Korean J Gastroenterol.  2011 Mar;57(3):180-183. 10.4166/kjg.2011.57.3.180.

Esophageal Sinus Formation due to Cyanoacrylate Injection for Esophageal Variceal Ligation-induced Ulcer Bleeding in a Cirrhotic Patient

• Kim EK
• Sohn JH
• Kim TY
• Kim BK
• Yu YH
• Eun CS
• Jeon YC
• Han DS

• KMID: 1128357
• DOI: http://doi.org/10.4166/kjg.2011.57.3.180

Abstract

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

Keyword

Cyanoacrylate; Esophageal sinus; Esophageal variceal bleeding; Cirrhosis

MeSH Terms

Cyanoacrylates/administration & dosage/*adverse effects
*Embolization, Therapeutic
Endoscopy, Digestive System
Esophageal and Gastric Varices/complications/*diagnosis/therapy
Esophagus/radiography/ultrasonography
Ethiodized Oil/therapeutic use
Gastrointestinal Hemorrhage/surgery/*therapy
Humans
Ligation
Liver Cirrhosis, Alcoholic/*complications/diagnosis
Male
Middle Aged
Tissue Adhesives/administration & dosage/*adverse effects
Ulcer/*complications

Figure

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  Fig. 1. Endoscopic findings. (A) It showed post-EVL ulcer bleeding and hemostatic trial by endoscopic sclerotherapy with total 5 mL (2 and 3 ml) of 5% ethanolamine oleate at two sites of paraesophageal varices. (B) It showed successful hemostasis of post-EVL ulcer bleeding after injection of total 1 ml of mixed solution of cyanoacrylate (0.5 mL) diluted with lipiodol (0.5 mL). EVL: endoscopic variceal ligation.

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  Fig. 2. Endoscopic finding of esophageal varices about 3 months after cyanoacrylate injection (A) and endoscopic ultrasongraphic finding of esophageal sinus (B). (A) It showed remained esophageal varices and a esophageal sinus (black arrow) at the lower esophagus. (B) The 10.9 mm sized sinus is indicated by yellow-colored x-marks and the orifice of sinus was 2.4 mm indicated by green-colored x-marks.

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  Fig. 3. Barium esophagography. It revealed a 1 cm-sized linear outpouching structure in the left side of distal esophagus, indicating a sinus formation.

Reference

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