EUS-guided cyanoacrylate glue injection for the management of refractory bleeding from postglue ulcer following gastric varices treatment (with video)

Gastric varices (GVs) can be observed in 20%–30% of patients with portal hypertensive and cause severe upper gastrointestinal bleed.[1] Endoscopic cyanoacrylate injection is the recommended treatment for hemostasis and prevention of rebleeding from GVs.[2,3] Ulcer can form at the site of glue injection over GV, and it can cause rebleeding. In addition to drug therapy, several modalities have been reported including cyanoacrylate reinjection, transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO), with variable treatment success.[4] Here we present a case using EUS-guided cyanoacrylate glue injection to control refractory bleeding from postglue ulcer following GV treatment. A 60-year-old female patient presented with hematemesis 1 month following treatment for esophageal varices and GVs resulting from hepatitis C–related cirrhosis. Her Child-Pugh score was categorized as B/8, with a MELD (Model for End-Stage Liver Disease) score of 10. After resuscitation, emergency endoscopy identified active bleeding from postglue ulcer attributed to cyanoacrylate glue injection used in treating GOV2 GVs [Figure 1]. Ten milliliters of sclerosant and 4 mL cyanoacrylate were injected into the gastric fundal varices at 3 points by a sandwich method (sclerosant, cyanoacrylate, and hypertonic glucose) via endoscope. Twenty-four hours afterward, bleeding had persisted despite emergency treatment. The patient’s previous computed tomography venography scan of the portal vein done 1 month back showed occlusions in the main, right, and left branches of the portal vein [Figure 2], complicating hemostasis strategy implementation. TIPS and BRTO are difficult to perform. EUS-guided cyanoacrylate glue injection emerged as a preferable therapeutic approach EUS-guided cyanoacrylate glue injection emerged as a preferable therapeutic approach [Video 1]. EUS assessment detected a gastric fundal varix with increased flow signals; a varix with a flow signal tract was seen going from the varix toward the postglue ulcer, although part of the visual field showed hyperechogenicity due to prior cyanoacrylate glue injections [Figure 3]. With EUS guidance, a Cook echo-tip 19-gauge EUS needle was inserted into the gastric fundal variceal vein, delivering 7 mL of sclerosant and 1.5 mL of cyanoacrylate, effectively obliterating the varix confirmed by EUS-Doppler imaging [Figure 4A]. Follow-up endoscopy confirmed the cessation of active bleeding [Figure 4B]. Within 24 hours, the patient experienced minor melena on 2 occasions, yet no significant drop in hemoglobin levels was observed compared with pretreatment assessments. At follow-up 1 month later, endoscopy revealed the persistence of the postglue ulcer [Figure 5]; however, no active bleeding was observed, and there were no occurrences of significant complications.Figure 1: Active bleeding from postglue ulcer.Figure 2: Computed tomography venography of the portal vein showed occlusions in the main, right, and left branches of the portal vein.Figure 3: EUS illustrated a gastric fundal varix with increased flow signals, going from the varix toward the postglue ulcer.Figure 4: The varix’s flow signal almost disappeared after EUS-guided coil and cyanoacrylate injection (A). Follow-up endoscopy confirmed the cessation of active bleeding (B).Figure 5: Endoscopy revealed the persistence of the postglue ulcer after 1 month.There is an approximately 85.8% of patients having glue extrusion 1 month after glue injection for GV.[5] Early rebleeding is potentially due to ulcer formation at the injection site. Postglue ulcer is attributed to inaccurate needle placement within the vessel, the injection of an improper glue volume, and the deeper vessel. In this case, the patient’s hematemesis stemmed from ulceration following earlier direct endoscopic cyanoacrylate treatment, leading to hardened GVs and difficulty in identifying suitable sites for hemostasis injections. Emergency endoscopic cyanoacrylate glue injection hemostasis was not effective. Additionally, occlusions within the portal vein added complexity to the TIPS and BRTO procedure. EUS-guided cyanoacrylate glue injection was the only therapeutic method available.[6] EUS revealed the presence of a high echo shadow caused by postglue ulcer, which presents challenges for direct hemostatic treatment from the ulcer surface. However, EUS uses a forward strabismus lens, allowing glue injection from the side unaffected by the high echo shadow. This method offers enhanced precision by allowing for accurate visualization of the targeted blood vessels and minimizing the amount of glue used.[7] Furthermore, EUS incorporates Doppler imaging to provide immediate hemostasis feedback and assess the effectiveness of the treatment. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Legend","caption":"Endoscopy showed active bleeding from post-glue ulcer. EUS assessment detected a gastric fundal varix with increased flow signals, a varix with a flow signal tract was seen going from the varix toward the post-glue ulcer. With EUS guidance, a Cook Echo Tip 19G EUS needle was inserted into the gastric fundal variceal vein, delivering 7 mL of sclerosant and 1.5 mL of cyanoacrylate, effectively obliterating the varix confirmed by EUS-Doppler imaging. Follow-up endoscopy confirmed the cessation of active bleeding.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_b406fubr"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Declaration of Patient Consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity.