Case Report

Diaphragmatic embolism after endoscopic injection sclerotherapy for gastric variceal bleeding

Endoscopic injection sclerotherapy with n-butyl-2- cyanoacrylate (Histoacryl, B Braun, Melsungen, Germany) is commonly used in the treatment for gastric variceal bleeding. Complications after sclerotherapy include fever, impaction of the injected needle, ulceration after injection, early rebleeding, and distal embolization to the brain, lungs, and pelvis. We report a Rare occurrence of chest pain secondary to diaphragmatic embolism after Histoacryl endoscopic injection sclerotherapy for gastric variceal bleeding. To our knowledge, this is the first case of its kind to be reported in the English literature.

Endoscopic injection sclerotherapy (EIS) with n-butyl-2- cyanoacrylate (Histoacryl, B Braun, Melsungen, Germany) is highly effective in the treatment for gastric variceal bleeding [1]. Common complications after sclerotherapy include fever, impaction of the injected needle, ulceration after injection, and early rebleeding [2]. Serious complica- tions such as distal embolization to the brain [3], lungs [4], and pelvis [5] have also been reported occasionally. We report a rare occurrence of chest pain secondary to diaphragmatic embolism after Histoacryl EIS for gastric variceal bleeding. To our knowledge, this is the first case of its kind to be reported in the English literature.

A 57-year-old man presented to the emergency depart- ment (ED) with a 4-day history of melena. Two years ago, he was diagnosed with gastric varices secondary to splenic vein invasion by carcinoma of the pancreatic tail. Upon ED arrival, he was alert, and his vital signs were normal. Laboratory tests revealed prerenal azotemia with blood urea nitrogen level of 34 mg/dL and creatinine level of

0.9 mg/dL. There was no anemia (hemoglobin level of 13.4 g/dL), and his electrocardiogram and chest radiograph results were also normal.

An esophagogastroduodenal endoscopy was arranged, which showed multiple ulcerated varices over the gastric fundus and cardia. Endoscopic injection sclerotherapy was then performed with injection of 1 mL Histoacryl plus

0.7 mL Lipiodol (Guerbet, Aulnay-sous-Bois, France). Immediately after the treatment, the patient complained of a severe left-sided chest and shoulder pain that could be relieved temporarily by holding his breath. There was no Retrosternal chest pain, dyspnea, abdominal pain, or cold sweating. Results of a repeat electrocardiogram were

normal, but the follow-up chest radiograph showed curvi- linear radiopacities over the left side of the diaphragm (Fig. 1). A computed tomographic scan confirmed that most of the radiopaque densities were located inside the diaphragm (Fig. 2). Results of subsequent laboratory tests such as arterial blood gases, cardiac markers, and D-dimer were also nonremarkable.

The patient was admitted to the general ward and was managed conservatively with narcotic analgesics and a short course of terlipressin. The hospital course was uneventful, and his pleuritic chest pain gradually subsided. A follow-up esophagogastroduodenal endoscopy 3 days later showed complete hemostasis. He was discharged without symptoms after 8 days of hospitalization.

The management of gastric variceal bleeding remains a clinical challenge. tissue adhesives such as Histoacryl can control acute bleeding in more than 80%, with rebleeding rates of 20% to 30%, and should be first-line therapy where available [2]. Histoacryl is a radiolucent glue that rapidly polymerizes on contact with blood and carries the risk of needle sticking in the varix. Radiographic opacity can be

Fig. 1 Chest radiograph showing curvilinear radiopacities over the left side of the diaphragm (arrow).

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860.e6 Case Report

Fig. 2 Unenhanced Computed tomographic scans demonstrating radiopaque Histoacryl-Lipiodol mixture embolized within the left side of the diaphragm (arrows).

achieved by mixing Histoacryl with radiopaque Lipiodol. Lipiodol also serves as a diluent that delays polymerization of Histoacryl [6]. However, delaying polymerization may increase the risk of distal embolization [4]. Another important cause of increased risk of embolism during procedure is the instillation of more than 1 mL of Histoacryl-Lipiodol mixture per injection.

Etiology of gastric varices includes liver cirrhosis, non- cirrhotic portal fibrosis, and extrahepatic portal venous obstruction [5]. Chikamori et al [7] proposed a new vascular map of portal collateral system, which consists of the portoazygos and the portophrenic Venous systems. They suggested that esophageal and cardiac varices usually drain into the azygos and/or the hemiazygos vein, whereas isolated gastric varices, as in our case, generally drain into the inferior phrenic vein through gastrorenal, gastrophrenic, and/or gastropericardiac shunts. This explains how the injected Histoacryl-Lipiodol mixture in this patient became embol- ized in the left side of the diaphragm (via the portophrenic venous system).

Although there is good evidence for the efficacy of Histoacryl in the management of acute gastric variceal bleeding, potential risks of embolic phenomena should be kept in mind. Most of the risks of Histoacryl EIS are preventable. Our case shows that diaphragmatic embolism should be included in the differential diagnosis of chest pain after Histoacryl EIS. Proper preparation, Experienced nursing staff, and standardized injection technique may help in minimizing the risk of complications and improve the outcome of bleeding varices.

Chi-Fang Yu MD Li-Wei Lin MD Shih-Wen Hung MD Chun-Ting Yeh MD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei 111, Taiwan, ROC

Chee-Fah Chong MS, MD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei 111, Taiwan, ROC School of Medicine

Fu Jen Catholic University Taipei 242, Taiwan, ROC

E-mail address: [email protected] doi:10.1016/j.ajem.2007.02.013

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