Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

Abstract

SUMMARYCyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A noncontrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications. BACKGROUND

Acute pulmonary embolism following endoscopic sclerotherapy for gastroesophageal variceal hemorrhage: A case report and literature review

“…There were 17 cases of sclerotherapy-associated pulmonary embolism, including our patient (Table 1). 5–15 The median age of the patients was 56 years (range 11–77 years, IQR 41 and 60 years), and 58.8% were male. The etiology of cirrhosis includes alcohol (3, 17.6%), hepatitis B (3, 17%), hepatitis C (2, 11.7%), others (3, 17.6%), and unknown cause (6, 35.2%).…”

A case report of bleeding from a duodenal varix: Rare cause of upper gastrointestinal bleeding

“…Endoscopic ligation or injection sclerotherapy with cyanoacrylate is a useful first-line therapy [ [16] , [17] , [18] ]. However, caution must be exercised when using the cyanoacrylate injection as it can lead to complication such as migration to lungs (causing pulmonary embolism) [ 19 ], abdomen and pelvis [ 20 ]. Endoscopic haemostasis using mini loop ligation with detachable nylon loop [ 21 ], and endoscopic ultrasonography (EUS)-guided clipping [ 22 ], embolization coiling [ 23 , 24 ] were attempted, with good outcomes even in acute emergency setting.…”

Duodenal variceal bleed: an unusual cause of upper gastrointestinal bleed and a difficult diagnosis to make

“…There are well-documented cases of glue causing pulmonary embolism. 26 27 We therefore urge caution with the use of histoacryl glue. This should ideally be performed by an experienced endoscopist.…”