Post written by Victoria Gómez, MD, from the Mayo Clinic, Jacksonville, Florida, USA.

We present a case of a 58-year-old woman in whom challenging gastric fundic varices were managed successfully with endoscopic variceal obturation using EUS-guided coil placement with subsequent glue injection.

Treatment options were limited in this patient due to radiographic findings of liver cirrhosis with diffuse areas of multifocal hepatocellular carcinoma, bland and tumor thrombus within the portal vein, and a large splenorenal shunt. Given the multifocal hepatocellular carcinoma, liver transplantation was not an option. Banding of gastric varices was not an option as this is seldom successful and can increase the risk of significant bleeding and mortality. TIPS was not recommended given the extensive portal vein thrombus burden seen on CT imaging. Balloon-occluded retrograde transvenous obliteration with variceal embolization would have quickly exacerbated hepatic decompensation. Thus, despite the increased risk of embolic events given the large splenorenal shunt with EUS-guided coiling and gluing, the patient desired treatment, and this procedure was determined the best treatment option for the specific patient and case.

EUS was performed. Coiling was first carried out on the identified large cluster of fundic gastric varices. The deeper gastric varices were first targeted by puncturing the fine aspiration needle deep into the variceal cluster, followed by deployment of a coil. Coils were repeatedly placed into the varices working into the more superficial vessels. Once coiling was complete, cyanoacrylate was injected, also starting with the deeper clusters of gastric varices. In total, 11 coils were placed, followed by 12 mL of cyanoacrylate glue. Post deployment and injection, EUS demonstrated significantly diminished lack of flow within the variceal cluster. The patient’s post-procedure hospital course was uneventful, and repeat EGD and EUS performed 4 days later demonstrated little to no flow within the treated gastric varices, indicating adequate treatment.

Because of a higher tendency for massive hemorrhage and higher mortality rates, gastric variceal bleeds are challenging to manage with conventional techniques. The emerging use of endoscopic ultrasound provides a promising management option. Given limited treatment options in this case and after extensive discussion with multidisciplinary team members, EUS-guided placement of coils into the gastric varices followed by glue injection was determined to be the best treatment option for the specific patient and case. Here, we successfully demonstrated that EUS-guided coil placement may serve as a scaffold for subsequent glue injection, leading to obliteration of varices.

Endoscopic variceal obturation appears to be highly promising in achieving hemostasis in active bleeding and primary and secondary bleeding prophylaxis. Nonetheless, gastric fundic varices are challenging to manage, and a multidisciplinary approach with careful, extensive discussion must be taken when determining the best treatment option.

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