Recurrent bacteremia due to retained embolized glue following variceal obliteration

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Cyanoacrylate glue injection is the endoscopic treatment of choice for gastric variceal hemorrhage [1]. Though generally safe [2], glue is rarely associated with systemic embolization and significant bacteremia [3]. Prolonged bacteremia (≥ 4 weeks) has only been reported in two patients [4], in whom retained variceal casts acted as infected foci. Here we report a patient, 24 weeks after variceal injection, with recurrent life-threatening septicemia due to retained “embolized” glue.

A 38-year-old man presented with decompensated alcoholic liver disease complicated by spontaneous bacterial peritonitis (SBP). Intravenous tazocin (piperacillin/tazobactam) treatment was commenced after ascitic cultures isolated extended spectrum β-lactamase (ESBL)-producing Escherichia coli sensitive to tazocin and ertapenem. Between days 3 and 14, recurrent gastric variceal hemorrhage required repeated endoscopic glue injection to achieve hemostasis. On day 14, renal function suddenly deteriorated (despite terlipressin and albumin); CT imaging revealed glue in the gastric varix and inferior vena cava extending to the left renal vein ([Fig. 1]). Renal function improved with supportive measures. From week 3, recurrent swinging pyrexia proved unresponsive to empiric treatment with cefotaxime and later tazocin. Investigation, which included full viral and bacteriological screens, transthoracic echocardiogram, dental radiographs, gallium scan, and gastrointestinal endoscopies, failed to identify an infective source until, at weeks 7, 14, and 22, following antibiotic-free periods, ESBL-producing Escherichia coli sensitive to ertapenem was isolated from blood, and repeat CT at week 24 showed persistence of the glue observed at week 3 ([Fig. 2]). Only 6 weeks of intravenously administered ertapenem, following on from shorter courses, successfully treated the pyrexia, with negative culture and sustained improvement in hepatic function.

Fig. 1 a – d Abdominal/pelvic CT scan showing multifocal radiopaque densities in the gastric fundal varix and also inferior vena cava (IVC) extending to the left renal vein (LRV) consistent with retained systemically embolized glue, within days of repeated endoscopic injections of glue/lipiodol for gastric variceal hemorrhage.

Fig. 2 a, b Abdominal CT scan demonstrating the persistence of the multifocal radiopaque densities in the inferior vena cava (IVC) extending to the left renal vein (LRV) at 24 weeks after glue injection therapy.

The exclusion of other infective foci suggests that the embolized glue acted as a nidus for bacterial seeding on or within the adhesive casts during the original procedure. Breakdown of the casts over time could have resulted in the intermittent release of colonized microbes into the systemic circulation, which would have been only partially responsive to short courses of intravenous antibiotics. In conclusion, embolized glue may persist beyond 24 weeks and should be considered if recurrent infection develops which may necessitate protracted courses of antibiotics. This reiterates the need for caution with glue, and the benefit of endosonographic or fluoroscopic monitoring.

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References

• 1 Seewald S, Sriram P V, Naga M. et al . Cyanoacrylate glue in gastric variceal bleeding.  Endoscopy. 2002;  34 926-932
• 2 Huang Y H, Yeh H Z, Chen G H. et al . Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety.  Gastrointest Endosc. 2000;  52 160-167
• 3 Chen W C, Hou M C, Lin H C. et al . Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding.  Gastrointest Endosc. 2001;  54 214-218
• 4 Liao S C, Ko C W, Yeh H Z. et al . Successful treatment of persistent bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric varices bleeding.  Endoscopy. 2007; ;  http://www.thieme-connect.de/journals/toc/endoscopy/29237; DOI: 10.1055/s-2007-966556