Embolic complications associated with endoscopic injection of cyanoacrylate for bleeding duodenal ulcer

An 87-year-old man with severe cardiac disease, on treatment with an antiplatelet agent, was admitted to our department with acute melena, in a hemodynamically unstable state, and with a hemoglobin level of 6 mg/dL. Emergency endoscopy revealed an extensive ulcer in the anterosuperior bulb wall with pulsatile bleeding. This was initially injected with epinephrine and fibrin glue (as it was a deep ulcerated lesion). When this failed to stop the bleeding, we used a 1 : 0.6 mixture of N-butyl-2-cyanoacrylate (NB2C; Histoacryl) and lipiodol, which did stop it. At second-look endoscopy, a large pulsatile vessel was still present ([Fig. 1 ] a), which was permanently occluded after a second NB2C application ([Fig. 1 ] b). Five days later, the patient developed febrile peaks (40 °C) without complaints but with leukocytosis and a five-fold increase in levels of aminotransferases, amylase, and lipase. A thoracoabdominal computed tomography (CT) scan showed linear opacification of the common hepatic artery ([Fig. 2 ] a), its right branch, and some splenic branches ([Fig. 2 ] b), with a heterogeneous area in the spleen ([Fig. 2 ] b) and in the pancreatic head ([Fig. 3]) highly suggestive of infarction lesions. The patient started treatment with an intravenous broad-spectrum antibiotic, along with nutritional support measures, and the liver test parameters improved considerably. Blood cultures failed to isolate any bacterial strain. The patient was discharged on day 15. Six-month imaging follow-up showed remarkable improvement.

Fig. 1 Ulcer on the anterosuperior bulb wall, on 24-hour second-look endoscopy: a with visible vessel; b after second NB2C treatment.

Fig. 2 Abdominal CT scan showing radiopaque material in a the common hepatic artery and b its right branch and some splenic branches. Multiple areas of splenic infarctions are visible in b.

Fig. 3 Abdominal CT scan showing a heterogeneous area in the pancreatic head.

Bleeding peptic ulcer is still the main cause of upper gastrointestinal hemorrhage [1]. Several endoscopic hemostatic methods of similar efficacy are currently available [1]. The use of NB2C, a successful and well-established substance used in variceal hemorrhage, is still controversial in the context of bleeding peptic ulcer [2] [3]. Encouraging results have shown it to have good hemostatic efficacy when conventional endoscopic techniques have failed to control bleeding [2] [3]. However, it has been associated with severe embolization with infarction [2] [4] [5]. The present case highlights a potential adverse effect of cyanoacrylate use.

Endoscopy_UCTN_Code_CPL_1AH_2AC

References

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• 2 Repici A. et al. Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis.  Dig Liver Dis. 2002;  34 349-355
• 3 Kok K Y, Kum C K, Goh P M. et al . Endoscopic hemostasis of upper gastrointestinal bleeding with histoacryl: last resort before surgery.  Endoscopy. 1996;  28 256-258
• 4 Lee G H, Kim J H, Lee K J. et al . Life threatening intraabdominal arterial embolization after histoacryl injection for bleeding gastric ulcer.  Endoscopy. 2000;  32 422-424
• 5 Vallieres E, Jamieson C, Haber G B. et al . Pancreatoduodenal necrosis after endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: a case report.  Surgery. 1989;  106 901-903