- Email: [email protected]
Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate in a patient with massive rectal variceal bleeding: a case report
Case Reports 2. Juler GL, Labitzke HG, Lamb R, Allen R. The pathogenesis of Dieulafoy’s gastric erosion. Am J Gastroenterol 1984;79:195-200. 3. Schmulewitz N, Baillie J. Dieulafoy lesions: a review of 6 years of experience at a tertiary referral center. Am J Gastroenterol 2001;96: 1688-94. 4. Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy’s lesion. Gastrointest Endosc 2003;58:236-43. 5. Stiegmann GV, Goff JS, Sun JH, Wilborn S. Endoscopic elastic band ligation for active variceal hemorrhage. Am Surg 1989;55:124-8. 6. Brown GR, Harford WV, Jones WF. Endoscopic band ligation of an actively bleeding Dieulafoy lesion. Gastrointest Endosc 1994;40: 501-3. 7. Murray KF, Jennings RW, Fox VL. Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child. Gastrointest Endosc 1996;44:336-9. 8. Wong RM, Ota S, Katoh A, Yamauchi A, Arai K, Kaneko K, et al. Endoscopic ligation for non-esophageal variceal upper gastrointestinal hemorrhage. Endoscopy 1998;30:774-7. 9. Gerson LB, Yap E, Slosberg E, Soetikno RM. Endoscopic band ligation for actively bleeding Dieulafoy’s lesions. Gastrointest Endosc 1999;50: 454-5. 10. Chung IK, Kim EJ, Lee MS, Kim HS, Park SH, Lee MH, et al. Bleeding Dieulafoy’s lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods. Gastrointest Endosc 2000;52:721-4. 11. Nikolaidis N, Zezos P, Giouleme O, Budas K, Marakis G, Paroutoglou G, et al. Endoscopic band ligation of Dieulafoy-like lesions in the upper gastrointestinal tract. Endoscopy 2001;33:754-60. 12. Matsui S, Kamisako T, Kudo M, Inoue R. Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation. Gastrointest Endosc 2002;55:214-8.
13. Hurlstone DP. Successful endoscopic band ligation of duodenal Dieulafoy’s lesions. Further large controlled studies are required. Scand J Gastroenterol 2002;37:620. 14. Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K. Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage. J Laparoendosc Adv Surg Tech A 2002; 12:41-5. 15. Mumtaz R, Shaukat M, Ramirez FC. Outcomes of endoscopic treatment of gastroduodenal Dieulafoy’s lesion with rubber band ligation and thermal/injection therapy. J Clin Gastroenterol 2003;36:310-4. 16. Park CH, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ. A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy’s lesions. Endoscopy 2004;36:677-81. 17. Toyoda H, Fukuda Y, Katano Y, Ebata M, Nagano K, Morita K, et al. Fatal bleeding from a residual vein at the esophageal ulcer base after successful endoscopic variceal ligation. J Clin Gastroenterol 2001;32: 158-60. 18. Raju GS, Faruqi S, Bhutani MS, Soloway R. Catheter probe EUS-assisted treatment with hemoclips of a colonic Dieulafoy’s lesion with recurrent bleeding. Gastrointest Endosc 2004;60:851-4. Current affiliations: Department of Gastroenterology, Changhua Christian Medical Center, Changhua, Taiwan. Reprint requests: Hsu-Heng Yen, MD, Changhua Christian Medical Center, 135 Nanhsiao Street Changhua, 500 Taiwan. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(05)01583-X
Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate in a patient with massive rectal variceal bleeding: a case report Soo H. Ryu, MD, Jeong S. Moon, MD, Il Kim, MD, You S. Kim, MD, Jung H. Lee, MD Seoul, Korea
Bleeding from a varix caused by portal hypertension has been known as a common cause of death in patients with liver cirrhosis.1-3 Endoscopic treatments with different sclerosants and rubber bands for the treatment of bleeding colorectal varices, which are rare but may be massive and fatal, have been used in a few cases but rarely with successful results. N-butyl-2-cyanoacrylate, a tissue adhesive, which has been reported to be effective in the treatment of bleeding gastric varices, has not been commonly used in the treatment of bleeding colorectal varices.4 Here we present a case of massive hemorrhage from a rectal varix that was treated by endoscopic injection with N-butyl-2-cyanoacrylate and followed with a weekly endoscopy for 4 weeks.
A 63-year-old man was admitted from the emergency department because of massive hematochezia. Six months
ago, he was diagnosed and treated with supportive care for multinodular hepatocellular carcinoma combined with advanced alcoholic liver cirrhosis at the outpatient clinic. At that time, no effective treatment for hepatocellular carcinoma was available, because the hepatocellular carcinoma was multinodular and the main portal vein was occluded by tumor thrombus. An EGD performed 6 months ago revealed grade II staged esophageal varices, with no red color sign, and a colonoscopy had not been performed. On physical examination, the patient was cachexic, anemic, and icteric, and tense ascites was noted. Vital signs were as follows: blood pressure, 90/60 mm Hg; resting heart rate, 100 beats per minute; body temperature, 37.0 C; and respiratory rate, 26 breaths per minute. On presentation, laboratory data were notable for the following: Hb, 6.7 g/dL (normal: 13.0-17.0 g/dL); hematocrit, 28.3% (39%-52%); white blood cell count, 4500/mm3 (4000-10,000/mm3); platelet, 67,000/mm3 (150,000-400,000/mm3); serum
632 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 4 : 2005
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CASE REPORT
Case Reports
Figure 1. Emergency colonoscopic view showing a large varix with active bleeding focus in the rectum 5 cm above the anal verge.
Figure 2. Colonoscopic view of rectal varix immediately after endoscopic Histoacryl injection therapy.
alanine aminotransferase, 31 IU/L (0-41 IU/L); serum total protein, 6.2 mg/dL (6.7-8.3 mg/dL); serum albumin, 2.3 mg/ dL (3.8-5.3 mg/dL); total bilirubin, 8.2 mg/dL (0.2-1.0 mg/ dL); prothrombin time international normalized ratio, 1.75; serum urea nitrogen, 17.0 mg/dL (7-22 mg/dL); and creatinine, 0.9 mg/dL (0.5-1.3 mg/dL). Gastric lavage through a nasogastric tube showed no blood; but, a large amount of fresh blood was seen on a diaper and on digital rectal examination. He was resuscitated with 2 units of packed red blood cells, 3 units of fresh frozen plasma, and normal saline solution. An intravenous somatostatin analogue administration was started. Emergently performed EGD revealed esophageal varices with red color signs but no definite active bleeding foci and stigmata. On the colonoscopy, a 2 2-cm, round, large varix, with an active bleeding focus was noted in the rectum 5 cm above the anal verge (Fig. 1). Also, several small caliber rectal varices were seen around the bleeding rectal varix. There was no blood on the sigmoid colon proximal to this bleeding lesion. We hesitated the injection with sclerosant such as 5% ethanolamine oleate or endoscopic band ligation, because the varix was too large to achieve effective hemostasis and prevent massive recurrent bleeding in the near future. The bleeding varix was injected with N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) mixed with lipiodol (1:1) by using a commercial flexible sclerotherapy injector with a 6-mm, 21-gauge needle. Each 2 mL at 2 sites of the bleeding varix, a total of 4 mL, Histoacryl mixed with lipiodol was injected, and the bleeding stopped immediately (Fig. 2). An EUS performed immediately after sclerotherapy revealed a huge rectal varix filled with sclerosant of Histoacryl mixed with lipiodol on the submucosal layer beneath mucosal erosion seemed to be the bleeding focus (Fig. 3). On the sigmoidoscopy performed 1 day later, the rectal varix showed no bleeding and was hard on probing with a catheter tip. The patient was followed with sigmoidoscopy weekly for
4 weeks. An endoscopic examination of the rectum 1 week later revealed a shallow ulcer on the surface of the varix (Fig. 4). Two weeks later, sigmoidoscopy showed a deep ulcer on a part of the treated varix and a Histoacryl cast extruding outside on the other part of it (Fig. 5). During an endoscopic examination 3 and 4 weeks later, the deep ulcer previously noted was fully healed and the Histoacryl cast was nearly totally sloughed into the rectal lumen (Fig. 6). During hospitalization, a follow-up endoscopy revealed that the variceal size was significantly reduced, and no bleeding was noted at the treated varix. Also, during the follow-up period on an outpatient base, the patient had no complaint, except poor oral intake because of chronic terminal disease. We
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Volume 62, No. 4 : 2005 GASTROINTESTINAL ENDOSCOPY 633
Figure 3. EUS image immediately after sclerotherapy, showing huge rectal varix filled with sclerosant of Histoacryl on the submucosal layer.
Case Reports
Figure 4. Endoscopic examination of the rectum 1 week later, showing a shallow ulcer on the surface of the treated varix.
Figure 6. Follow-up endoscopic finding 4 weeks later, showing significantly reduced variceal size and Histoacryl cast nearly totally sloughed into the rectal lumen.
The ectopic varices resulting from portal hypertension are large venous collaterals occurring anywhere in the abdomen, including in the duodenum, the jejunum, the ileum, the cecum, the colon, the rectum, and the peritoneum, except in the cardioesophageal region.5 Ectopic varices are relatively common findings at endoscopy in patients with portal hypertension. Anorectal varices, one of the most common sites for colorectal varices,2 could be found in 40% of patients with portal hypertension who undergo colonoscopy.6,7 However, bleeding from ectopic varices have been known to be rare, accounting for 1% to 5% of all variceal bleeding.7-10 Bleeding ectopic varices may be massive, torrential, and fatal.11-14 Most patients with ectopic variceal hemorrhage
are presented with sudden and profuse melena or hematochezia. Hematemesis is possible in the case of duodenal variceal bleeding. The optimal endoscopic treatment for bleeding rectal varices remains to be determined, although there were a few reports of successful hemostasis by endoscopic band ligation15-17 and endoscopic sclerotherapy when using variable sclerosants, including ethanolamine oleate18-21 for bleeding rectal varices. N-butyl-2-cyanoacrylate (Histoacryl), a tissue adhesive, rapidly polymerizes upon contact with living tissues and forms a plug. Injection of Histoacryl into the varix induces rapid polymerization and successful hemostasis via plug formation. After Soehendra et al21 reported a large series of sclerotherapy with Histoacryl in 1986, many successful results for bleeding gastric varices have been reported.22-27 However, few cases of endoscopic injection sclerotherapy with Histoacryl have been reported in bleeding colorectal varices. Chen et al4 reported temporary hemostasis in rectal variceal bleeding with endoscopic injection of Histoacryl. But, in that case, the patients died 4 days later from massive rectal bleeding. In our case, a single injection with Histoacryl for large bleeding rectal varices induced successful hemostasis immediately and a good response for a relatively long period. Although our patient died 6 weeks later, the cause of death was hepatic failure due to a hepatocellular carcinoma, not recurrence of rectal bleeding. During the follow-up period after initial sclerotherapy with Histoacryl, the investigators performed sigmoidoscopy weekly to find changes in the varix treated with Histoacryl. Without any complication, such as treatment-induced ulcer bleeding, recurrent bleeding, necrosis and perforation of the rectum,20 and embolization of other organs by the glue,28 the size of treated rectal varix was significantly reduced, and the Histoacryl cast was extruded into the rectal lumen, with partial eradication of the varix. The full eradication of the treated rectal varix could have been expected if the patient had lived for a longer time.
634 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 4 : 2005
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Figure 5. Sigmoidoscopic view 2 weeks later, showing a large cavity from which the glue sloughed on a part of the treated varix and Histoacryl cast extruding outside on the other part of it.
heard from his family that he died at home peacefully, 6 weeks after the first Histoacryl injection therapy for a bleeding rectal varix not caused by hematochezia.
DISCUSSION
Case Reports
In conclusion, endoscopic injection sclerotherapy with Histoacryl may be a good treatment modality in controlling large bleeding rectal varices. REFERENCES 1. Burroughs AK. The natural history of varices. J Hepatol 1993;17:S10-3. 2. Brewer TG. Treatment of acute gastroesophageal variceal hemorrhage. Med Clin North Am 1993;77:993-1014. 3. Pagliaro L, D’Amico G, Luca A, Pasta L, Politi F, Aragona E, et al. Portal hypertension: diagnosis and treatment. J Hepatol 1995;23:S36-44. 4. Chen WC, Hou MC, Lin HC, Chang FY, Lee SD. An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature. Am J Gastroenterol 2000; 95:540-2. 5. Hamlyn AN, Morris JS, Lunzer MR, Puritz H, Dick R. Portal hypertension with varices in unusual sites. Lancet 1974;28:1531-4. 6. Naveau S, Poynard T, Pauphilet C, Aubert A, Chaput JC. Rectal and colonic varices in cirrhosis [letter]. Lancet 1989;1:624. 7. Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet 1989;1:349-52. 8. Kinkhabwala M, Mousavi A, Iyer S, Adamsons R. Bleeding ileal varicosity demonstrated by transhepatic portography. AJR Am J Roentgenol 1977;129:514-6. 9. Chawla Y, Dilawari JB. Anorectal varices: their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut 1991;32:309-11. 10. Bresci G, Gambardella L, Parisi G, Federici G, Bertini M, Rindi G, et al. Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation. J Clin Gastroenterol 1998;26:222-7. 11. Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987;102:548-52. 12. Batoon SB, Zoneraich S. Misdiagnosed anorectal varices resulting in a fatal event. Am J Gastroenterol 1999;94:3076-7. 13. Herman BE, Baum S, Denobile J, Volpe RJ. Massive bleeding from rectal varices. Am J Gastroenterol 1993;88:939-42. 14. Waxman JS, Tarkin N, Dave P, Waxman M. Fatal hemorrhage from rectal varices. Report of two cases. Dis Colon Rectum 1984;27:749-50. 15. Firoozi B, Gamagaris Z, Weinshel EH, Bini EJ. Endoscopic band ligation of bleeding rectal varices. Dig Dis Sci 2002;47:1502-5. 16. Uno Y, Munakata A, Ishiguro A, Fukuda S, Sugai M, Munakata H. Endoscopic ligation for bleeding rectal varices in a child with primary extrahepatic portal hypertension. Endoscopy 1998;30:S107-8. 17. Levine J, Tahiri A, Banerjee B. Endoscopic ligation of bleeding rectal varices. Gastrointest Endosc 1993;39:188-90.
18. Yamanaka T, Shiraki K, Ito T, Sugimoto K, Sakai T, Ohmori S, et al. Endoscopic sclerotherapy (ethanolamine oleate injection) for acute rectal varices bleeding in a patient with liver cirrhosis. Hepatogastroenterology 2002;49:941-3. 19. Wang M, Desigan G, Dunn D. Endoscopic sclerotherapy for bleeding rectal varices: a case report. Am J Gastroenterol 1985;80:779-80. 20. Weiserbs DB, Zfass AM, Messmer J. Control of massive hemorrhage from rectal varices with sclerotherapy. Gastrointest Endosc 1986;32: 419-21. 21. Soehendra N, Grimm H, Nam VC, Berger B. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 1987;19:221-4. 22. 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. 23. Binmoeller KF, Soehendra N. Nonsurgical treatment of variceal bleeding: new modalities. Am J Gastroenterol 1995;90:1923-31. 24. 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. 25. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160-7. 26. Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001;33: 1060-4. 27. Kim HG, Han KH, Lee CY, Chon CY, Moon YM, Kang JK, et al. Outcome of endoscopic injection therapy of Histoacryl in bleeding gastric varices [abstract]. Gastroenterology 1998;114:A1273. 28. Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30: S89-90. Current affiliations: Department of Internal Medicine, University of Inje College of Medicine, Seoul Paik Hospital, Seoul, Korea. Reprint requests: Jeong Seop Moon, MD, Department of Internal Medicine, University of Inje College of Medicine, Seoul Paik Hospital, 2-85 Jeo-dong, Joong-ku, 100-032, Seoul, Korea. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 doi:10.1016/j.gie.2005.05.012
Closure of a benign bronchoesophageal fistula with endoscopic clips Andrew Murdock, MRCP, R. J. Moorehead, FRCS, Tony C. K. Tham, FRCP Belfast, Northern Ireland, United Kingdom
Fistulas, although rare, may develop between the esophageal lumen and any other mediastinal structure. These tracheo- or bronchoesophageal fistulas can be divided into either congenital or acquired causes. Fistulas in adults are mostly acquired in nature, because it is rare for a congenital fistula to remain asymptomatic until adulthood. The majority of cases are caused by malignancy either
from a metastatic deposit or via direct invasion of a tumor. Benign causes also are seen and may be caused by a number of mechanisms. Infections, such as tuberculosis and histoplasmosis, can result in fistula formation, as can inflammatory conditions such as Crohn’s disease. Trauma from surgery or a prolonged period of intubation can predispose one to fistulas. The most common cause of
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Volume 62, No. 4 : 2005 GASTROINTESTINAL ENDOSCOPY 635
13. Hurlstone DP. Successful endoscopic band ligation of duodenal Dieulafoy’s lesions. Further large controlled studies are required. Scand J Gastroenterol 2002;37:620. 14. Ertekin C, Taviloglu K, Barbaros U, Guloglu R, Dolay K. Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage. J Laparoendosc Adv Surg Tech A 2002; 12:41-5. 15. Mumtaz R, Shaukat M, Ramirez FC. Outcomes of endoscopic treatment of gastroduodenal Dieulafoy’s lesion with rubber band ligation and thermal/injection therapy. J Clin Gastroenterol 2003;36:310-4. 16. Park CH, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ. A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy’s lesions. Endoscopy 2004;36:677-81. 17. Toyoda H, Fukuda Y, Katano Y, Ebata M, Nagano K, Morita K, et al. Fatal bleeding from a residual vein at the esophageal ulcer base after successful endoscopic variceal ligation. J Clin Gastroenterol 2001;32: 158-60. 18. Raju GS, Faruqi S, Bhutani MS, Soloway R. Catheter probe EUS-assisted treatment with hemoclips of a colonic Dieulafoy’s lesion with recurrent bleeding. Gastrointest Endosc 2004;60:851-4. Current affiliations: Department of Gastroenterology, Changhua Christian Medical Center, Changhua, Taiwan. Reprint requests: Hsu-Heng Yen, MD, Changhua Christian Medical Center, 135 Nanhsiao Street Changhua, 500 Taiwan. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(05)01583-X
Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate in a patient with massive rectal variceal bleeding: a case report Soo H. Ryu, MD, Jeong S. Moon, MD, Il Kim, MD, You S. Kim, MD, Jung H. Lee, MD Seoul, Korea
Bleeding from a varix caused by portal hypertension has been known as a common cause of death in patients with liver cirrhosis.1-3 Endoscopic treatments with different sclerosants and rubber bands for the treatment of bleeding colorectal varices, which are rare but may be massive and fatal, have been used in a few cases but rarely with successful results. N-butyl-2-cyanoacrylate, a tissue adhesive, which has been reported to be effective in the treatment of bleeding gastric varices, has not been commonly used in the treatment of bleeding colorectal varices.4 Here we present a case of massive hemorrhage from a rectal varix that was treated by endoscopic injection with N-butyl-2-cyanoacrylate and followed with a weekly endoscopy for 4 weeks.
A 63-year-old man was admitted from the emergency department because of massive hematochezia. Six months
ago, he was diagnosed and treated with supportive care for multinodular hepatocellular carcinoma combined with advanced alcoholic liver cirrhosis at the outpatient clinic. At that time, no effective treatment for hepatocellular carcinoma was available, because the hepatocellular carcinoma was multinodular and the main portal vein was occluded by tumor thrombus. An EGD performed 6 months ago revealed grade II staged esophageal varices, with no red color sign, and a colonoscopy had not been performed. On physical examination, the patient was cachexic, anemic, and icteric, and tense ascites was noted. Vital signs were as follows: blood pressure, 90/60 mm Hg; resting heart rate, 100 beats per minute; body temperature, 37.0 C; and respiratory rate, 26 breaths per minute. On presentation, laboratory data were notable for the following: Hb, 6.7 g/dL (normal: 13.0-17.0 g/dL); hematocrit, 28.3% (39%-52%); white blood cell count, 4500/mm3 (4000-10,000/mm3); platelet, 67,000/mm3 (150,000-400,000/mm3); serum
632 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 4 : 2005
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CASE REPORT
Case Reports
Figure 1. Emergency colonoscopic view showing a large varix with active bleeding focus in the rectum 5 cm above the anal verge.
Figure 2. Colonoscopic view of rectal varix immediately after endoscopic Histoacryl injection therapy.
alanine aminotransferase, 31 IU/L (0-41 IU/L); serum total protein, 6.2 mg/dL (6.7-8.3 mg/dL); serum albumin, 2.3 mg/ dL (3.8-5.3 mg/dL); total bilirubin, 8.2 mg/dL (0.2-1.0 mg/ dL); prothrombin time international normalized ratio, 1.75; serum urea nitrogen, 17.0 mg/dL (7-22 mg/dL); and creatinine, 0.9 mg/dL (0.5-1.3 mg/dL). Gastric lavage through a nasogastric tube showed no blood; but, a large amount of fresh blood was seen on a diaper and on digital rectal examination. He was resuscitated with 2 units of packed red blood cells, 3 units of fresh frozen plasma, and normal saline solution. An intravenous somatostatin analogue administration was started. Emergently performed EGD revealed esophageal varices with red color signs but no definite active bleeding foci and stigmata. On the colonoscopy, a 2 2-cm, round, large varix, with an active bleeding focus was noted in the rectum 5 cm above the anal verge (Fig. 1). Also, several small caliber rectal varices were seen around the bleeding rectal varix. There was no blood on the sigmoid colon proximal to this bleeding lesion. We hesitated the injection with sclerosant such as 5% ethanolamine oleate or endoscopic band ligation, because the varix was too large to achieve effective hemostasis and prevent massive recurrent bleeding in the near future. The bleeding varix was injected with N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) mixed with lipiodol (1:1) by using a commercial flexible sclerotherapy injector with a 6-mm, 21-gauge needle. Each 2 mL at 2 sites of the bleeding varix, a total of 4 mL, Histoacryl mixed with lipiodol was injected, and the bleeding stopped immediately (Fig. 2). An EUS performed immediately after sclerotherapy revealed a huge rectal varix filled with sclerosant of Histoacryl mixed with lipiodol on the submucosal layer beneath mucosal erosion seemed to be the bleeding focus (Fig. 3). On the sigmoidoscopy performed 1 day later, the rectal varix showed no bleeding and was hard on probing with a catheter tip. The patient was followed with sigmoidoscopy weekly for
4 weeks. An endoscopic examination of the rectum 1 week later revealed a shallow ulcer on the surface of the varix (Fig. 4). Two weeks later, sigmoidoscopy showed a deep ulcer on a part of the treated varix and a Histoacryl cast extruding outside on the other part of it (Fig. 5). During an endoscopic examination 3 and 4 weeks later, the deep ulcer previously noted was fully healed and the Histoacryl cast was nearly totally sloughed into the rectal lumen (Fig. 6). During hospitalization, a follow-up endoscopy revealed that the variceal size was significantly reduced, and no bleeding was noted at the treated varix. Also, during the follow-up period on an outpatient base, the patient had no complaint, except poor oral intake because of chronic terminal disease. We
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Volume 62, No. 4 : 2005 GASTROINTESTINAL ENDOSCOPY 633
Figure 3. EUS image immediately after sclerotherapy, showing huge rectal varix filled with sclerosant of Histoacryl on the submucosal layer.
Case Reports
Figure 4. Endoscopic examination of the rectum 1 week later, showing a shallow ulcer on the surface of the treated varix.
Figure 6. Follow-up endoscopic finding 4 weeks later, showing significantly reduced variceal size and Histoacryl cast nearly totally sloughed into the rectal lumen.
The ectopic varices resulting from portal hypertension are large venous collaterals occurring anywhere in the abdomen, including in the duodenum, the jejunum, the ileum, the cecum, the colon, the rectum, and the peritoneum, except in the cardioesophageal region.5 Ectopic varices are relatively common findings at endoscopy in patients with portal hypertension. Anorectal varices, one of the most common sites for colorectal varices,2 could be found in 40% of patients with portal hypertension who undergo colonoscopy.6,7 However, bleeding from ectopic varices have been known to be rare, accounting for 1% to 5% of all variceal bleeding.7-10 Bleeding ectopic varices may be massive, torrential, and fatal.11-14 Most patients with ectopic variceal hemorrhage
are presented with sudden and profuse melena or hematochezia. Hematemesis is possible in the case of duodenal variceal bleeding. The optimal endoscopic treatment for bleeding rectal varices remains to be determined, although there were a few reports of successful hemostasis by endoscopic band ligation15-17 and endoscopic sclerotherapy when using variable sclerosants, including ethanolamine oleate18-21 for bleeding rectal varices. N-butyl-2-cyanoacrylate (Histoacryl), a tissue adhesive, rapidly polymerizes upon contact with living tissues and forms a plug. Injection of Histoacryl into the varix induces rapid polymerization and successful hemostasis via plug formation. After Soehendra et al21 reported a large series of sclerotherapy with Histoacryl in 1986, many successful results for bleeding gastric varices have been reported.22-27 However, few cases of endoscopic injection sclerotherapy with Histoacryl have been reported in bleeding colorectal varices. Chen et al4 reported temporary hemostasis in rectal variceal bleeding with endoscopic injection of Histoacryl. But, in that case, the patients died 4 days later from massive rectal bleeding. In our case, a single injection with Histoacryl for large bleeding rectal varices induced successful hemostasis immediately and a good response for a relatively long period. Although our patient died 6 weeks later, the cause of death was hepatic failure due to a hepatocellular carcinoma, not recurrence of rectal bleeding. During the follow-up period after initial sclerotherapy with Histoacryl, the investigators performed sigmoidoscopy weekly to find changes in the varix treated with Histoacryl. Without any complication, such as treatment-induced ulcer bleeding, recurrent bleeding, necrosis and perforation of the rectum,20 and embolization of other organs by the glue,28 the size of treated rectal varix was significantly reduced, and the Histoacryl cast was extruded into the rectal lumen, with partial eradication of the varix. The full eradication of the treated rectal varix could have been expected if the patient had lived for a longer time.
634 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 4 : 2005
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Figure 5. Sigmoidoscopic view 2 weeks later, showing a large cavity from which the glue sloughed on a part of the treated varix and Histoacryl cast extruding outside on the other part of it.
heard from his family that he died at home peacefully, 6 weeks after the first Histoacryl injection therapy for a bleeding rectal varix not caused by hematochezia.
DISCUSSION
Case Reports
In conclusion, endoscopic injection sclerotherapy with Histoacryl may be a good treatment modality in controlling large bleeding rectal varices. REFERENCES 1. Burroughs AK. The natural history of varices. J Hepatol 1993;17:S10-3. 2. Brewer TG. Treatment of acute gastroesophageal variceal hemorrhage. Med Clin North Am 1993;77:993-1014. 3. Pagliaro L, D’Amico G, Luca A, Pasta L, Politi F, Aragona E, et al. Portal hypertension: diagnosis and treatment. J Hepatol 1995;23:S36-44. 4. Chen WC, Hou MC, Lin HC, Chang FY, Lee SD. An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature. Am J Gastroenterol 2000; 95:540-2. 5. Hamlyn AN, Morris JS, Lunzer MR, Puritz H, Dick R. Portal hypertension with varices in unusual sites. Lancet 1974;28:1531-4. 6. Naveau S, Poynard T, Pauphilet C, Aubert A, Chaput JC. Rectal and colonic varices in cirrhosis [letter]. Lancet 1989;1:624. 7. Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet 1989;1:349-52. 8. Kinkhabwala M, Mousavi A, Iyer S, Adamsons R. Bleeding ileal varicosity demonstrated by transhepatic portography. AJR Am J Roentgenol 1977;129:514-6. 9. Chawla Y, Dilawari JB. Anorectal varices: their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut 1991;32:309-11. 10. Bresci G, Gambardella L, Parisi G, Federici G, Bertini M, Rindi G, et al. Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation. J Clin Gastroenterol 1998;26:222-7. 11. Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987;102:548-52. 12. Batoon SB, Zoneraich S. Misdiagnosed anorectal varices resulting in a fatal event. Am J Gastroenterol 1999;94:3076-7. 13. Herman BE, Baum S, Denobile J, Volpe RJ. Massive bleeding from rectal varices. Am J Gastroenterol 1993;88:939-42. 14. Waxman JS, Tarkin N, Dave P, Waxman M. Fatal hemorrhage from rectal varices. Report of two cases. Dis Colon Rectum 1984;27:749-50. 15. Firoozi B, Gamagaris Z, Weinshel EH, Bini EJ. Endoscopic band ligation of bleeding rectal varices. Dig Dis Sci 2002;47:1502-5. 16. Uno Y, Munakata A, Ishiguro A, Fukuda S, Sugai M, Munakata H. Endoscopic ligation for bleeding rectal varices in a child with primary extrahepatic portal hypertension. Endoscopy 1998;30:S107-8. 17. Levine J, Tahiri A, Banerjee B. Endoscopic ligation of bleeding rectal varices. Gastrointest Endosc 1993;39:188-90.
18. Yamanaka T, Shiraki K, Ito T, Sugimoto K, Sakai T, Ohmori S, et al. Endoscopic sclerotherapy (ethanolamine oleate injection) for acute rectal varices bleeding in a patient with liver cirrhosis. Hepatogastroenterology 2002;49:941-3. 19. Wang M, Desigan G, Dunn D. Endoscopic sclerotherapy for bleeding rectal varices: a case report. Am J Gastroenterol 1985;80:779-80. 20. Weiserbs DB, Zfass AM, Messmer J. Control of massive hemorrhage from rectal varices with sclerotherapy. Gastrointest Endosc 1986;32: 419-21. 21. Soehendra N, Grimm H, Nam VC, Berger B. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 1987;19:221-4. 22. 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. 23. Binmoeller KF, Soehendra N. Nonsurgical treatment of variceal bleeding: new modalities. Am J Gastroenterol 1995;90:1923-31. 24. 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. 25. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160-7. 26. Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001;33: 1060-4. 27. Kim HG, Han KH, Lee CY, Chon CY, Moon YM, Kang JK, et al. Outcome of endoscopic injection therapy of Histoacryl in bleeding gastric varices [abstract]. Gastroenterology 1998;114:A1273. 28. Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30: S89-90. Current affiliations: Department of Internal Medicine, University of Inje College of Medicine, Seoul Paik Hospital, Seoul, Korea. Reprint requests: Jeong Seop Moon, MD, Department of Internal Medicine, University of Inje College of Medicine, Seoul Paik Hospital, 2-85 Jeo-dong, Joong-ku, 100-032, Seoul, Korea. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 doi:10.1016/j.gie.2005.05.012
Closure of a benign bronchoesophageal fistula with endoscopic clips Andrew Murdock, MRCP, R. J. Moorehead, FRCS, Tony C. K. Tham, FRCP Belfast, Northern Ireland, United Kingdom
Fistulas, although rare, may develop between the esophageal lumen and any other mediastinal structure. These tracheo- or bronchoesophageal fistulas can be divided into either congenital or acquired causes. Fistulas in adults are mostly acquired in nature, because it is rare for a congenital fistula to remain asymptomatic until adulthood. The majority of cases are caused by malignancy either
from a metastatic deposit or via direct invasion of a tumor. Benign causes also are seen and may be caused by a number of mechanisms. Infections, such as tuberculosis and histoplasmosis, can result in fistula formation, as can inflammatory conditions such as Crohn’s disease. Trauma from surgery or a prolonged period of intubation can predispose one to fistulas. The most common cause of
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