A Sticky Situation Upper GI bleed in a young female Jehovah’s Witness Dr. Leigh Minuk , PGY2 General Internal Medicine, University of Toronto Co-authors: Dr. Deb Chakraborty (Western University), Dr. Amir Rumman (University of Toronto), Dr. Gary May (University of Toronto, Department of Gastroenterology)
Conflicts of Interest • None
Learning Objectives After reading this clinical vignette, the practitioner should be able to: 1. Understand the state of current therapeutic options for variceal bleed 2. Recognize the complications of cyanoacrylate glue 3. Develop an approach to the patient with non-cirrhotic portal hypertension
25 year old female with two episodes of black, tarry stool Past medical history • Long history of “functional” abdominal pain. • Splenectomy for presumed ITP • Cholecystectomy for gallstones Family History: FAP gene (She is negative) Social History: Non-smoker, no alcohol, no drug use. Jehovah's Witness. Caucasian. No consanguinity.
Initial Exam and Labs Examination Initial Laboratory Investigations Appears well, no pallor, no distress Hgb 121, WBC 15.6, Plt 262 Vitals PT 12.5, INR 1.13 HR 100, BP 112/76, RR 18, O2 98% on RA Normal electrolytes, extended Abdo: bowel sounds present, no electrolytes, creatinine tenderness, no hepatomegaly, digital rectal exam negative for melena stools. AST 33, ALT 23, ALP 47 CV/Resp: normal LD 329, Alb 30, TBili 7
Initial Exam and Labs Examination Initial Laboratory Investigations Appears well, no pallor, no distress Hgb 121, WBC 15.6, Plt 262 Vitals PT 12.5, INR 1.13 HR 100, BP 112/76, RR 18, O2 98% on RA Normal electrolytes, extended Abdo: bowel sounds present, no electrolytes, creatinine tenderness, no hepatomegaly, digital rectal exam negative for melena stools. AST 33, ALT 23, ALP 47 CV/Resp: normal LD 329, Alb 30, TBili 7
Repeat Hemoglobin 121 77
Unexpected Endoscopy Rapidly bleeding gastroesophageal varices
Options for Management Medical Therapy • Splanchnic Vasoconstriction (i.e., Octreotide) Endoscopic Therapy • Endoscopic Variceal Ligation • Endoscopic Injection Sclerotherapy • Endoscopic variceal obturation Trans-jugular Intrahepatic Portal Shunt https://www.gastrointestinalatlas.com/e nglish/variceal_banding_iv.html
2 Minutes after injection… Loss of Consciousness Code Blue Seizure
MR Brain Axial images from T2 FLAIR sequences demonstrating small scattered bilateral hyperintensities (black arrows) correlating with small subacute infarcts post glue embolization
Complications of Cyanoacrylate Glue Rebleeding • Sepsis • Splenic Emboli • Pulmonary Emboli • Cerebral Emboli •
Thoracoabdominal CTA
• CT scan/MR – No intraabdominal or intrathoracic AVMs, no blood vessel obstruction • Portal venous doppler x 2 – no portal VTE • No hepatomegaly or cirrhosis on CT/MRI/US
Posthepatic Budd Chiari • Prehepatic Right sided heart • Portal Vein thrombosis Hepatic failure Sinusoidal Splenic vein thrombosis IVC obstruction • Alcoholic Cirrhosis • Presinusoidal Viral Hepatitis • Idiopathic non- • NASH • cirrhotic Portal Drug induced Hypertension • Infiltrative (incl. amyloid) Biliary diseases • • Sarcoidosis Gaucher’s • • Congenital hepatic Post Sinusoidal • cirrhosis Sinusoidal obstruction syndrome
Next Steps • Definitive control of variceal bleed • Liver biopsy
References 1. Krynytska I, Marushchak M, Mikolenko A, et al. Differential diagnosis of hepatopulmonary syndrome (HPS): Portopulmonary hypertension (PPH) and hereditary hemorrhagic telangiectasia (HHT). Bosn J Basic Med Sci . 2017;17(4):276-285. doi:10.17305/bjbms.2017.2020 2. Kudo M, Zheng RQ, Kim SR, et al. Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. Intervirology . 2008;51(SUPPL. 1):17-26. doi:10.1159/000122595 3. Schouten JNL, Verheij J, Seijo S. Idiopathic non-cirrhotic portal hypertension: A review. Orphanet J Rare Dis . 2015;10(1):1-8. doi:10.1186/s13023-015-0288-8 4. Gioia S, Riggio O, Pentassuglio I, Nicoletti V, Valente M, d’Amati G. Idiopathic noncirrhotic portal hypertension: current perspectives. Hepatic Med Evid Res . 2016;Volume 8:81-88. doi:10.2147/HMER.S85544 5. Gallet B, Zemour G, Saudemont JP, Renard P, Hillion ML, Hiltgen M. Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices. J Am Soc Echocardiogr . 1995;8. 759-761. doi:10.1016/S0894-7317(05)80396- 7 6. N. U, P.S. K. Hepatopulmonary syndrome and portopulmonary hypertension. Hepatol Res . 2009;39(10):1020-1022. doi:10.1111/j.1872-034X.2009.00552.x 7. Christensen RD, Baer VL, MacQueen BC, O’Brien EA, Ilstrup SJ. ABO hemolytic disease of the fetus and newborn: Thirteen years of data after implementing a universal bilirubin screening and management program. J Perinatol . 2018;38(5):517-525. doi:10.1038/s41372-018-0048-4 8. Dandana A, Ben Khelifa S, Chahed H, Miled A, Ferchichi S. Gaucher Disease: Clinical, Biological and Therapeutic Aspects. Pathobiology . 2016;83(1):13-23. doi:10.1159/000440865 9. Chew Dr JRY, Balan A, Griffiths W, Herre J. Delayed onset pulmonary glue emboli in a ventilated patient: A rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage. BMJ Case Rep . 2014;2014:1-4. doi:10.1136/bcr- 2014-206461 10. Burke MP, O’Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection. Forensic Sci Med Pathol . 2017;13(1):82-85. doi:10.1007/s12024-016-9835-4 11. Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AET, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol . 2010;8(9):760-766. doi:10.1016/j.cgh.2010.05.019
Thank you! • Dr. Gary May • Dr. Deb Chakraborty, and Dr. Amir Rumman • Dr. Stephen Power, Radiology for assistance with the imaging
1 Contrast-enhanced Abdominal CT (1) coronal and (2) axial contrast enhanced CT demonstrating thrombus within the portal vein (solid white arrows) post trans-portal embolization 2 procedure
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