Gastroenterology
Volume 133, Issue 5 , Page 1413, November 2007

Clinical Challenges and Images in GI

Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, England

David A. Katzka and David L. Jaffe, Section Editors

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Image 2 

Question: A 52-year-old woman with alcoholic cirrhosis (MELD score 12) developed massive hematemesis and melena requiring tracheal intubation and balloon tamponade with a Sengstaken-Blakemore tube (SBT). At endoscopy, nonbleeding esophageal varices and a gastroesophageal varix (GOV type 2, extending to the greater curve) were identified; the former were banded. Massive rebleeding occurred 24 hours later, and at re-endoscopy the GOV was seen to be actively bleeding. Eight milliliters of a 1:2 mixture of N-butyl-2-cyanoacrylate (histoacryl “glue”) and lipiodol was injected into the GOV. During the procedure, the patient developed hypoxia, hypotension, and nonsustained ventricular tachycardia. High-flow oxygen, colloid, and amiodarone were administered. Hemostasis was not achieved, and the SBT was reinserted. Repeat glue injection to the GOV was complicated by further episodes of ventricular tachycardia; however, bleeding was arrested. The chest radiograph (Figure A) demonstrated changes that appeared to contraindicate further attempts with this mode of treatment. What has happened?

Look on page 1748 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 1413): Pulmonary Embolization of Histoacryl “Glue” Causing Hypoxia and Cardiovascular Instability 

The chest radiograph demonstrates a “glue and lipiodol pulmonary angiogram,” lipiodol being radiopaque. The SBT tube is in situ. The cardiovascular instability and hypoxia were undoubtedly caused by embolization of liquid phase glue into the pulmonary vasculature via portosystemic venous anastomoses. The patient’s hemodynamic and oxygen parameters normalized over the following 48 hours and she was discharged after a lengthy recovery period. Glue injection is an accepted treatment for bleeding gastric varices; however, reported complications have included pulmonary embolization as described herein,1 paradoxical passage of glue particles into the systemic arterial circulation resulting in myocardial and cerebral infarction,2 and inflammatory pulmonary exudates secondary to pleural contamination.3 Patients with significant intrapulmonary vascular shunts (hepatopulmonary syndrome) or patent foramen ovale may be at higher risk of systemic arterial embolization after entry of emboli into the left atrium.

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References 

  1. Alexander S, Korman MG, Sievert W. Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli. Intern Med J. 2006;36:462–465
  2. Upadhyay AP, Ananthasivan R, Radhakrishnan S, et al. Cortical blindness and acute myocardial infarction following injection of bleeding gastric varices with cyanoacrylate glue. Endoscopy. 2005;37:1034
  3. Boonsarngsuk V, Suwatanpongched T. Eosinophilic pleural effusion after gastric variceal obliteration with cyanoacrylate. Respir Med. 2006;101:859–862

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(07)01761-1

doi:10.1053/j.gastro.2007.09.051

Gastroenterology
Volume 133, Issue 5 , Page 1413, November 2007

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