Histoacryl injection for treatment of varices in the ascending colon.

A 50-year-oldmanwith alcoholic liver cirrhosis was admitted to our emergency department with massive hematochezia and hypovolemic shock. On admission, laboratory data included hemoglobin 3.1g/dL, hematocrit 9.9%, platelet count 81×109/L, lactates 13.9mmol/L, and international normalized ratio 1.29. Resuscitation was initiated with intravenous fluids and transfusion of 4 units of packed red blood cells. Terlipressin 2mg and ceftriaxone 1g were administered. Esophagogastroduodenoscopy revealed small esophageal varices with no evidence of recent bleeding. After oral preparation, total colonoscopy was performed, which showed markedly dilated, tortuous veins with a visible fibrin plug in the ascending colon, indicative of colonic varix with recent bleeding (●" Fig.1a); there was no blood in the colon. N-butyl-2-cyanoacrylate (Histoacryl; B. Braun,Melsungen, Germany) was injected into the varix, resulting in initial active spurting bleeding from the site of the fibrin plug and from the site of injection (●" Fig.1b), which resolved after subsequent injections. In total, 2mL of Histoacryl was injected (●" Fig.1c, ●" Video1). The patient had no recurrent bleeding and hemoglobin levels remained stable. He was discharged 7 days later with nonselective beta blocker medication. Esophageal varices are a common cause of gastrointestinal bleeding in patients with portal hypertension, but ectopic varices are extremely rare (between 1% and 5% of all variceal bleeding), especially in the ascendingcolon [1,2]. Becauseof the infrequency with which bleeding ectopic varices present, the ideal therapeutic intervention is unknown [3,4]. This is the first report of successful endoscopic hemostasis with injection of N-butyl-2-cyanoacrylate in bleeding ascending colonic varices.