Large bleeding rectal varices treated with endoscopic ultrasound-guided coiling and cyanoacrylate injection

There is no consensus as to the optimal treatment strategy for bleeding rectal varices. Current endoscopic options include endoscopic injection sclerotherapy and band ligation. We present the successful use of endoscopic ultrasound (EUS)-guided coil placement and cyanoacrylate injection in obliterating symptomatic large rectal varices.

A 78-year-old woman with cryptogenic cirrhosis presented after multiple admissions for large-volume hematochezia. Esophagogastroduodenoscopy revealed grade 2 gastroesophageal varices. Colonoscopy revealed three distinct variceal columns extending 5 cm proximally from the dentate line ([Fig. 1]). Lower EUS with color Doppler revealed a large feeding varix measuring 45 × 12 mm ([Fig. 2]). Under sonographic guidance, a 19-gauge needle preloaded with a 10 mm embolization coil (MReye, Cook Medical, Winston Salem, NC, USA) was used to puncture the feeding varix and intravariceal coil deployment was confirmed sonographically ([Fig. 3]). This was immediately followed by injection of 1 ml of N-butyl 2-cyanoacrylate (Histoacryl; B. Braun Medical, Bethlehem, PA, USA) and 1.5 ml of 5 % dextrose. Subsequent color Doppler demonstrated significantly attenuated flow.

Fig. 1 Endoscopic view of the three variceal columns (3, 6, and 9 o’clock), extending 5 cm proximal to the dentate line.

Fig. 2 Color Doppler sonographic view of the treated variceal column revealing active blood flow prior to endoscopic ultrasound-guided angiotherapy.

Fig. 3 Endoscopic ultrasound image demonstrating the embolization coil within the varix.

EUS with color Doppler 2 weeks later revealed ongoing flow within the previously treated varix, now measuring 15 × 9 mm. The procedure was repeated as described above, though on this occasion 2 ml of cyanoacrylate was injected following coil deployment to ensure complete obliteration. Cessation of blood flow was confirmed via Doppler US. At 4-week follow-up the patient complained of anal pruritus but no hematochezia. Sigmoidoscopy revealed thrombosed varices, two areas of ulceration, and extravasation of cyanoacrylate encroaching onto the dentate line ([Fig. 4]). The anal pruritus was successfully managed with topical 3 % lidocaine/2.5 % hydrocortisone ointment. No rectal bleeding was reported at 12-week follow-up.

Fig. 4 Sigmoidoscopy at 4-week follow-up showing cyanoacrylate extravasation into the rectal lumen.

Large (> 3 cm) rectal varices are challenging to treat with cyanoacrylate alone, because of the excessive volume of cyanoacrylate needed, which increases the risk of systemic embolization [1] [2]. Embolization coils occupy part of the variceal volume and offer a scaffold for cyanoacrylate which permits the use of smaller volumes of cyanoacrylate, thereby decreasing the risk of systemic embolization [3]. Cyanoacrylate extravasation is less tolerated in rectal than in gastric varices. The resultant patient discomfort may be managed with topical therapies. Our current practice has been revised such that a maximum of 1 ml of cyanoacrylate is injected per session and repeat sessions are performed at weekly intervals if necessary.

Endoscopy_UCTN_Code_TTT_1AS_2AZ

Competing interests: Yes. Mouen A. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical. Anthony Kalloo is a founding member, equity holder, and consultant for Apollo Endosurgery. All other authors have no relevant disclosures.

• References

• 1 Seewald S, Sriram PV, Naga M et al. Cyanoacrylate glue in gastric variceal bleeding. Endoscopy 2002; 34: 926-932
• 2 Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2: 322-334
• 3 Binmoeller KF, Weilert F, Shah JN et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74: 1019-1025