Introduction Gastric varices are present in 5%–33% of patients with portal hypertension with incidence of bleeding of around 25% in 2 years.¹ If gastric varices are identified as the source of bleeding, therapeutic options include endoscopic Methods, TIPSS, surgery and non-selective beta blockade.² There are reports of EUS guided coiling combined with cyanoacrylate glue³ but limited literature on safety and efficacy of EUS guided coil embolisation with human thrombin injection. We report our experience.

Methods We analysed data of all EUS guided interventions for the management of bleeding gastric varices between 2015–2017 at a liver transplant centre. Olympus EUS linear scope was used to inject human thrombin (Tisseel; 500IU/ML) in gastric varices with or without coils (Nester Embolization Coils).

Results A total of 10 EUS guided interventions in 6 patients (4 M and 2 F), aged 55 (41–59) yrs for secondary prophylaxis. 67% patients had cirrhosis with MELD score of 14(10–21) and 75% were Child-Pugh class C. The remainder had non-cirrhotic portal hypertension. All patients had previous bleeding from gastric varices and 2/3rd were intolerant of beta-blockers. 67% had previous thrombin injection that had failed to obliterate the gastric varices. EUS guided coil embolisation was undertaken with thrombin injection in 6, and thrombin alone in 4 (2 had previous coils embolisation). The largest feeding vessel was 12(7–16) mm with a median 5 (2–10) coils placement followed by thrombin injection of 3500 (2500–5000) IU.

Most (8/10) stayed overnight after intervention and only 2 required longer stays, Median F/U was 9 (3–20) months with zero 30 day mortality. 1 patient had fever 2 days post procedure requiring IV antibiotics. No reported episodes of re-bleeding except in 1 patient at 23 months. 4 had follow up EUS (5–7 months) and showed no flow at the level of the coils. 1 patient died within 3 months of procedure secondary to hepatic decompensation.

Conclusions In our experience EUS guided coil embolisation and injection of thrombin, is a technically safe and well-tolerated procedure even in patients with advanced liver disease especially who have failed eradication of gastric varices from single modality therapy. Due to the lower incidence of gastric variceal bleeding in comparison to oesophageal varices bleeding, we recommend multi-centre prospective data collection evaluating the modalities being used and reporting of outcomes to help inform national guidelines.

References

1. . Hepatology1992;16:1343–1349.

2. . Gut2015;64:1680–704.

3. . Gastrointest Endosc. 2016Jun;83(6):1164–72.