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Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate
Y-M Tan, K-L Goh, A Kamarulzaman, et al.
BRIEF REPORTS Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate Yan-Mei Tan, MRCP, Khean-Lee Goh, MD, Adeeba Kamarulzaman, FRACP, Patrick S.Tan, FRCA, Prabhakeran Ranjeev, MRCP, Omar Salem, MMed, Andy E. Vasudevan, MMed, Md-Said Rosaida, MMed, Mohamed Rosmawati, MD, Lian-Huat Tan, MMed
Endoscopic injection of the tissue adhesive cyanoacrylate in the treatment of bleeding esophagogastric varices was first described by Soehendra et al.1 in 1986. Since then, this modality has become widely established in the treatment of bleeding esophagogastric varices. It is now the treatment of choice in many regions of the world for obliteration of gastric varices.2,3 Common complications of the procedure include transient chest pain and fever.4,5 Distal embolization has been described,5-10 in some cases with a fatal outcome.9 Although this outcome is rare, patients undergoing treatment of gastric varices with cyanoacrylate, especially as an elective procedure, should be made aware of the risk of this potentially life-threatening complication. This is a report of a case of near-fatal multiple pulmonary embolisms and splenic infarction with septicemia after elective obliteration of gastric varices with cyanoacrylate. From the Department of Medicine and Anesthesia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Reprint requests: Yan-Mei Tan, Department of Medicine, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/54/118651 doi:10.1067/mge.2001.118651 276
GASTROINTESTINAL ENDOSCOPY
Brief Reports
CASE REPORT A 53-year-old man with known hepatitis B-related liver cirrhosis, portal hypertension, and hypersplenism was admitted with a 1-week history of high-grade fever associated with chills and rigors. Apart from passing loose stools for 2 days, there were no other symptoms. Large fundal varices were noted at gastroscopy 1.5 months before admission. Elective endoscopic obliteration of the gastric varices was performed with N-butyl-2-cyanoacrylate (Histoacryl, BBraun Surgical GmbH, Melsungen, Germany) by using a mixture of 0.5 mL Histoacryl and 0.7 mL Lipiodol (Laboratoire Guerbet, Aulnay-Sous-Bois, France). The Histoacryl-Lipiodol mixture was injected at 4 points on the gastric varices through a 21-gauge needle (Injector Force, NM-200L-0821, Olympus Optical Co., Ltd., Tokyo, Japan). Two weeks before hospitalization, he underwent a second session of Histoacryl-Lipiodol injection (ratio 0.5 mL:0.7 mL; 2 injections of 0.5 mL), again seemingly without sequelae. On examination, the patient was in no distress but was febrile (temperature 38°C) and jaundiced. The chest was clear, abdomen was soft and nontender, and there was no hepatomegaly although the spleen was just palpable. A plain chest radiograph revealed an opacification at the right pulmonary hilar region (Fig. 1). Abdominal US did not reveal any collections or focal lesions. Blood culture yielded streptococcus sp (group F). A gram-negative filamentous organism was also seen on a smear from the anaerobic culture bottle, but this organism could not be cultured. The patient was initially treated by intravenous administration of ceftriaxone, but he continued to have spiking fever and subsequently went into septic shock. CT revealed occlusion of the right descending pulmonary artery with Lipiodol with multiple wedge-shaped lung infarctions (Fig. 2). A wedge-shaped splenic infarct was also noted (Fig. 3). Echocardiography showed essentially normal results with no evidence of a patent foramen ovale. The antibiotic was changed to imipenem. With intensified supportive treatment and monitoring in the intensive care unit, the fever resolved and the patient’s condition stabilized. CT showed radiologic improvement of both lung and splenic lesions, and he was well enough to be discharged after 15 days of hospitalization. VOLUME 55, NO. 2, 2002
Brief Reports
Y-M Tan, K-L Goh, A Kamarulzaman, et al.
Figure 2. CT of chest showing bilateral pulmonary infarcts (arrows) and radiopaque Histoacryl-Lipiodol in the descending branch of right pulmonary artery (arrowhead).
Figure 1. Chest radiograph showing opacification at right hilar region (arrow).
DISCUSSION Undiluted cyanoacrylate polymerizes almost immediately on contact with blood, thus securing rapid hemostasis.11,12 D’Imperio et al.13 reported 2 cases in which the injection needle became stuck in the newly formed polymer; fatal hemorrhage occurred in 1 of these patients after forced needle extraction. Variceal injection with a mixture of Histoacryl and Lipiodol is widely practiced2,4,14,15 because the Lipiodol prevents the tissue adhesive from hardening too quickly and allows for radiographic monitoring. The majority of cases of distal embolization with Histoacryl injection have occurred when a mixture of Histoacryl and Lipiodol was used. The rare, serious complications that have been reported include pulmonary, cerebral, and coronary embolism as well as portal and splenic vein thrombosis.5-8 Delayed polymerization of the Histoacryl-Lipiodol mixture has been suggested as a possible explanation.10 In our case, it is probable that pulmonary embolization of Histoacryl from the varix occurred by means of the collateral portosystemic circulation and presumably through anomalous arteriovenous pulmonary shunts to cause paradoxical splenic infarction. Over the past 2 years, 56 sessions of gastric variceal obliteration with Histoacryl have been performed by us in 31 patients.16 There were no complications observed as a result of this procedure. Similar to other investigators,2-4,14,15 our findings are that this modality is safe and effective in the treatment of bleeding gastric varices. However, endoscopists should be aware of the potential, though rare, complication of VOLUME 55, NO. 2, 2002
Figure 3. CT of abdomen demonstrating wedge-shaped splenic infarct (arrow).
distal embolization and septicemia in the patient who has persistent fever develop with or without other systemic signs of complications after injection therapy, even after the patient has been discharged. REFERENCES 1. Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986;18:25-6. 2. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CV, Poon SK, et al. Endoscopic treatment of bleeding gastric varices by Nbutyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160-7. 3. Ogawa K, Ishikawa S, Naritaka Y, Shimakawa T, Wagatsuma Y, Katsube A, et al. Clinical evaluation of endoscopic injection sclerotherapy using n-butyl-2-cyanoacrylate for gastric variceal bleeding. J Gastroenterol Hepatol 1999;14:245-50. 4. Feretis C, Tabakopoulos D, Benakis P, Xenofontos M, Golematis B. Endoscopic hemostasis of esophageal and gastric variceal bleeding with Histoacryl. Endoscopy 1990;22:282-4. GASTROINTESTINAL ENDOSCOPY
277
5. Naga M, Foda A. An unusual complication of Histoacryl injection. Endoscopy 1997;29:140. 6. Palejwala AA, Smart HL, Hughes M. Multiple pulmonary glue emboli following gastric variceal obliteration [abstract]. Endoscopy 2000;32:S1-2. 7. Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30:S89-90. 8. Shim CS, Cho JD, Kim JO, Bong HK, Kim YS, Lee JS, et al. A case of portal and splenic vein thrombosis after Histoacryl injection therapy in gastric varices. Endoscopy 1996;28:461. 9. Tsokos M, Bartel A, Schoel R, Rabenhorst G, Schwerk WB. Todliche Lungenarterienembolie nach endoskopischer Embolisation einer “Down-hill Varize” des Oesophagus. Dtsch Med Wochenschr 1998;123:691-5. 10. See A, Florent C, Lamy P, Levy VG, Bouvry M. Accidents vasculaires cérébraux aprés obturation endoscopique des varices oesophagiennes par l’isobutyl-2-cyanoacrylate en 2 patients. Gastroenterol Clin Biol 1986;10:604-07. 11. Spiegel SM, Vinuela F, Goidwasser JM, Fox AJ, Pelz DM.
278
GASTROINTESTINAL ENDOSCOPY
12.
13.
14.
15.
16.
Adjusting the polymerization time of isobutyl-2-cyanoacrylate. Am J Neuroradiol 1986;7:109-12. Goldman ML, Freeny PC, Tallman JM, Galambos JT, Bradley EL 3rd, Salem A, et al. Transcatheter vascular occlusion therapy with isobutyl 2-cyanoacrylate (Bucrylate) for control of massive upper-gastrointestinal bleeding. Radiology 1978;129:41-9. D’Imperio N, Piemontese A, Baroncini D, Billi P, Borioni D, Dal Monte PP, et al. Evaluation of undiluted n-butyl-2-cyanoacrylate in the endoscopic treatment of upper gastrointestinal tract varices. Endoscopy 1996;28:239-43. Sohendra N, Grimm H, Nam VC, Berger B. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 1987;19:221-4. Ramond MJ, Valla D, Mosnier JF, Degott C, Bernuau J, Rueff B, et al. Successful endoscopic obturation of gastric varices with butyl cyanoacrylate. Hepatology 1989;10:488-93. Rosaida MS, Goh KL, Ranjeev P, Tan YM, Rosmawati M, Salem O. Histoacryl injection therapy: The endoscopic treatment of gastro-esophageal varices [abstract]. Med J Malaysia 2000;55(Suppl A):25.
VOLUME 55, NO. 2, 2002
BRIEF REPORTS Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate Yan-Mei Tan, MRCP, Khean-Lee Goh, MD, Adeeba Kamarulzaman, FRACP, Patrick S.Tan, FRCA, Prabhakeran Ranjeev, MRCP, Omar Salem, MMed, Andy E. Vasudevan, MMed, Md-Said Rosaida, MMed, Mohamed Rosmawati, MD, Lian-Huat Tan, MMed
Endoscopic injection of the tissue adhesive cyanoacrylate in the treatment of bleeding esophagogastric varices was first described by Soehendra et al.1 in 1986. Since then, this modality has become widely established in the treatment of bleeding esophagogastric varices. It is now the treatment of choice in many regions of the world for obliteration of gastric varices.2,3 Common complications of the procedure include transient chest pain and fever.4,5 Distal embolization has been described,5-10 in some cases with a fatal outcome.9 Although this outcome is rare, patients undergoing treatment of gastric varices with cyanoacrylate, especially as an elective procedure, should be made aware of the risk of this potentially life-threatening complication. This is a report of a case of near-fatal multiple pulmonary embolisms and splenic infarction with septicemia after elective obliteration of gastric varices with cyanoacrylate. From the Department of Medicine and Anesthesia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Reprint requests: Yan-Mei Tan, Department of Medicine, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/54/118651 doi:10.1067/mge.2001.118651 276
GASTROINTESTINAL ENDOSCOPY
Brief Reports
CASE REPORT A 53-year-old man with known hepatitis B-related liver cirrhosis, portal hypertension, and hypersplenism was admitted with a 1-week history of high-grade fever associated with chills and rigors. Apart from passing loose stools for 2 days, there were no other symptoms. Large fundal varices were noted at gastroscopy 1.5 months before admission. Elective endoscopic obliteration of the gastric varices was performed with N-butyl-2-cyanoacrylate (Histoacryl, BBraun Surgical GmbH, Melsungen, Germany) by using a mixture of 0.5 mL Histoacryl and 0.7 mL Lipiodol (Laboratoire Guerbet, Aulnay-Sous-Bois, France). The Histoacryl-Lipiodol mixture was injected at 4 points on the gastric varices through a 21-gauge needle (Injector Force, NM-200L-0821, Olympus Optical Co., Ltd., Tokyo, Japan). Two weeks before hospitalization, he underwent a second session of Histoacryl-Lipiodol injection (ratio 0.5 mL:0.7 mL; 2 injections of 0.5 mL), again seemingly without sequelae. On examination, the patient was in no distress but was febrile (temperature 38°C) and jaundiced. The chest was clear, abdomen was soft and nontender, and there was no hepatomegaly although the spleen was just palpable. A plain chest radiograph revealed an opacification at the right pulmonary hilar region (Fig. 1). Abdominal US did not reveal any collections or focal lesions. Blood culture yielded streptococcus sp (group F). A gram-negative filamentous organism was also seen on a smear from the anaerobic culture bottle, but this organism could not be cultured. The patient was initially treated by intravenous administration of ceftriaxone, but he continued to have spiking fever and subsequently went into septic shock. CT revealed occlusion of the right descending pulmonary artery with Lipiodol with multiple wedge-shaped lung infarctions (Fig. 2). A wedge-shaped splenic infarct was also noted (Fig. 3). Echocardiography showed essentially normal results with no evidence of a patent foramen ovale. The antibiotic was changed to imipenem. With intensified supportive treatment and monitoring in the intensive care unit, the fever resolved and the patient’s condition stabilized. CT showed radiologic improvement of both lung and splenic lesions, and he was well enough to be discharged after 15 days of hospitalization. VOLUME 55, NO. 2, 2002
Brief Reports
Y-M Tan, K-L Goh, A Kamarulzaman, et al.
Figure 2. CT of chest showing bilateral pulmonary infarcts (arrows) and radiopaque Histoacryl-Lipiodol in the descending branch of right pulmonary artery (arrowhead).
Figure 1. Chest radiograph showing opacification at right hilar region (arrow).
DISCUSSION Undiluted cyanoacrylate polymerizes almost immediately on contact with blood, thus securing rapid hemostasis.11,12 D’Imperio et al.13 reported 2 cases in which the injection needle became stuck in the newly formed polymer; fatal hemorrhage occurred in 1 of these patients after forced needle extraction. Variceal injection with a mixture of Histoacryl and Lipiodol is widely practiced2,4,14,15 because the Lipiodol prevents the tissue adhesive from hardening too quickly and allows for radiographic monitoring. The majority of cases of distal embolization with Histoacryl injection have occurred when a mixture of Histoacryl and Lipiodol was used. The rare, serious complications that have been reported include pulmonary, cerebral, and coronary embolism as well as portal and splenic vein thrombosis.5-8 Delayed polymerization of the Histoacryl-Lipiodol mixture has been suggested as a possible explanation.10 In our case, it is probable that pulmonary embolization of Histoacryl from the varix occurred by means of the collateral portosystemic circulation and presumably through anomalous arteriovenous pulmonary shunts to cause paradoxical splenic infarction. Over the past 2 years, 56 sessions of gastric variceal obliteration with Histoacryl have been performed by us in 31 patients.16 There were no complications observed as a result of this procedure. Similar to other investigators,2-4,14,15 our findings are that this modality is safe and effective in the treatment of bleeding gastric varices. However, endoscopists should be aware of the potential, though rare, complication of VOLUME 55, NO. 2, 2002
Figure 3. CT of abdomen demonstrating wedge-shaped splenic infarct (arrow).
distal embolization and septicemia in the patient who has persistent fever develop with or without other systemic signs of complications after injection therapy, even after the patient has been discharged. REFERENCES 1. Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986;18:25-6. 2. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CV, Poon SK, et al. Endoscopic treatment of bleeding gastric varices by Nbutyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160-7. 3. Ogawa K, Ishikawa S, Naritaka Y, Shimakawa T, Wagatsuma Y, Katsube A, et al. Clinical evaluation of endoscopic injection sclerotherapy using n-butyl-2-cyanoacrylate for gastric variceal bleeding. J Gastroenterol Hepatol 1999;14:245-50. 4. Feretis C, Tabakopoulos D, Benakis P, Xenofontos M, Golematis B. Endoscopic hemostasis of esophageal and gastric variceal bleeding with Histoacryl. Endoscopy 1990;22:282-4. GASTROINTESTINAL ENDOSCOPY
277
5. Naga M, Foda A. An unusual complication of Histoacryl injection. Endoscopy 1997;29:140. 6. Palejwala AA, Smart HL, Hughes M. Multiple pulmonary glue emboli following gastric variceal obliteration [abstract]. Endoscopy 2000;32:S1-2. 7. Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30:S89-90. 8. Shim CS, Cho JD, Kim JO, Bong HK, Kim YS, Lee JS, et al. A case of portal and splenic vein thrombosis after Histoacryl injection therapy in gastric varices. Endoscopy 1996;28:461. 9. Tsokos M, Bartel A, Schoel R, Rabenhorst G, Schwerk WB. Todliche Lungenarterienembolie nach endoskopischer Embolisation einer “Down-hill Varize” des Oesophagus. Dtsch Med Wochenschr 1998;123:691-5. 10. See A, Florent C, Lamy P, Levy VG, Bouvry M. Accidents vasculaires cérébraux aprés obturation endoscopique des varices oesophagiennes par l’isobutyl-2-cyanoacrylate en 2 patients. Gastroenterol Clin Biol 1986;10:604-07. 11. Spiegel SM, Vinuela F, Goidwasser JM, Fox AJ, Pelz DM.
278
GASTROINTESTINAL ENDOSCOPY
12.
13.
14.
15.
16.
Adjusting the polymerization time of isobutyl-2-cyanoacrylate. Am J Neuroradiol 1986;7:109-12. Goldman ML, Freeny PC, Tallman JM, Galambos JT, Bradley EL 3rd, Salem A, et al. Transcatheter vascular occlusion therapy with isobutyl 2-cyanoacrylate (Bucrylate) for control of massive upper-gastrointestinal bleeding. Radiology 1978;129:41-9. D’Imperio N, Piemontese A, Baroncini D, Billi P, Borioni D, Dal Monte PP, et al. Evaluation of undiluted n-butyl-2-cyanoacrylate in the endoscopic treatment of upper gastrointestinal tract varices. Endoscopy 1996;28:239-43. Sohendra N, Grimm H, Nam VC, Berger B. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 1987;19:221-4. Ramond MJ, Valla D, Mosnier JF, Degott C, Bernuau J, Rueff B, et al. Successful endoscopic obturation of gastric varices with butyl cyanoacrylate. Hepatology 1989;10:488-93. Rosaida MS, Goh KL, Ranjeev P, Tan YM, Rosmawati M, Salem O. Histoacryl injection therapy: The endoscopic treatment of gastro-esophageal varices [abstract]. Med J Malaysia 2000;55(Suppl A):25.
VOLUME 55, NO. 2, 2002