Introduction Recurrent bleeding from stomal varices secondary to portal hypertension can be challenging to treat. Treatments available include transjugular intrahepatic portosystemic shunt (TIPSS) and/or coil embolisation of the dominant vein passing to the stoma or surgical portosystemic shunt formation.¹ A more recent approach to treat gastric varices is using endoscopic ultrasound (EUS) guidance using coil embolisation or in combination with cyanoacrylate glue.² Endoscopic use of human thrombin in gastric varices has also been proposed as a treatment.³ To date there are no publications on the EUS guided thrombin injection combined with coil embolisation. We have experience of adopting this approach to treat stomal varices by EUS guidance

Methods We analysed data and outcomes of all EUS guided intervention for bleeding stomal varices from January 2014 to October 2017 at a regional liver transplant centre. All cases were done using Olympus EUS linear scopes, human thrombin (Tisseel; 500IU/ML)±coils (Nester Embolization Coils). After intubation of the stoma with the EUS scope, the dominant feeding vessel to the stoma was targeted for injection with thrombin ±coils. All procedures were undertaken without sedation, and the majority without analgesia. Data presented as median (lower and upper quartile), unless stated otherwise.

Results 19 patients (7 M and 12 F) patients aged 63.5 (54–70) years with recurrent bleeding from parastomal varices despite optimal medical therapy for portal hypertension had a total 27 EUS guided injections of 3000 (2500–4500) IU of human thrombin. 47% (9/19) had thrombin alone and 53% (10/19) had concomitant coil embolisation. 68% (13/19) required single intervention, 21% (4/19) required two interventions and 11% (2/19) required 3 interventions with median follow up of 8 (6–17) months, 3 lost f/u and 3 died due to primary disease. Failure of treatment was defined as bleeding requiring transfusion or hospital admission. Only one patient failed treatment and went on to have an emergency venogram +embolisation. No immediate complications or 30 day mortality were encountered.

Conclusions EUS guided injection of thrombin ±coil embolisation appears to be technically feasible and safe with good efficacy. To our knowledge this is the first series of EUS guided thrombin injection ±embolisation of stomal varices. Due to the relative low number of patients and short follow up, further prospective evaluation of this promising technique is required.

References

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2. . Cadiovasc Intervent Radiolo. 2011Feb;34Suppl 2:S210–3.

3. . Eur J Gastroenterol Hepatol. 2014Aug;26(8):846–52.