EUS GUIDED COIL PLACEMENT FOR THE MANAGEMENT OF ACUTE GASTRIC VARICES BLEEDING FOLLOWING UNSUCCESSFUL GLUE INJECTION

Background:

Endoscopic ultrasound (EUS) guided coil placement is a new emerging technique for the management of gastric varices. In this video case report, we describe the EUS guided single coil placement for managing acute gastric varices (GVs) bleeding following glue injection.

Case report:

A 51-year old male with known primary sclerosing cholangitis and liver cirrhosis was referred to the endoscopy lab for Histoacryl glue therapy of GVs as a prerequisite before evaluation for liver transplantation. Upper endoscopy was performed using a therapeutic gastroscope (Olympus, 2TH-180, Tokyo, Japan). Protruding varices, seen by retroflection of the endoscope, were located in the fundus (Sarin GOV2). Following a single injection of 1.3 ml mixture of 0.8 ml Lipiodol and 0.5 ml Histoacryl, an acute bleeding occurred, rapidly filling the stomach with blood and obscuring the endoscopic view. Due to the unavailability of urgent transjugular intrahepatic portosystemic shunt (TIPS), an endoscopic ultrasound was performed by linear array echoendoscope (Pentax EG-3870TK, Tokyo, Japan) and GVs were identified as round and oval shaped anechoic structures (30 × 20 mm) within submucosa and were confirmed by demonstration of flow by color-Doppler. The previously injected Histoacryl glue was identified as a hyperechoic structure that was not completely filling the lumen of the GVs. Under EUS guidance, a 19 gauge EUS needle (EchoTip, Cook Medical, Salem, USA) was used to puncture vessel of the GV and a single 12 mm coil for intravascular use (Nester, Cook Medical, Bloomington, USA) was placed inside the varices using the stylet of the EUS needle. A second-look endoscopy was performed after four days and showed continued hemostasis.

Conclusion:

EUS guided coil placement can be implemented to achieve hemostasis in acute GVs bleeding following unsuccessful glue injection.