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Case Reports
. 2022 Jun 26;10(18):6254-6260.
doi: 10.12998/wjcc.v10.i18.6254.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

Jian Yang  1 , Yan Zeng  2 , Jun-Wen Zhang  3
Affiliations
Case Reports

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

Jian Yang et al. World J Clin Cases. .

Abstract

Background: Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

Case summary: A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

Conclusion: EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Keywords: Case report; Endoscopic ultrasound; Gastric varices; Left-sided portal hypertension; N-butyl-2-cyanoacrylate; Selective.

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Conflict of interest statement

Conflict-of-interest statement: The authors declare that they have no conflict of interest.

Figures

Figure 1
Figure 1
Gastroscopic image. Gastroscopy revealed gastric variceal with signs of recent bleeding in the absence of active bleeding.
Figure 2
Figure 2
Abdominal computed tomography venography image. Computed tomography venography revealed stenosis of the proximal superior mesenteric vein (red arrow), invisible proximal splenic vein, and increased collateral circulations (yellow arrows).
Figure 3
Figure 3
Endoscopic ultrasound images. A: Endoscopic ultrasound revealed an enlarged portal vein; B: A confluence of gastric varices was identified and selected as the injection site (red arrow); C: Undiluted N-butyl-2-cyanoacrylate (red arrow) was injected into the selected gastric varix via a 22-gauge needle; D: Hyperechoic fillings (red arrow) and decreased blood flow signals were observed after injections.
Figure 4
Figure 4
Gastroscopic image. With the help of biopsy forceps, the follow-up gastroscopy revealed firm gastric submucosa and no sign of N-butyl-2-cyanoacrylate expulsion.
Figure 5
Figure 5
Computed tomography venography image. Compared with the results before the operation (Figure 2), follow-up computed tomography venography revealed improvements in left-sided portal hypertension and collateral circulations (red arrows).
See this image and copyright information in PMC

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