Update on Treatment of Variceal Hemorrhage

Wu, Justin C.Y.; Sung, Joseph J.Y.

doi:10.1159/000067485

Cited by 6 publications

(2 citation statements)

References 123 publications

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“…Enbucrilate, also know as N‐butyl‐2‐cyanoacrylate, is a form of liquor adhesives that polymerizes immediately upon contact with blood and other body fluid. It has been used as an embolic agent in medicine for almost three decades, notably in the treatment of cerebral arteriovenous malformations 7 and gastric bleeding 8 . Although widely used in general surgery, neuroradiology, otolaryngology and plastic surgery, the use of enbucrilate in obstetrics is limited.…”

Section: Discussionmentioning

confidence: 99%

Prenatal embolisation of a large chorioangioma using enbucrilate

Lau

Leung

et al. 2005

BJOG

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a Case reportThe patient was a 31-year-old nulliparous woman. She had a normal routine morphology scan at 19 weeks. The placenta was posterior, not low lying and without any local lesions. She presented at 24 weeks of gestation with an antepartum haemorrhage. According to the patient's dates, the uterus was large with a fundal height of 30 cm. Ultrasound examination revealed a hydropic fetus with marked generalized skin oedema, bilateral pleural effusion, pericardial effusion, placentomegaly and cardiomegaly. The amniotic fluid index was 21 cm and the umbilical venous blood flow was pulsatile. There was an 8 Â 9 cm well-circumscribed highly vascular solid tumour with low echogenicity arising from the lower part of the placenta protruding into the amniotic cavity (Fig. 1a). The umbilical cord inserted approximately 5 cm from the tumour, sending an artery to supply the tumour. The diagnosis was compatible with severe fetal hydrops secondary to high-output cardiac failure due to a large placental chorioangioma. Cordocentesis showed a fetal haemoglobin concentration of 12.3 g/dL and a normal fetal karyotype of 46XX.Due to extreme prematurity and grave prognosis, embolisation of the chorioangioma was discussed and accepted. The procedure was performed at 24 weeks and 2 days of gestation under local anaesthesia. Under ultrasound guidance, a 20-gauge spinal needle was inserted into the lumen of the distal end of the feeding vessel within the tumour. The needle was flushed with 7 mL of 5% dextrose solution, followed by 1.5 mL of enbucrilate (Histoacryl, Braun, Melsungen, Germany), diluted with lipiodol (Lipiodol Ultra-Fluid, Guerbet, Aulnay-sous-Bois, France) at a ratio of 1:5. There was immediate and complete blockage of the vascular tree starting from the distal end and cessation of blood flow (Fig. 1b), observable by grey-scale ultrasonography and confirmed by colour and gated Doppler. The whole procedure took 10 minutes.One week after the procedure, a repeat ultrasound scan confirmed the complete absence of blood flow within the tumour, resolving hydrops with mild scalp oedema and mild left pleural effusion, although cardiomegaly persisted. The tumour appeared more echolucent then before and the thrombosed vascular tree within the tumour was easily identified (Fig. 1b).Since admission, the patient had persistent vaginal spotting of blood, and presented with spontaneous rupture of the membranes followed by onset of labour at 26 weeks (12 days after embolisation) with the fetus in breech presentation. The baby was delivered by an emergency lower segment caesarean section. The baby girl weighed 845 g without observable hydropic features. The baby was immediately resuscitated and intubated. However, 27 h after the birth the baby succumbed because of severe cardiac failure.The placenta weighed 692 g. The 10 Â 8 Â 6 cm ovalshaped tumour which was attached to the edge of the placenta weighed 350 g. Cross section of the tumour revealed reddish to greyish necrotic tissues. Thrombosed vessels were grossly noted. The feeding v...

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Section: Discussionmentioning

confidence: 99%

Prenatal embolisation of a large chorioangioma using enbucrilate

Lau

Leung

et al. 2005

BJOG

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“…Endoscopic ultrasound may also be useful for confirming that varices have been occluded by treatment 11 . Acute bleeding from ectopic gastric varices is optimally treated endoscopically by injecting cyanoacrylate glue into the lumen of the varix and producing ‘obturation’ of the varix 12,13 . Immediate control of bleeding is achieved in approximately 90% of patients and early rebleeding occurs in up to 40%.…”

Section: Ectopic Gastric Varicesmentioning

confidence: 99%

Diagnosis and management of ectopic varices

Stiegmann¹

2004

J of Gastro and Hepatol

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Ectopic varices are dilated portosystemic venous collateral vessels that may occur anywhere in the gastrointestinal tract. Ectopic varices account for approximately 5% of all hemorrhages from varices. Ectopic varices may occur as a result of portal hypertension from any cause but are more common (particularly duodenal and biliary varices) in patients with extrahepatic portal vein thrombosis. Ectopic varices may also develop following successful endoscopic obliteration of gastroesophageal varices. With the exception of isolated gastric fundal varices, ectopic varices have relatively low risk for bleeding. Diagnosis is often made by endoscopy; however, computed tomography, magnetic resonance imaging and portal venography may be needed in some cases. Endoscopic treatment is successful in many cases and is the safest option provided bleeding is definitively controlled. Surgical options are now reserved for treatment of life-threatening bleeding or for shunt insertion in patients who are not candidates for transjugular intrahepatic portosystemic shunt (TIPS) as a result of portal vein thrombosis. Portal decompression using TIPS, in spite of the risk for encephalopathy, is the treatment of choice for bleeding from ectopic varices that cannot be successfully managed endoscopically.

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