Cerebral and splenic infarctions after injection of N-butyl-2-cyanoacrylate in esophageal variceal bleeding

Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

Background

Herein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs.

Methods

Ninety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding.

Results

The mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed.

Conclusion

The bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09412-6.

Multi-organ infarction following percutaneous transhepatic esophageal variceal obliteration with glue injection: a case report

Percutaneous transhepatic variceal obliteration (PTVO) is currently one of the best treatment options for controlling acute recurrent bleeding in cirrhotic patients. Nevertheless, this procedure is associated with major and minor complications such as fever, pain, fatal intraperitoneal hemorrhage, and rarely, embolization of embolic agents to the systemic circulation. Only one study has reported systemic emboli following the use of glue-lipiodal mixture for percutaneous transhepatic embolization of esophageal varices and here we report another case of this complication. Here, we report a 44-year-old man presenting with multi-organ infarction following PTVO with glue-Lipiodol mixture. He was a known case of liver cirrhosis who was admitted for recurrent bleeding from esophageal varices. The patient became a candidate for transjugular intrahepatic portosystemic shunt surgery; however, he did not provide consent for this procedure. the patient eventually decided to undergo PTVO as an alternative option. Twelve hours after the procedure, the patient developed neurological symptoms such as left side weakness, dysarthria, and fecal incontinence. Further investigation showed glue particles in brain, liver, spleen and both lungs. Contrast echocardiography and splenoportography did not show any evidence of right-to-left shunt. Thus, conservative management was initiated for the patient, which resulted in the gradual improvement after three weeks. Prior evaluation with splenoportography and contrast echocardiography before performing PTVO may help in the early detection of any connection with systemic circulation. Also, based on the desired procedure, the most appropriate glue/Lipiodol ratio and injection technique should be selected to minimize the risk of adverse events.

Removal of giant blood clots in patients with gastroesophageal variceal bleeding using novel methods: two case reports

Gastroesophageal variceal bleeding is a severe complication of cirrhotic portal hypertension. Endoscopic treatment is recommended as the first-line therapy for gastroesophageal variceal bleeding, and its therapeutic effect is closely related to the visualization of endoscopy. We reported 2 cases of gastric variceal bleeding in which clear endoscopic visualization was obtained with two simple approaches assisted by suction tube and stone retrieval basket, respectively. Endoscopic treatments were successfully conducted after the removal of giant blood clots. Serious complications were not found.

Thromboembolic Events Secondary to Endoscopic Cyanoacrylate Injection: Can We Foresee Any Red Flags?

BACKGROUND

Gastric varices (GV) are associated with high morbidity and mortality in patients with portal hypertension. Endoscopic cyanoacrylate injection is the first-line recommended therapy for GV obliteration. This study aims to explore the reason behind related adverse events and better prevent its occurrence.

METHODS

A retrospective case series study was conducted from January 1, 2013, to December 31, 2016, to identify patients who experienced severe adverse events secondary to endoscopic cyanoacrylate injection. A literature review of similar cases was performed on two medical databases, Medline and Embase.

RESULTS

A total of 652 patients underwent cyanoacrylate injection at our center within the study duration. Five cases of severe adverse events related to the use of tissue adhesives were identified. Detailed clinical presentation, patient treatment, and outcomes were reviewed and analyzed. Twenty-seven similar cases were identified based on the literature review providing further insight into the study.

CONCLUSION

Although rare in incidence, systemic embolism associated with cyanoacrylate injection is often fatal or debilitating. This report may raise awareness in treatment protocol, including the necessity of preoperative angiographic studies, to avoid similar adverse events in clinical practice.

Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review

RATIONALE

Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results.

PATIENT CONCERNS

We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years.

DIAGNOSES

All patients were diagnosed with liver cirrhosis presenting melena or hematemesis.

INTERVENTIONS

All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case).

OUTCOMES

Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case.

LESSONS

EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome

Few case series provide a current, comprehensive, and detailed description of splenic infarction (SI), an uncommon condition.Retrospective chart review complemented by imaging evaluation and patient follow-up.All adult patients with a confirmed diagnosis of acute SI discharged over 10 years from a single academic center were studied. A systematic literature review was done to compile a complete list of SI etiologies.SI was found in 32 patients, 0.016% of admissions. Ages ranged from 18 to 86 (median 64) years. Cardiogenic emboli were the predominant etiology (20/32, 62.5%) and atrial fibrillation was frequent. Other patients had autoimmune disease (12.5%), associated infection (12.5%), or hematological malignancy (6%). Nine of the patients (28%) had been previously healthy or with no recognized morbidity predisposing to SI. In 5 of 9 hitherto silent antiphospholipid syndrome or mitral valve disease had been identified. Two remained cryptogenic. Most patients presented with abdominal pain (84%), often felt in the left upper quadrant or epigastrium. Associated symptoms, leukocytosis or increased serum lactate dehydrogenase occurred inconsistently (∼25% each). Chest X-ray showed suggestive Lt. supra-diaphragmatic findings in 22%. Thus, the typical predisposing factors and/or clinical presentation should suggest SI to the clinician and be followed by early imaging by computed tomography (CT), highly useful also in atypical presentations. Complications were rare and patients were discharged after 6.5 days (median) on anticoagulant treatment. The systematic literature review revealed an extensive list of conditions underlying SI. In some, SI may be the first and presenting manifestation.SI is a rare event but should be considered in predisposed patients or those with any combination of suggestive clinical features, especially abdominal pain CT evaluation is diagnostic and the outcome is good.