P0901 - Case Series: Endoscopic Ultrasound Guided Coil and Glue Injection for the Evaluation and Management of Rectal Varices

Gabriel Heering, MD, Anila Kumar, DO, Menasche Krupka, MD, Roxana Bodin, MD, Shireen Pais, MD
Westchester Medical Center, Valhalla, NY

Introduction: Rectal variceal bleeding can be catastrophic if treated inadequately. It is often difficult to identify and treat the site of rectal variceal bleeding. Endoscopic ultrasound (EUS) provides diagnostic and therapeutic advantages over other endoscopic, radiologic, and surgical therapies such as sclerotherapy, band ligation, transjugular intrahepatic portosystemic shunt, balloon-occluded retrograde transvenous obliteration, and suture ligation. Case reports have described successful treatment of rectal varices with EUS guided cyanoacrylate injection, however, there are no established guidelines that dictate management of rectal varices.

Case Description/Methods: We describe four patients with cirrhosis who presented with life-threatening hematochezia secondary to bleeding rectal varices (Table 1). Two of the four patients had failed prior endoscopic and surgical interventions. In this case series, each patient was treated with EUS-guided injection of cyanoacrylate-lipiodol glue mixture at a 4:1 ratio. Embolization coils were placed for patient 2 to treat particularly large varices with relatively high blood flow. Following EUS-guided treatments, diminished or absent blood flow was observed by color doppler in all four cases with complete resolution of rectal bleeding. Rebleeding was seen in patient 1 only, eight months after glue injection. That patient underwent a second glue injection and since then no further bleeding has occurred. No post-operative complications, such as glue emboli or sepsis, developed in any patients.

Discussion: Recent case reports have shown that EUS guided therapies should be considered during the multidisciplinary discussion to treat bleeding rectal varices. The advantage of EUS over endoscopic injection is the direct visualization of the intramural varix. Consequently, less glue is required, and lower dilutions can be used, which decreases the chance of embolization. Furthermore, the benefits of adding coils to the glue, especially for larger varices with increased flows increases the odds of successful treatment with minimal risks. EUS doppler is particularly useful to confirm obliteration of flow in the treated varix. Given the high safety and efficacy of this technique we argue glue injection should be considered first line treatment for bleeding rectal varices.



Disclosures:


Gabriel Heering, MD, Anila Kumar, DO, Menasche Krupka, MD, Roxana Bodin, MD, Shireen Pais, MD. P0901 - Case Series: Endoscopic Ultrasound Guided Coil and Glue Injection for the Evaluation and Management of Rectal Varices, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.