Histoacryl injection for treatment of varices in the ascending colon

A 50-year-old man with alcoholic liver cirrhosis was admitted to our emergency department with massive hematochezia and hypovolemic shock. On admission, laboratory data included hemoglobin 3.1 g/dL, hematocrit 9.9 %, platelet count 81 × 10⁹/L, lactates 13.9 mmol/L, and international normalized ratio 1.29. Resuscitation was initiated with intravenous fluids and transfusion of 4 units of packed red blood cells. Terlipressin 2 mg and ceftriaxone 1 g were administered.

Esophagogastroduodenoscopy revealed small esophageal varices with no evidence of recent bleeding. After oral preparation, total colonoscopy was performed, which showed markedly dilated, tortuous veins with a visible fibrin plug in the ascending colon, indicative of colonic varix with recent bleeding ([Fig. 1 a]); there was no blood in the colon. N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) was injected into the varix, resulting in initial active spurting bleeding from the site of the fibrin plug and from the site of injection ([Fig. 1 b]), which resolved after subsequent injections. In total, 2 mL of Histoacryl was injected ([Fig. 1 c], [Video 1]).

Fig. 1 Histoacryl injection for treatment of varices in the ascending colon. a Ascending colonic varix with visible fibrin plug. b Active spurting bleeding from the site of the fibrin plug and from the site of needle injection with N-butyl-2-cyanoacrylate. c Colonic varix after hemostasis with 2 mL of injected N-butyl-2-cyanoacrylate.

Colonic varix in the ascending colon with a visible fibrin plug. Hemostasis was achieved following injection of 2 mL of N-butyl-2-cyanoacrylate, with initial active spurting bleeding from the site of the injection, which resolved after subsequent injections.

The patient had no recurrent bleeding and hemoglobin levels remained stable. He was discharged 7 days later with nonselective beta blocker medication.

Esophageal varices are a common cause of gastrointestinal bleeding in patients with portal hypertension, but ectopic varices are extremely rare (between 1 % and 5 % of all variceal bleeding), especially in the ascending colon [1] [2]. Because of the infrequency with which bleeding ectopic varices present, the ideal therapeutic intervention is unknown [3] [4]. This is the first report of successful endoscopic hemostasis with injection of N-butyl-2-cyanoacrylate in bleeding ascending colonic varices.

Endoscopy_UCTN_Code_TTT_1AQ_2AZ

Competing interests: None

• References

• 1 Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28: 1154-1158
• 2 Almadi MA, Almessabia A, Wong P et al. Ectopic varices. Gastrointest Endosc 2011; 74: 380-388
• 3 Helmy A, Kahtani K, Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2: 322-334
• 4 Christian K, McCurdy M, Potosky D. Massive hematochezia from ascending colonic varices. West J Emerg Med 2015; 16: 577-578