A 50-year-old man with alcoholic liver cirrhosis was admitted to our emergency department
with massive hematochezia and hypovolemic shock. On admission, laboratory data included
hemoglobin 3.1 g/dL, hematocrit 9.9 %, platelet count 81 × 109/L, lactates 13.9 mmol/L, and international normalized ratio 1.29. Resuscitation was
initiated with intravenous fluids and transfusion of 4 units of packed red blood cells.
Terlipressin 2 mg and ceftriaxone 1 g were administered.
Esophagogastroduodenoscopy revealed small esophageal varices with no evidence of recent
bleeding. After oral preparation, total colonoscopy was performed, which showed markedly
dilated, tortuous veins with a visible fibrin plug in the ascending colon, indicative
of colonic varix with recent bleeding ([Fig. 1 a]); there was no blood in the colon. N-butyl-2-cyanoacrylate (Histoacryl; B. Braun,
Melsungen, Germany) was injected into the varix, resulting in initial active spurting
bleeding from the site of the fibrin plug and from the site of injection ([Fig. 1 b]), which resolved after subsequent injections. In total, 2 mL of Histoacryl was injected
([Fig. 1 c], [Video 1]).
Fig. 1 Histoacryl injection for treatment of varices in the ascending colon. a Ascending colonic varix with visible fibrin plug. b Active spurting bleeding from the site of the fibrin plug and from the site of needle
injection with N-butyl-2-cyanoacrylate. c Colonic varix after hemostasis with 2 mL of injected N-butyl-2-cyanoacrylate.
Colonic varix in the ascending colon with a visible fibrin plug. Hemostasis was achieved
following injection of 2 mL of N-butyl-2-cyanoacrylate, with initial active spurting
bleeding from the site of the injection, which resolved after subsequent injections.
The patient had no recurrent bleeding and hemoglobin levels remained stable. He was
discharged 7 days later with nonselective beta blocker medication.
Esophageal varices are a common cause of gastrointestinal bleeding in patients with
portal hypertension, but ectopic varices are extremely rare (between 1 % and 5 % of
all variceal bleeding), especially in the ascending colon [1]
[2]. Because of the infrequency with which bleeding ectopic varices present, the ideal
therapeutic intervention is unknown [3]
[4]. This is the first report of successful endoscopic hemostasis with injection of
N-butyl-2-cyanoacrylate in bleeding ascending colonic varices.
Endoscopy_UCTN_Code_TTT_1AQ_2AZ
