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INJECTION OF CYANOACRYLATE TO MANAGE BLEEDING SMALL BOWEL VARICES: CASE REPORT AND LITERATURE REVIEW
M Li, K Czarnecka-Kujawa, K Elgadi, SC Grover
Division of Gastroenterology, St Michael’s Hospital, Toronto, Ontario
Small bowel varices are a rare cause of obscure gastrointestinal hemorrhage in patients with portal hypertension, and can be difficult to diagnose and manage. Management options for bleeding from small bowel varices include injection sclerotherapy with cyanoacrylate or other agents, TIPS and liver transplantation.
We report the case of a 43 year old chronic alcoholic who was transferred to our tertiary-care intensive care unit for massive gastrointestinal bleeding from a duodenal varix, which was managed with cyanoacrylate injection. This male patient was admitted to a peripheral hospital with maroon coloured rectal bleeding. A first gastroscopy revealed no gastro-esophageal varices or cause for bleeding. On arrival to our intensive care unit, the patient was hemodynamically stable but had ongoing maroon-coloured stool, and his hemoglobin had not responded to blood transfusion. His platelet count was 55 × 109/L and his INR was 1.64. Octreotide and pantoprazole infusions were initiated. Repeat gastroscopy showed portal gastropathy, but again no gastro-esophageal varices were seen. A colonoscopy and ileoscopy revealed only fresh blood coming from beyond the reach of the colonoscope. The bleeding was refractory to tranexamic acid, transfusion of blood products, and administration of recombinant Factor VIIA. An enhanced abdominal CT scan showed extravasated blood in the distal duodenum; this led us to perform an enteroscopy, which detected a distal duodenal varix with a nipple lesion and stigmata of recent hemorrhage. We injected 2 cc of cyanoacrylate mixed 1:1 with lipiodol intravariceally. The patient’s bleeding stopped; however, he succumbed to complications of systemic inflammatory response syndrome over the next two days.
Bleeding from small bowel varices is a life-threatening complication of liver cirrhosis and the diagnosis and management remains challenging. The literature shows successful cases of endoscopic injection therapy of small bowel varices with cyanoacrylate, which can be administered by conventional or double-balloon enteroscope. Other identified therapeutic modalities are TIPS, ileocolic vein obliteration, percutaneous coil interventions, and liver transplantation, which can be offered to patients with refractory hemorrhage. Patient, physician, and hospital factors may identify which therapy is most appropriate.