A 73-year-old woman with hepatitis B-related cirrhosis was referred to our hospital
with
recurrent episodes of hematochezia. Computed tomography (CT) revealed the presence
of the
rectal–pelvic variceal plexus, as well as ascites ([Fig. 1]). Colonoscopy identified isolated varices with stigmata of recent bleeding in the
upper
rectum ([Fig. 2]). Endoscopic ultrasound (EUS) demonstrated that the rectal varices measured 20 mm
in
diameter and were connected to extraluminal varices via perforating veins ([Fig. 3]
a, b).
Fig. 1 Contrast-enhanced computed tomography image showing the rectal–pelvic variceal plexus
and ascites.
Fig. 2 Colonoscopy images showing: a isolated varices; b stigmata of recent bleeding in upper rectum.
Fig. 3 Endoscopic ultrasound (EUS) images showing the rectal varices: a,
b prior to injection; c, d after coil deployment and
subsequent glue injection, with a significant reduction in Doppler flow.
After the available therapeutic options had been discussed with the patient, she opted
for
EUS-guided coiling and glue embolization for initial hemostasis. Under EUS guidance,
a 19-gauge
needle preloaded with a 0.035-inch × 10-mm × 14-cm embolization coil (Nester, Cook
Medical,
Bloomington, Indiana, USA) was used to puncture the varices. After the coil had been
deployed, 1
mL of cyanoacrylate glue and 1.5 ml of lauromacrogol were injected ([Video 1]). A significant reduction in Doppler flow was observed, confirming the obliteration
of
the varices ([Fig. 3]
c, d). No adverse events were reported during or after the
procedure. A post-procedural plain radiograph revealed the coil positioned in the
pelvis ([Fig. 4]). The patient did not experience any recurrence of hematochezia during a follow-up
period of 6 months.
Successful treatment of bleeding from isolated rectal varices with endoscopic ultrasound-guided
coiling and glue injection.Video 1
Fig. 4 Post-procedural plain radiograph showing the coil in the pelvis.
There is currently no consensus regarding the optimal therapeutic strategy for managing
hemorrhage from isolated rectal varices. Endoscopic glue injection alone guided by
fluoroscopy has recently been recommended [1]. EUS not only facilitates precise intravariceal delivery of embolizing agents, but
also allows for real-time monitoring of the therapeutic effect. The deployment of
a coil serves as a scaffold for the glue, thereby reducing the volume of glue required
and minimizing the risk of ectopic embolization [2]. Our findings demonstrate that EUS-guided coiling, in conjunction with glue injection,
is a safe, effective, and straightforward approach to achieving initial hemostasis
in cases of bleeding from isolated rectal varices.
Endoscopy_UCTN_Code_TTT_1AS_2AZ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
