Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

lNTRODUCTlON

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Gastric variceal (GV) hemorrhage leads to significant mortality in patients with portal hypertension.Although N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, the early expulsion of NBC and the resultant hemorrhage is not uncommon[5]. Compared with conventional endoscopic injection, endoscopic ultrasound (EUS)-guided procedures in patients with GV bleeding demonstrated better diagnostic capability and clinical efficacy[6,7].

Herein, we report the successful management of GV hemorrhage secondary to LSPH using modified EUS-guided selective NBC injection.

CASE PRESENTATlON

Chief complaints

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage.

History of present illness

A few hours before admission, the patient had no apparent reason for one occurrence of sudden vomiting of blood mixed with stomach contents and the amount was estimated to be about 50-100 mL.He denied melena and syncope.

History of past illness

All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Personal and family history

This patient had a 10-year smoking history (a pack per day) and has not quit smoking. He denied alcoholism and taking nonsteroidal anti-inflammatory drugs.

Physical examination

最后，还应当定期实施药物手段，实现疫病的有效预防。应当在坚持对饲养猪群进行免疫接种的基础上，还要牢牢把握猪传染性胸膜肺炎的流行特征，着重在疫病爆发的高峰时期（如换季时节、仔猪断奶时期等）进行严格防控，依据科学标准适当提升饲料的营养性，并酌情在饲料中掺入保健药物以起到良好的预防功效，最大限度提升猪群的免疫力与抗病能力。此外，一经发现有生猪发病，则应当立刻将病猪进行隔离，并依据其症状表现选择有针对性药物、敏感药物进行积极治疗，以起到控制传染源、避免传播流行的作用。

After admission, physical examination revealed no abnormality except for 130/91 mmHg blood pressure.

Laboratory examinations

No apparent abnormalities were found in the emergency blood analysis.

Imaging examinations

Pancreatic diseases such as pancreatitis and pancreatic tumors are the most common etiology of LSPH[3,8]. The anatomical proximity between the splenic vein and the pancreas makes the splenic vein more susceptible to pancreatic diseases. When pancreatic disease obstructs the splenic vein flow, the pressure of the left portal vein system increases and blood flows retrogradely through the short and posterior gastric veins and the gastroepiploic veins, which would lead to GVs. In patients with acute pancreatitis,infected walled-off necrosis was one of the risk factors for LSPH and early anticoagulation could not wholly prevent its occurrence[8]. In this case, the patient had a history of SAP and infected pancreatic necrosis which may be responsible for his LSPH. About 20% of patients with portal hypertension may develop GVs[9], and although LSPH is a rare cause of upper GI hemorrhage, GV hemorrhage in patients with LSPH secondary to pancreatic disease is not uncommon. Liu[10] reported that about 15.3% of LSPH patients had complicated bleeding GVs and the death risk is relatively higher when recurrent GV hemorrhage occurs so this is worthy of attention.

(1)电解槽。电解槽对电镍产品质量和生产效益影响巨大，本项目通过借鉴其他镍项目电解槽防腐方法，对电解槽结构、防腐材料、防腐方法改进后，防腐性能进一步提高，在5年多的生产使用过程中未发现电解槽衬里分层、开裂、渗漏现象。

FlNAL DlAGNOSlS

LSPH and GV hemorrhage.

TREATMENT

The patient requested endoscopic procedures and rejected surgical therapies including splenectomy.EUS-guided selective NBC injections were performed for the treatment and prophylaxis of GV hemorrhage.

A linear Pentax echoendoscope (Hoya Co., Tokyo, Japan) and the color Doppler flow imaging were employed to determine the puncture site. EUS revealed an enlarged portal vein without cavernous transformation (Figure 3A). The confluences of GVs were selected as the injection sites to reduce the injection dose. A 22-gauge needle (Boston Scientific Co., Natick, MA, United States) was used to perform the puncture into the selected GVs (Figure 3B). The “sandwich” method using undiluted NBC(0.5 mL/ampoule; Beijing Compont Medical Devices Co., Beijing, China) and hypertonic glucose was applied (Figure 3C). A total of 2 mL of NBC was injected into three different confluences of GVs.Hyperechoic fillings and decreased blood flow signals were observed after injections (Figure 3D).

OUTCOME AND FOLLOW-UP

The patient fasted for 1 d after the procedure. No complications, including ectopic embolism, fever and post-injection GI bleeding occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed no sign of NBC expulsion (Figure 4) and follow-up CTV showed improvements in LSPH (Figure 5). No recurrent GI hemorrhage and other complications were reported during the 3-mo follow-up.

DlSCUSSlON

After admission, gastroscopy confirmed GV hemorrhage (IGV1 by Sarin classification), and no esophageal varices or portal hypertensive gastropathy was found (Figure 1). Abdominal computed tomography venography (CTV) revealed stenosis of the proximal superior mesenteric vein, invisible proximal splenic vein and increased collateral circulations (Figure 2). Neither a portal vein thrombosis nor a splenorenal shunt was detected.

It is well known that splenectomy is the most effective treatment for LSPH. However, transjugular intrahepatic portosystemic shunt, balloon retrograde transvenous obliteration, endoscopic injection sclerotherapy (EIS) and endoscopic NBC injection were reported effective for patients who are not suitable or unwilling to choose surgery[11]. Although endoscopic NBC injection therapy has been proven minimally invasive and effective[12], conventional endoscopic NBC injections may also cause severe complications including renal or pulmonary thromboembolism, fever, severe pain caused by intraperitoneal injection, mucosal necrosis at the injection site and GI bleeding[13]. As reported in recent years, an EUS-guided hemostasis treatment, including injection of NBC or in combination with coils,injection of thrombin or absorbable gelatin sponge, and clip-assisted endoscopic NBC injection,demonstrated promising results in reducing complication risks[14,15].

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

CONCLUSlON

Modified EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

FOOTNOTES

Yang J, Zeng Y and Zhang JW designed the research study; Yang J and Zhang JW performed the endoscopic procedures; Yang J and Zeng Y performed the literature search, analyzed the data and wrote the manuscript; All authors have read and approved the final manuscript.

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis[1-3]. LSPH accounts for about 5% of extrahepatic portal hypertension and is characterized by isolated gastric varices (GVs) and normal liver functions[3]. Pancreatic diseases are the major causes of LSPH.Most patients with LSPH have no obvious clinical symptoms and they are often diagnosed during the endoscopic examination after gastrointestinal (GI) bleeding. Therefore, LSPH should be considered in patients with pancreatic diseases who develop unexplained GI hemorrhage[1,4].

Nine months previously, this patient was admitted to our hospital due to persistent upper abdominal pain. He was diagnosed with severe acute pancreatitis (SAP) and underwent EUS-guided drainage of a pancreatic walled-off necrosis. He also had a 6-year history of hypertension and took enalapril regularly.

The authors declare that they have no conflict of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

多元化是指多元化的培养目标、多元化的培养方式、多元化的课程设置、多元化的就业方向。第一，应培养适应社会发展需求的多元化创新人才，完善政府相关的政策保障制度。第二，完善并落实高校人才培养的目标与方案。第三，提升自我，发挥学生的主观能动性。第四，加大宣传科学幼教理念的力度，营造良好的社会氛围，齐抓共管才是达成目标的前提。

Modified EUS-guided selective NBC injection was applied for three distinct advantages in this present case. First, a reduced NBC dose may result in a lower occurrence of post-operational GI bleeding and ectopic embolism. EUS can also provide the detection of submucosal GVs, their confluences and real-time effectiveness evaluation for GV obliteration[7]. These advantages make it possible to identify and select confluences of gastric varices which were in the direction of bleeding gastric vessels and used as injection sites to reduce the injection dose. Although EUS-guided coil injection is reported superior to conventional NBC injection in terms of rebleeding after treatment[16], it was believed that a reduced dose of NBC would be injected into GVs in the modified EUS-guided selective NBC injection, which would lead to lower chances of post-injection ulcer and GI hemorrhage.Besides, reduced NBC dose may result in a similar lower occurrence of ectopic embolism in selective NBC injection as in the coils-combined injection method and clip-assisted injection method. Second,there would be no additional risk of radioactive exposure; coils and metal clips were not used in this modified injection procedure, which decreased the cost of endoscopic procedures. Third, selective NBC injection demonstrated a faster and firmer obliteration effect in GV hemorrhage than thrombin and absorbable gelatin sponge injections, making NBC injection more suitable than other procedures for acute GV bleeding. NBC rarely causes vascular necrosis and was reported superior to EIS in the hemostasis rate for GV bleeding[17]. Thus, EUS-guided selective NBC injection was performed for this patient based on the above factors and the result was adequate. Despite all these advantages, the operation time of EUS-guided selective NBC injection seemed a little longer than that of conventional endoscopic NBC injection due to time consumption to confirm confluences of GVs during the EUS procedure. Additional cases are needed to verify our findings and compare the efficacies and complications of different embolization methods guided by EUS. Currently, this described technique is recommended to be used only in hemodynamically stable patients. To the best of our knowledge, this case is the first report choosing confluences of gastric varices as injection sites to reduce the injection dose and postoperative complications in patients with LSPH.

China

Jian Yang 0000-0001-8170-0727; Yan Zeng 0000-0003-4935-1306; Jun-Wen Zhang 0000-0003-2911-598X.

根据国家发改委有关部门的统一安排，中国煤炭加工利用协会研究提出了我国“十二五”期间煤炭工业环境保护、资源综合利用、煤炭洗选、煤矸石低热值煤发电、矿井水利用、节能、循环经济规划发展战略，以引导煤炭企业按照科学发展观的要求，转变经济增长方式，推动煤炭工业又好又快健康发展。本文摘要介绍我国“十一五”期间煤炭洗选加工方面取得的重要成绩、存在的主要问题及“十二五”发展目标。

Chinese Society of Gastroenterology.

Analysis on distribution characteristics of secondary geo-hazards before and after Jiuzhaigou

Zhang H

广东人吃海鲜火锅，格外讲究，火锅配以鱿鱼、海螺肉、鸡肉、牛肉、墨鱼、牛百叶、海参等生料，再加上蔬菜和佐料。吃时先将各种海鲜依次倒入没油的清汤里，煮熟后捞到各人碗中，然后再倒入鸡肉、牛肉等。吃完肉类，再倒入香菇、青菜等清口，鲜而不腻，味美无比。

Filipodia CL

Zhang H