LAUSR

We report here a very severe complication after endoscopic N-butyl-2-cyanoacrylate glue sclerotherapy of an ectopic gastrointestinal varix in a 52-year-old man. The patient was admitted to the medical ICU for acute digestive tract bleeding with hematemesis, melena, and shock. The medical history mainly consisted of cirrhosis secondary to hepatitis B virus and non-alcoholic steato hepatitis (NASH). An upper gastrointestinal endoscopy found stage II esophageal varices with red color signs. A band ligation was performed with primary endoscopic success. Recurrent massive bleeding occurred 2 days later. After hemodynamic stabilization, an upper gastrointestinal endoscopy was again performed, following general recommendations [1]. No further oesophageal varix bleeding was evidenced. However, a duodenal varix with red color sign was found in the 2nd part of the duodenum. Red color sign of the duodenal varix was characterized by the association of red wale markings with a red spot. An endoscopic sclerotherapy was achieved with injection of a 2 ml preparation of glue premixed with N-butyl-2-cyanoacrylate (Glubran 2, GEM, Viareggio, Italy) and lipiodol at a ratio of 1:1. Following the intervention, the patient woke up confused, aphasic, and with a right hemiplegia. A brain computerized tomography evidenced a left middle cerebral stroke with total occlusion of the corresponding artery by very high attenuation material (Fig. 1). Magnetic resonance imaging of the brain revealed multifocal infarctions, corresponding to left cerebellar, right posterior cerebral, and right middle cerebral arteries, in addition to the left middle cerebral artery stroke. A thoracic–abdominal–pelvic computerized tomography was also performed, evidencing multiple embolisms in the lung and the colonic lining. A patent foramen oval (PFO) was, therefore, suspected and confirmed by a transthoracic echocardiogram with bubble study. No neurological improvement was observed during the 3 following months. Ectopic (not located in the gastroesophageal area) varices are rare and often asymptomatic. In patients with portal hypertension, bleeding from ectopic varices only accounts for 1–5% of all variceal bleeding episodes, with the duodenum as one of the most common location sites [2]. Nevertheless, such bleedings are generally massive and life threatening. Beyond symptomatic critical care support, management of ectopic varices is often difficult, with the need of a multidisciplinary team, including intensivists, endoscopists, hepatologists, interventional radiologists, and surgeons. Endoscopic bleeding control can be achieved by band ligation, injection sclerotherapy, argon plasma coagulation, or coils depending on the localization of the ectopic varices and the local expertise. Endoscopic sclerotherapy with injection of cyanoacrylate glue has been advocated in such situations. Indeed, cyanoacrylate glue is a liquid adhesive with well-established chemical properties favoring an effective sclerotherapy. Lipiodol is usually used as a diluent of N-butyl-2-cyanoacrylate to prevent early polymerization. Theoretically, the higher the volume of lipiodol injected, the longer is the clogging time of the N-butyl-2-cyanoacrylate, and the higher could be the risk of glue migration and embolization. In a series focusing on gastric varices, the use of a reduced lipiodol to glue mixture ratio (from 1/1 to 0.3/1 * Jean-Luc Diehl [email protected]