1.1. Background: Gastric varices is one of the most serious complication of portal hypertension. Endoscopic injection therapy with Histoacryl is the preferred method in managing gastric variceal bleeding. Iatrogenic ectopic embolism is the most serious complication associated with Histoacryl injection in patients with co-existing gastro-renal shunt. Because of this complication risk, endoscopic injection therapy for the gastric varices co-existing with gastro-renal shunt (GRS) is greatly limited. This paper reports one case of giant gastric varices with a significant gastro-renal shunt being treated with E-BRTO and high-dose Histoacryl.
1.2. Methods: We performed modified balloon-occluded retrograde transvenous obliteration assisted endoscopic Histoacryl injection, which provided a transient occlusion of the GRS during endoscopic high-dose Histoacryl injection. A total of 31.5 mL Histoacryl is injected into the varices by the "sandwich" technique at different locations. Before removing the balloon catheter, angiogram demonstrates the resolution of gastric varices.
1.3. Results: At 1 year, the gastric varices had almost completely disappeared. No embolism or further re-bleeding developed in this patient up to date.
1.4. Conclusions: This case suggests that it is effective and safe with balloon-occluded retrograde transvenous obliteration followed by endoscopic high-dose Histoacryl injection. This hybrid approach offers another option to the patients with large and high-risk gastric varices with gastro-renal shunt.
Keywords:BRTO; Gastro-renal shunt; Gastric varices; Histoacryl
2. List of Abbreviations:BRTO: Balloon-occluded Retrograde Transvenous Obliteration; E-BRTO: BRTO Assisted Endoscopic Histoacryl Injection; GV: Gastric Varices; GRS: Gastro-Renal Shunt; MRI: Magnetic Resonance Imaging
3. Case ReportThe prevalence of Gastric Varices (GV) in patients with portal hypertension is about 10%~50%, with a bleeding risk 10%~36% and bleeding related mortality risk as high as 25%~55% [1, 2]. Endoscopic injection therapy with Histoacryl (N-butyl-2-cyanoacrylate) is the preferred method in managing acute GV bleeding [3]. For GV, ectopic glue embolism is the most serious complication associated with Histoacryl injection, and this risk increases significantly in patients with co-existing gastro-renal shunt (GRS) [2]. The authors report a case of giant gastric varices with a significant GRS that was treated with a novel method of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic high-dose Histoacryl injection which we coined the acronym E-BRTO. The modified BRTO provided a transient occlusion of the GRS during endoscopic high dose Histoacryl injection. A 46-years-old man with end stage liver disease due to hepatitis B presented with a 3 days history of hematemesis and melena. He was admitted to our hospital in July, 2017. Abdominal magnetic resonance imaging (MRI) revealed hepatic cirrhosis, splenomegaly, ascites, GRS, and varices involving the esophagus and gastric fundus (Figure 1a and 1b). Upper endoscopy showed small esophageal varices and giant varices along the lesser curvature and at the gastric fundus (Figure 2a). The gastric varices appeared to be isolated with red markings, suggestive of recent hemorrhage. A B Figure 1: Imaging of gastric varices: a) MRI images showing the giant GVs and b) prominent GRS. A B Figure 2: a) Endoscopic images of the giant gastric fundal varices. b) Endoscopic images showing injection of tissue adhesive at different locations. Hybrid therapy of the GV was performed starting with E-BRTO. Angiography showed the prominent GRS and giant GV (Figure 3a) before therapy. During the combined intervention, a 5.5 French balloon catheter (Fogarty Thru-Lumen Embolectomy Catheter, Edwards Life sciences LLC, USA) was advanced within the GRS through the right femoral vein. After inflating the balloon to occlude the shunt, E-BRTO was performed. High dose Histoacryl (Compont, Beijing Compont Medical Devices Company, Beijing, China) (a total of 31.5 mL or 63 vials), was injected into the GV in 21 aliquots at different locations (Figure 2b). Each injection adopted the "sandwich" technique: 1.5 ml tissue adhesive sandwiched by 2 mL 50% glucose solution depending on the volume of the needle. At each injection location, satisfactory result was judged by hardening of the varices on gentle probing using the needle catheter. At the end of the intervention, before removing the balloon catheter, a repeat angiogram demonstrated the resolution of GV (Figure 3b). The patient enjoyed an uneventful course after the hybrid therapy. During routine follow up in one month, upper endoscopy demonstrated no change of esophageal varices, but the size of gastric varices had decreased significantly (Figure 4a). At 1 year, the gastric varices had almost completely disappeared (Figure 4b). No re-bleeding developed up to three years so far.
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Citation:Wen Hui Zhang. Management of Gastric Varices with BRTO Assisted Endoscopic High-Dose Histoacryl Injection: A Case Report and Review. Annals of Clinical and Medical Case Reports 2020