CASE REPORT Glue Embolism: A Rare Cause of Pulmonary Embolism Pervez Ashraf, Syed Afzal-ul-Haq Haqqi, Hafeezullah Shaikh and Asif J. Wakani ABSTRACT N-butyl-2-cyanoacrylate is widely used to sclerose bleeding gastric varices. We report the case of a 65-year-old lady, known case of cirrhosis secondary to hepatitis C infection, who presented to the emergency department with coffee ground vomiting and melena for four days. Gastroscopy showed non-bleeding small esophageal varices, mild portal hypertensive gastropathy and a large gastric fundal varix. Injection sclerotherapy was completed successfully and haemostasis was secured. During the procedure, she was hemodynamically stable with an oxygen saturation of 98%. Immediately after the procedure, she went into cardiopulmonary arrest; cardiopulmonary resuscitation (CPR) was started, but she could not be revived. A provisional diagnosis of pulmonary embolism was made. X-ray chest showed linear hyperdense shadows in both pulmonary arteries and in some of their branches, which were not seen on pre-procedural chest X-ray. The patient died of massive pulmonary embolism as confirmed on X-ray chest. Key words: Glue embolism. Pulmonary embolism. Varices. Hepatitis C. Cyanoacrylate embolism. Chest X-ray. INTRODUCTION stable vital signs with normal respiratory and Upper gastrointestinal haemorrhage (UGIH) secondary cardiovascular systems. Physical examination revealed to fundal (gastric) variceal bleeding is an uncommon normal lung examination, abdominal ascites with and life-threatening complication of portal hypertension. umbilical hernia and mild splenomegaly. Gastric varices bleed less frequently than esophageal Laboratory testing revealed haemoglobin level of varices, but bleeding from gastric fundal varices (GV) 7.5 g/dl; leukocytes count of 5.5 x 109/l; platelets count tends to be more severe and is associated with a high of 71 x 109/l; prothrombin time of 17/9 seconds; and mortality rate. serum creatinine level of 1.2 mg/dl. Chest X-ray did not Endoscopic variceal ligation of esophageal varices is reveal any abnormality. recognized as a main stay of treatment modality now a On admission to the gastroenterology ward, the patient days. Endoscopic treatments with tissue glue cyano- was given intravenous (I/V) ceftriaxone, I/V sandostatin acrylate (N-butyl-2-cyanoacrylate) has been used infusion and packed red blood cells. Upper GI successfully in many countries for 20 years and is endoscopy showed non-bleeding small esophageal considered by many clinicians to be the optimal initial varices, mild portal hypertensive gastropathy and a treatment for bleeding gastric varices. Many physicians large gastric varix in the fundus (Figure 1). may be unaware of glue embolization because of its Endoscopic sclerotherapy was performed with a solution rarity. Important risk factors for first gastric variceal bleeding are child pugh class B and C, red wale marks, containing 4 ml of N-butyl cyanoacrylate and 8 ml multiple and large size of the varices located in the lipoidol (a lipid based radiological contrast agent to fundus.2 prevent premature polymerization of the glue). A 19-guage needle with 10 ml syringe was used to inject We report a case of pulmonary embolization of N-butyl- the large gastric varix. Injection sclerotherapy was 2-cyanoacrylate that occurred after endoscopic injection completed successfully and haemostasis confirmed. therapy for gastric variceal bleeding. During the procedure, she was hemodynamically stable with an oxygen saturation of 98%. CASE REPORT Immediately after the procedure, her oxygen saturation This 65-year-old lady, who was a cirrhotic secondary to dropped and she became tachycardic. She was given hepatitis C infection (child turcotte pugh class C) supplemental oxygen therapy and was shifted to presented to the emergency department with a 4 days monitored setting. A chest X-ray was ordered, she went history of coffee coloured vomiting and melena. She had into cardiopulmonary arrest, CPR was started, but she could not be revived. A provisional diagnosis of Department of Gastroenterology, Liaquat National Hospital, pulmonary embolism was made. X-ray chest showed Karachi. linear hyperdense shadows in both pulmonary arteries Correspondence: Dr. Hafeezullah Shaikh, Bunglow No. G-72, and in some of their branches (Figure 2), which were not Defence View, Phase II, Expressway Road, Karachi. seen on pre-procedural chest X-ray. This confirmed the E-mail: [email protected] diagnosis of massive pulmonary embolism as the cause Received September 06, 2010; accepted July 27, 2011; of death. 574 Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (9): 574-576 Glue embolism Other less common, but potentially serious compli- cations include abscesses and bacteremia. Rupture of esophagogastric varices is one of the most severe complications of portal hypertension in patients with liver cirrhosis. Multidisciplinary approach and close coordi- nation among gastroenterologists, surgical team and interventional radiologists will be required for the proper management of FVO. Obturation of bleeding fundal varices is technically difficult and demanding because of its location and size.8 Sohendra et al. first described in 1986 that hemostasis of bleeding gastric varices could be achieved by injecting the tissue adhesive agent with butyl cyanoacrylate.9 Figure 1: Endoscopic image showing large gastric fundal varix. Various other treatment modalities are transjugular intrahepatic portosystemic shunts (TIPS), balloon occluded retrograde transvenous obliteration techni- ques (BORTO) and gastric variceal ligation, although this modality is falling out of favour. Intra-gastric balloon tamponade is used as a bridge to further therapy. Liver transplantation is the final option. N-butyl-2-cyanoacrylate (NBC) is the only promising agent. In Pakistan, the rate for primary haemostasis with cyanoacrylate injection is consistent with the reported rate of 90% to 97% even as in other countries.10 Pulmonary embolism is a rare and potentially serious complication, but systemic (arterial) embolization has also been reported. An important cause of increased risk of embolism during procedure is instillation of more than 1 ml of the histoacryl/lipiodol mixture per injection. Cyanoacrylate, when used to obliterate esophageal and Figure 2: Chest X-ray showing linear hyperdense shadows in both pulmonary arteries and in some of their branches. gastric varices, has been reported in the endoscopy and radiology literature to cause pulmonary emboli. Most DISCUSSION fundal gastric varices are supplied by short gastric and epiploic veins and drain to the left renal vein through a Fundal (gastric) varix obliterative therapy with N-butyl-2- large gastrorenal shunt. Cyanoacrylate is the treatment of choice for the management of acute gastric variceal bleeding and its Pulmonary glue embolism is difficult to diagnose and relation with decompensated liver cirrhosis was first manage. So because of diagnostic dilemma gastro- published in German literature in 1913.3,4 The incidence enterologists should have a high index of suspicion for of UGIH secondary to fundal (gastric) varices is embolism in the setting of tachycardia, chest pain, or relatively low, varies from 10% to 36% despite the fact of hypoxia after an endoscopic FVO therapy. its high prevalence rate in patients with decompensated liver cirrhosis ranging from 18% to 70%.5 Procedure- REFERENCES related complications of fundal varix obturation (FVO) 1. Sato T, Yamazaki K. 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