Post written by Calvin J. Koh, MBBS, FRCP, FASGE, from The Gastroenterology Group, Gleneagles Hospital, and the Division of Gastroenterology and Hepatology, National University Hospital, and the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

The method of N-butyl-2-cyanoacrylate and Lipiodol injection is more commonly used for hemostasis in gastric variceal injections, but this article demonstrates its utility in an emergent case of esophageal variceal bleeding, where subsequent three-dimensional reconstructed imaging showed the bleeding spot and much of the esophageal portal system were successfully occluded.

Three-dimensional imaging has been used mainly in orthopedic, spine, and neurosurgical fields, but its use in real-time biliary tree imaging in endoscopy has been reported. We have similarly found CT reconstructions to be helpful in the assessment of the extent of esophageal varices, as in this case.

Although only one spot was injected, the reconstructed imaging shows embolization of a signification portion of the esophageal portal circulation in continuity with the bleeding varix.

Esophageal variceal bleeding is a serious adverse event of portal hypertension, and this case is an apt reminder that in bleeding varices, the bleeding spot is often just the tip of the iceberg, and a holistic approach to lowering the portal pressure should be pursued.

Glue injection is part of the armamentarium in the management of bleeding varices, and this case graphically illustrates the interconnected nature of varices with an image.

Three-dimensional reconstructed view of the glue outlining the esophageal varices.

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