Authors: Bechien U. Wu, MD; David L. Carr-Locke, MD, FRCP, FACG, FASGESeries Editor: David L. Carr-Locke, MD, FRCP, FACG, FASGE


September 20, 2006

Introduction and Case Presentation

The acute management of gastric variceal hemorrhage poses a challenge to endoscopists in the United States. Although the use of cyanoacrylate compounds has gained acceptance in Asia and Europe, such adhesives are not US Food and Drug Administration (FDA) approved for endoscopic therapy. We report a case of gastric variceal hemorrhage that was successfully treated with off-label injection of 2-octyl cyanoacrylate.

A 72-year-old woman presented to the emergency department with a syncopal event. Upon regaining consciousness, she described the onset of hematemesis in addition to several episodes of melena. Her medical history included scleroderma with both pulmonary and skin involvement, rheumatoid arthritis, and hypertension. There was no history of abdominal pain and no recent alcohol ingestion. Notable medications included aspirin (150 mg daily), lansoprazole (30 mg daily), methotrexate (15 mg weekly), and piroxicam (20 mg daily), all of which she had been taking for several years.

On initial examination, the patient was found to be orthostatic but in no apparent distress. Her abdomen was benign but rectal examination was notable for black, guaiac-positive stool. There were no stigmata of chronic liver disease. Initial nasogastric lavage revealed "coffee-ground" material that cleared after 500 cc irrigation with normal saline.

Laboratory testing revealed the following: hemoglobin, 8.7 g/dL; hematocrit, 25.3%; mean corpuscular volume, 91.5 fL; platelet count, 155 x 103/microliters; blood urea nitrogen, 49 g/dL; mildly elevated serum aspartate aminotransferase at 47 U/L; and low albumin of 2.8 g/dL. The remainder of the liver function tests, serum chemistries, and coagulation profile were all within normal limits.

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