Three-dimensional CT reconstruction for visualization of esophageal varices after injection with combined cyanoacrylate and Lipiodol (with video)

Three-dimensional imaging has been used mainly in orthopedic, spine, and neurosurgical fields, although its use in real-time biliary tree imaging in endoscopy has been reported.1Koh C.J. Koo C.S. Doshi B.K. Real-time 3D imaging of post-transplant biliary stricture: a novel application of existing technology.Am J Gastroenterol. 2021; 116: 2145-2146Crossref PubMed Scopus (0) Google Scholar We have similarly found CT reconstructions to be helpful in the assessment of the extent of esophageal varices. A 41-year-old man with a history of chronic ethanol use presented to the emergency department with massive hematemesis. Initial laboratory results showed a hemoglobin level of 3.8 g/dL, hematocrit of 12.2%, platelet count of 25 × 109/L, and a prothrombin time of 21.5 seconds (normal range, 9.7-11.8). An intravenous somatostatin infusion was initiated; packed red blood cells, platelets, and fresh frozen plasma were transfused; and he was intubated for airway protection. On urgent upper endoscopy, massive bleeding esophageal varices were seen (Fig. 1). Band ligation was unsuccessful because of scarring (Fig. 2), and injection therapy was performed for hemostasis (Fig. 3) with a combination of .5 mL N-butyl-2-cyanoacrylate with .8 mL of Lipiodol (GUERBET, Paris, France) as described by Seewald et al.2Seewald S. Ang T.L. Imazu H. et al.A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos).Gastrointest Endosc. 2008; 68: 447-454Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar This was performed by sequential injection in 1.3-mL aliquots, with reassessment after each injection to reduce the overall volume required. Although the routine use of glue in bleeding esophageal varices is not advocated because of the increased risk of adverse events, in particular glue embolization, this was performed as a salvage procedure because of the severity of the bleeding and the limited options given that the patient was at high risk of hepatic decompensation with a portal pressure–lowering shunt placement.Figure 2Unsuccessful band placement because of scarring.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Glue injection.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A subsequent CT performed the next day to evaluate for structural causes of worsening portal hypertension (eg, hepatocellular carcinoma) did not show any such etiology but did demonstrate the distal esophageal portal circulation, which had been successfully occluded with iodine-containing Lipiodol. Video 1 (available online at www.igiejournal.org) and Figure 4 show the 3-dimensional reconstruction of the CT. There was no evidence of distal glue embolization on the CT. The patient recovered and remained well for more than 6 months. The method of N-butyl-2-cyanoacrylate and Lipiodol injection is more commonly used for gastric variceal injections,3Garcia-Tsao G. Sanyal A.J. Grace N.D. et al.Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.Am J Gastroenterol. 2007; 102: 2086-2102Crossref PubMed Scopus (295) Google Scholar,4Cheng L.F. Wang Z.Q. Li C.Z. et al.Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate.Clin Gastroenterol Hepatol. 2010; 8: 760-766Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar but this case demonstrates its utility in an emergent case, where as subsequent imaging shows not only the bleeding spot but much of the esophageal portal system was successfully occluded. Esophageal variceal bleeding is a serious adverse event of portal hypertension, and this case is an apt reminder that in bleeding varices, the bleeding spot is often just the tip of the iceberg, and a holistic approach to lowering the portal pressure should be pursued. All authors disclosed no financial relationships. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyNDQzZmY3YWZkOTc1ZDQxMzdlMmE5ZmQxMWExYTQzOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4Mjg0NjI2fQ.L1mQ4YEn9w16zj3XjNTJfgXwJr4j8u01dQtIlruukQ7iFz2dr11BDB0fFkSN12PGGw9OqxyQDAZtvOEUfUBNLQbuzSmodtyfHOcnmyVUIxFfjBK2UAUolWJw5AMTgPAeYh1UOYMODX282LpWZ8zsZ15S19TkGHiLlBfVay46a28nePSalXcwOCMx4YWrp2kyra3OOjWXKcuCSFhi2mCvM7rkd5dI0JyHyoyYAEY0HMZPxZIpMgkUawyVQNNV1tzIhuIjpUWxZyHuRe-nLt6lQI7mL8SPeFmZbE8cbAsmGJA59NekwZ_r5iEFdSYayTp_Bm6AydiglaYsOhn43U7hbw Download .mp4 (20.62 MB) Help with .mp4 files Video 1Video showing the endoscopic intervention and the 3D reconstruction.