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267 SYSTEMIC EMBOLI FOLLOWING GASTRIC VARICEAL GLUING A Chatterjee, G May, P Kortan We present the case of a 26 year old man transferred to our unit from the community because of hematemesis and melena. There was no history of liver disease or significant alcohol use. The initial upper endoscopy revealed esophageal varices with high-risk stigmata as well as large gastric varices. The patient was treated with rubber banding of esophageal varices and he was monitored in hospital. Lab investigations revealed normal liver enzymes and negative viral, metabolic, and autoimmune screens. CAT scan of abdomen demonstrated a small nodular liver consistent with cirrhosis, splenomegaly, ascites and extensive gastroesophageal, gastrohepatic, and gastrosplenic varices. Doppler examination demonstrated patent portal, splenic and hepatic veins. The liver biopsy showed mild fibrosis and no activity.
Division of Gastroenterology, St Michael's Hospital, University of Toronto, Toronto, Ontario
Recurrent hematemesis and melena resulted in a decision to glue his gastric varices. The patient was consented and gastroscopy revealed small esophageal varices with ulcerations related to previous banding. One cluster of gastric varices had a platelet plug. This varix was injected with 1 ml of glue (50% mix of histoacryl (n-butyl cyanoacrylate); Braun Tuttlinger, Germany and Lipiodol; Ezem Montreal, Canada). A second injection of 1 ml was required to obtain complete obturation. Continued bleeding overnight prompted a repeat gastroscopy revealing a blood clot on an untreated gastric varix and this was injected with glue. Following the second 1 ml injection the patient developed tonic-clonic seizures. A Code Blue was initiated and he was transferred to the ICU. A CAT scan revealed multiple emboli in the brain, heart, liver, spleen and kidneys. During his early ICU stay he was non-responsive, and his troponins and creatinine peaked at 25.3 and 150, respectively. The patient has had a significant functional recovery and is currently independent with his activities of daily living.
Although there are several reports in the literature of systemic emboli following cyanoacrylate injection, it is unusual that the lungs were spared. We review the literature and discuss possible explanations for this rare phenomenon.