SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Gastric variceal bleeding is an uncommon complication of portal hypertension that carries a high mortality. Recently, there have been two randomized trials that have compared band ligation vs. N-Butyl-2- cyanoacrylate glue injection for treating gastric variceal bleeding, which showed glue injection is superior in preventing re-bleeding rates. Here we report a case of Acute Pulmonary Embolism (APE) as a complication of gastric variceal sclerotherapy with N-Butyl-2- cyanoacrylate injection, also known as “glue embolism”.
CASE PRESENTATION: A 69-year-old woman with medical history of cryptogenic cirrhosis and portal hypertension presented with a chief complaint of melena for two weeks. On examination she was hemodynamically stable with oxygen saturation of 99% on room air. Laboratory data was significant for hemoglobin of 7.4 g/dL. The patient received 2 units of packed blood and underwent EGD. Gastric varices with evidence of recent bleeding were found. They were treated with N-butyl-2-cyanoacrylate injection, “glue sclerotherapy”. Immediately post glue injection, the patient became tachypneic, tachycardic and hypotensive. Examination revealed clear lungs. Her oxygen saturation dropped to 84% on room air and came up to 93% with oxygen delivered via 6L nasal canula. CT pulmonary angiography was immediately performed and showed acute pulmonary emboli in the right lower lobe. She was treated with vasopressors, intravenous fluids for supportive care. No anticoagulation was given. Following one week of supportive management the patient’s blood pressure improved, and vasopressors were discontinued. She was discharged home without oxygen on day 10.
DISCUSSION: Gastric variceal bleeding is an uncommon but life-threatening complication of portal hypertension. The N-Butyl-2- cyanoacrylate, biological glue, is a watery solution that polymerizes and hardens instantaneously on contact with ionized material such as blood and endothelium, resulting in a clot in the vessel where applied. A rare complication is pulmonary embolism and has been associated with the volume of substance used during the procedure. APE is usually treated with anticoagulation, thrombolysis or embolectomy. In our patient, with active bleeding from gastric varices, none these of treatments were an option. There is no definitive treatment for glue embolism, beside the supportive care and management of complications.
CONCLUSIONS: Acute pulmonary embolism as a complication of glue sclerotherapy for treatment of gastric variceal bleeding and should be suspected in all patients who demonstrate respiratory distress immediately post procedure. To our knowledge, this is the first case of glue embolism reported in the United States.
1) Intern Medicine Journal. 2006 Jul;36(7):462-5.
2) Gastroenterologie Clinique et Biologique. 2008 Nov;32(11):926-30.
DISCLOSURE: The following authors have nothing to disclose: Miguel Benavides, Mohammed Sharif
No Product/Research Disclosure InformationBeth Israel Medical Center, New York, NY