Successful treatment of a giant exposed blood vessel in a gastric ulcer by endoscopic sclerotherapy with N-butyl-2-cyanoacrylate

An 80-year-old man was admitted with hematemesis. Endoscopic examination revealed a deep giant gastric ulcer, and bleeding from the exposed blood vessel was detected in the lesser curvature of the angles of the stomach (Figure [1] a). We thought that only the navel-like region in the center of the ulcer was an exposed blood vessel, and ethanol was injected into the edge of this region (Figure [1] b). However, after the needle was removed, pulsatile bleeding began from the injection point (Figure [1] c), revealing that the wider area around the navel-like region was also part of the giant exposed blood vessel, which measured 10 mm (using biopsy forceps).

We decided to use N-butyl-2-cyanoacrylate. Immediately after injecting a small amount of 50 % glucose, 0.5 mL of stock solution of N-butyl-2-cyanoacrylate (Histoacryl; Aesculap AG & Co., Tuttlingen, Germany) was injected into the center of the exposed blood vessel, followed by further injection of a small amount of 50 % glucose. The formation of polymer was observed on the surface of the blood vessel and the pulsatile bleeding finally stopped 5 minutes after the injection of N-butyl-2-cyanoacrylate (Figure [1] d). Follow-up endoscopy indicated that regenerative mucosa was growing around the ulcer and that the ulcer was gradually diminishing in size (Figure [1] e, f).

Figure 1 Endoscopic views of a giant exposed blood vessel in a gastric ulcer treated by endoscopic sclerotherapy with N-butyl-2-cyanoacrylate. The patient’s bleeding was seen to be coming from a giant exposed blood vessel (a). Ethanol was injected into the navel-like region in the center of the ulcer (b), but pulsatile bleeding began from the injection point after the needle was removed (c). We decided to use N-butyl-2-cyanoacrylate for sclerotherapy: polymer was observed to form on the surface of the blood vessel and the pulsatile bleeding finally stopped 5 minutes after the injection (d). Follow-up endoscopy indicated that regenerative mucosa was growing around the ulcer and that the ulcer was gradually diminishing in size (e, f).

If the blood vessel had been a real varix, an embolism produced by the moving polymer of N-butyl-2-cyanoacrylate could have arisen after the sclerotherapy [1] [2], so we used the stock solution of N-butyl-2-cyanoacrylate without diluting it in lipiodol. The injected N-butyl-2-cyanoacrylate did not appear to move from the surface of the exposed blood vessel. It is therefore sometimes useful to use the stock solution of N-butyl-2-cyanoacrylate for hemostasis of bleeding from a giant exposed blood vessel.

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References

• 1 Gallet B, Zemour G, Saudemont J P. et al . Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices.  J Am Soc Echocardiogr. 1995;  8 759-761
• 2 Tan Y M, Goh K L, Kamarulzaman A. et al . Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate.  Gastrointest Endosc. 2002;  55 276-278