Large fundal varices: to glue or not to glue?

A 45-year-old man was admitted with a one-day history of hematemesis and melena. He was had been followed up for chronic hepatitis C-related cirrhosis and had been admitted previously for management of spontaneous bacterial peritonitis. He was hemodynamically stable and general physical examination was noncontributory except for mild icterus. Investigations revealed hemoglobin 9.6 g/L, platelet count 66,000/mm 3 , INR 1.6, serum albumin 26 g/L, alanine transmainase 132 IU/mL, aspartate transaminase 141 IU/mL and serum bilirubin 53 mmol/L (normal <24). Abdominal ultrasound and doppler scan revealed cirrhotic liver, splenomegaly and patent hepatic and portal veins. Urgent gastroscopy revealed a large fundal varix (IGV1) with stigmata of recent bleed. He was planned for glue injection. As we injected 1 mL of glue (0.5 mL n-butyl cyanoacylate mixed with 0.5 mL lipiodol) into the fundal varix, there was active spurting (Fig. 1). Th e patient developed signifi cant bleeding and became hypotensive. He was stabilized with intravenous fl uids, blood transfusion and terlipressin. An attempt was