopic injection of cyanoacrylate, the serious but uncommon
complications of distant and remote thromboembolism have been reported
[2]
[3]
[4]. To
our knowledge, these are the first cases of esophageal variceal embolism
complicated by ulcer formation and bleeding after gastric variceal obliteration
(GVO). In our pilot study, the use of cyanoacrylate injection for gastric
varices and concomitant banding ligation for esophageal varices was better than
separate procedures to reduce re-bleeding [5]. The actual
pathogenesis is unknown. From these two cases, post-GVO cyanoacrylate embolism
may be a possible pathogenesis that causes esophageal variceal bleeding and
ligation failure. In summary, patients receiving GVO with large doses of
cyanoacrylate may be at increased risk of esophageal variceal embolism and
bleeding.
Endoscopy_UCTN_Code_CPL_1AH_2AC
