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.
A 48-year-old woman with liver cirrhosis was admitted with fundic
variceal bleeding. Endoscopic injection therapy with NBCA was initiated and
hemostasis was achieved. Following this treatment, the patient developed
ascites and pleural effusion. A computed tomography (CT) scan showed massive
ascites and an NBCA embolus in the portal vein ([Fig. 1]). The patient developed renal failure,
metabolic acidosis, massive leucocytosis, and an ileus. Intestinal ischemia was
suspected.
Fig. 1 Computed tomography scan
showing n-butyl-2-cyanoacrylate embolus in the portal vein. No intravenous
contrast was given because of compromised renal function.
This clinical picture was compatible with an abdominal compartment
syndrome. The femoral venous pressure, which can be regarded as a surrogate
marker for intra-abdominal pressure, was high (30 mm Hg),
supporting the diagnosis of abdominal compartment syndrome. Because of her poor
condition and liver cirrhosis it was decided not to perform a laparotomy, and
the patient died. Postmortem examination showed an NBCA embolus in both portal
and splenic veins. The small bowel was necrotic. No NBCA emboli were found in
the mesenteric arteries.
Injection treatment with NBCA in variceal bleeding is effective and
relatively safe [1]. Several complications have been
reported, among which are pulmonary embolism [2],
pericarditis [3], and intra-abdominal arterial
embolization [4]. In our patient, the treatment of the
bleeding fundic varices was complicated by portal and splenic vein
embolization. To our knowledge, this complication has only been described once
in the literature [5]. This resulted in tense ascites and
pleural effusion, giving rise to an abdominal compartment syndrome. The
intestinal ischemia can also be regarded as a result of this syndrome.
Portal vein occlusion following treatment with NBCA, although rare,
should be considered in patients who develop massive ascites following this
endoscopic intervention.
Endoscopy_UCTN_Code_CPL_1AH_2AC
