Efficacy of Thrombin and Glue for Post-Glue Gastric Variceal Bleed Recurrence: A Combined Endotherapy

Background and Aim: Gastric varices (GVs), a rare complication of portal hypertension, pose challenges in bleeding scenarios. Though glue is a standard recommendation, its challenges and risks prompt exploration of alternative therapies like Thrombin. This study investigates concurrent use of human thrombin with glue to manage gastric variceal bleeding.

Methods: From February 2021 to December 2023, a prospective study at a tertiary care center included 26 patients with acute GV bleed, who had previously received cyanoacrylate glue injections (≥2 sessions). Patients received concurrent endoscopic human thrombin and CYA glue injections during the same session. The study assessed baseline parameters, glue site ulcers, session hemostatic success, rebleeding, thrombin and glue doses, and monitored changes over 6 months, including ulcer healing and variceal resolution.

Results: Of 26 patients, 80% were males (mean age: 33.9 ± 9.48 years). Cirrhosis with portal hypertension was in 84.6%, half were alcoholics. 50% classified as CTP B, 36% as CTP C, average MELD score 18.4 ± 2.4. GOV2 observed in 73%, IGV1 in 24%. Initially, 30.7% had prior glue site ulcers. After simultaneous endoscopic human thrombin and CYA injections, 92.3% achieved initial hemostasis. One patient needed radiological intervention, another succumbed to respiratory failure during the index admission. Re-bleeds: 7.6% within 5 days, 11.5% between 5 and 30 days, and 4.1% after 30 days. Median thrombin dose: 2,000 IU (2,423.07 ± 913.15), median glue volume: 1 mL (1.13 ± 0.609). At 6 months, 37.5% showed endoscopic GV disappearance, 4.1% still had ulcers at the injection site (vs. preprocedure, p = 0.0354). No patient had embolic issues in the follow-up. Compared to baseline, significant alteration in blood transfusions, hemoglobin, and UGI bleeding-related hospital stays occurred.

Conclusion: Thrombin with CYA effectively halts GV bleeding, reduces CYA volume, enhances variceal obliteration, and minimizes ulcers and distal embolization. Due to its localized clotting and low embolic risks, thrombin with CYA is recommended for naïve and post-glue GV bleeding cases.

Publication History

Article published online:
22 April 2024