A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage

Abstract

Background Acute gastric variceal hemorrhage (AGVH) is a serious complication of portal hypertension. Endoscopic cyanoacrylate glue injection is standard therapy for acute hemostasis; however, it may be associated with serious complications. The role of thrombin injection has not been confirmed. This study compared endoscopic thrombin and glue injections in the hemostasis of AGVH. Methods 68 eligible patients with AGVH were randomized to receive thrombin injection (33 patients) or glue injection (35 patients). The primary end point was injection-induced gastric ulcers. Secondary end points were acute hemostasis, rebleeding, and mortality within 42 days. Results Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 90.0 % (9/10) in the thrombin group and 90.9 % (10/11) in the glue group (P = 0.58), and 48-hour hemostasis was achieved in 93.9 % (31/33) and 97.1 % (34/35), respectively (P = 0.60). Treatment failure at 5 days occurred in two patients (6.1 %) in the thrombin group and two patients (5.7 %) in the glue group (P > 0.99). Gastric ulcers occurred in none of the thrombin group and 11/30 (36.7 %) of the glue group (P < 0.001, 95 % confidence interval [CI] 8 % – 27 %). Complications occurred in 4 (12.1 %) and 18 (51.4 %) patients in the thrombin and glue groups, respectively (P < 0.001, 95 %CI 22 % – 45 %). Two patients who received glue had post-treatment gastric ulcer bleeding. One patient in each group died. Conclusions Endoscopic thrombin injection was similar to glue injection in achieving successful hemostasis of AGVH. However, a higher incidence of complications may be associated with glue injection.

Beyond the scope and the glue: update on evaluation and management of gastric varices

“…Even though thrombin treatment was found beneficial in controlling bleeding from GV, especially Type 2 GOV in small single-center series, high-quality studies were lacking [ 40 – 43 ]. Recently, Lo and colleagues, in a prospective randomized trial, showed that endoscopic thrombin injection was similar to glue injection in achieving successful haemostasis of acute GV bleeding but with higher incidence of complications associated with the latter [ 44 ]. Few reports demonstrating the use of inorganic absorbent powder TC-325 haemostatic spray (Hemospray®, Cook Medical, IN, USA) in patients with refractory gastric variceal bleeding after the failure of glue injection therapy has been published in the literature.…”

Endoscopy in Management of Portal Hypertension

“…In an only RCT available which compares thrombin to cyanoacrylate injection in the control of AGVH, thrombin injection and glue injection had similar success rate (90% vs. 90.9%). However, a higher incidence of complications (51% vs. 12%) and ulcers (37% vs. 0%) were noted with glue injection as compared to thrombin [36]. Results of this study cannot be generalized as the sample size used in this study was small.…”

Thrombin Is an Effective and Safe Therapy in the Management of Bleeding Gastric Varices. A Real-World Experience

“…Lo et al [ 34 ] recently reported on the first prospective randomised trial of thrombin versus cyanoacrylate in acute gastric variceal haemorrhage. 33 patients were randomised to the thrombin arm with 35 randomised to glue injection; the primary outcome was the development of injection-induced gastric ulceration.…”