LAUSR

Endoscopic cyanoacrylate injection is recommended for gastric variceal hemorrhage (GVH) as a means of achieving urgent endoscopic hemostasis [1, 2]. However, it can sometimes be technically difficult to secure the visual field because GVH produces a large amount of blood and bloody clots immediately fill the fundus. Gel immersion endoscopy (GIE) is useful for identification of the gastrointestinal bleeding point as it offers a secure visual field [3–5]. We report a case of successful hemostasis for GVH using cyanoacrylate injection under GIE (▶Video 1). A 70-year-old man with liver cirrhosis due to nonalcoholic fatty liver disease presented hematemesis. Emergency endoscopy identified active bleeding from ruptured gastric varices located in the fundus (▶Fig. 1). We immediately attempted endoscopic hemostasis, but the visual field became poor due to the large amount of blood, and gas insufflation and water immersion methods were ineffective in improving the visual field (▶Fig. 2 a). Electrolyte-free gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan) was therefore injected through the accessory channel using a waterjet pump (OFP; Olympus, Tokyo, Japan) with an auxiliary injection cap (BioShield irrigator; US Endoscopy, Mentor, Ohio, USA) (▶Fig. 3). Continuous gel injection gradually improved the visual field (▶Fig. 2b). Even with active bleeding, it was possible to identify the bleeding point because gel and blood took time to merge. Endoscopic cyanoacrylate injection was completed with gel immersion. A total of 500mL of this gel was used, and a total of 4mL of 62.5% cyanoacrylate with lipiodol was injected into the varices over five tries, resulting in complete hemostasis. Cyanoacrylate with lipiodol pooling in varices was confirmed by computed tomography (▶Fig. 4). To our knowledge, this is the first report of the successful use of endoscopic cyanoacrylate injection with GIE for active GVH. GIE was able to maintain a good visual field, even in a case of massive bleeding. Video 1 Endoscopic hemostasis for gastric variceal hemorrhage was achieved by cyanoacrylate injection under gel immersion endoscopy. ▶ Fig. 1 Active bleeding from gastric varices located in the fundus.