Raymond S. Tang, MD, from the Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, in Hong Kong, China presents this VideoGIE case “EUS-guided cyanoacrylate injection for treatment of endoscopically obscured bleeding gastric varices.”

Variceal bleeding is still a potentially lethal adverse event of cirrhosis. While resuscitation, early use of vasoactive drugs such as somatostatin analogue, antibiotic prophylaxis, and timely endoscopic intervention contribute to improved outcomes in recent years, there are still patients who would present with torrential variceal bleeding requiring repeated endoscopic intervention, balloon tamponade, TIPS, or even surgery for rescue.

This video describes the use of EUS-guided cyanoacrylate injection therapy in treating endoscopically obscured bleeding gastric varices that fail conventional cyanoacrylate injection by gastroscope,  and balloon tamponade in a patient unfit for TIPS.

Cyanoacrylate injection (CI) is the preferred endoscopic treatment for bleeding gastric varices (GV) when available. However, conventional CI requires direct visualization of the target GV, which may not be possible in the setting of massive bleeding.

Our patient is a 49-year-old man with alcoholic cirrhosis who presented with fundal GV bleeding, which was initially treated by conventional CI. However, rebleeding with shock developed shortly, requiring balloon tamponade. Recurrent bleeding again developed after balloon deflation 24 hours later. On repeated endoscopy, the culprit GV was persistently obscured by fresh blood and clots despite aggressive lavage and changes in the patient’s position. Because the patient remained in shock despite transfusion and support by vasopressor agents, and could not undergo portosystemic shunting because of his cardiopulmonary comorbidities, EUS was performed to identify the GV to guide CI (Fig. 1; Video 1, available at http://www.giejournal.org). Three CIs were performed with a 19-gauge needle and real-time Doppler confirmation of vascular signal loss in GV, without adverse event. The patient was eventually discharged and experienced no rebleeding during a 12-month follow-up period.

GV bleeding is generally more severe than esophageal variceal bleeding and conventional endoscopic cyanoacrylate injection may not be possible due to torrential bleeding. As interventional EUS has been increasingly used over time, it is worthwhile to describe a EUS-based technique to guide therapy for difficult to control GV bleeding due to lack of endoscopic view.

In patients with refractory bleeding from endoscopically obscured GV, EUS-guided cyanoacrylate injection is an effective option for acute bleeding control when other standard treatments fail or not suitable for the patients.

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