Post written by Yusuke Hashimoto, MD, from the Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan.
This case describes a 76-year-old woman with unresectable pancreatic head cancer who presented with hematemesis that was complicated by multinodular duodenal varices originating from a posterior lower pancreatic vein viewed on CT scan. Banding was initially performed by a prior endoscopist but failed to treat multinodular duodenal varices adequately. EUS showed the remaining duodenal varices with rich blood flow, and EUS-guided injection of N-butyl-2-cyanoacrylate was performed. Under EUS guidance, the target varix was punctured with the 22G EUS-FNA needle. After backflow of blood into the needle was confirmed, saline solution was injected into the varix. Immediately thereafter, 0.5 mL of undiluted CA was injected, followed by saline solution. We confirmed instant decreased blood flow in duodenal varices under EUS visualization. Follow-up CT showed extinction of contrast enhancement of the varices. The patient was discharged 15 days after the procedure. At her 12 month of follow-up visit after the procedure, the patient was able to continue on chemotherapy and had not experienced any new episodes of bleeding.
Duodenal varix rupture is a rare condition of upper gastrointestinal bleeding. The patient manifested marked left sided portal hypertension secondary to malignant tumor compression on portal vein. Although interventional radiology is a commonly selected therapeutic option using percutaneous approach via transhepatic portal vein or left renal-adrenal to obliterate upper gastrointestinal varices, portal vein compression or invasion by interposing malignant tumor was an anatomical difficulty of access to posterior lower pancreatic vein in this case. This rationalized therapeutic selection of EUS-guided local injection of N-butyl-2-cyanoacrylate to the varices for successful obliteration.
EUS-guided injection of N-butyl-2-cyanoacrylate and coiling therapy have been reported as highly effective and safe in obliterating gastric varices (Bhat MD, et al, Gastrointest Endosc 2016;83:1164-72). The authors suggested that they determined what emboli material to use depending on size of varix. In this case, we identified the active duodenal varices and the feeder vein under EUS. We injected pure N-butyl-2-cyanoacrylate into the varices and the feeder measuring about 10 mm with small space unavailable for coil placement. Pure N-butyl-2-cyanoacrylate becomes solidified instantly to react chemically to blood and may reduce the risk of distant embolization, though we needed to exchange the EUS–FNA needle after every single use. This case also highlights the advantage of EUS-guided intervention in visualizing active varices, needle puncture, injection, and occlusion under color doppler flow in real time throughout the procedure.
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