We describe a case of pulmonary embolism after sclerosant injection for bleeding oesophageal varices. The patient was managed successfully with enoxaparin. Systemic embolization after sclerotherapy is rare and depends upon a number of factors including the amount of sclerosant agent used. The incidence of this complication could be as high as 6% which warrants careful post procedure monitoring of patients.
A 56-year-old male was admitted with haematemesis & melaena. He had a background history of gastric ulcer, alcohol misuse, appendicectomy and shingles.
On examination he was tachycardic with blood pressure of 99/50 mmHg and respiratory rate of 14/min. His oxygen saturation was 100% on 10 liters of O2. Clinical examination revealed no signs of chronic liver disease and melaena on per rectal gloved-finger examination. Initial labrotary investigations showed haemoglobin (Hb) of 9.1g/L, white cell count (WCC) 7.1x109/L, platelets (PLT) 202x109/L, urea 8.3, creatinine 85 μmol/L (ref range: 55-120), bilirubin 45 μmol/L (ref range: 2-17), alkaline phosphatase 245 U/L (ref range: 40-125), ALT 29 U/L (ref range:10-35), AST 58U/L (ref range: 10-35), albumin 32 g/L prothrombin time(PT) 19 sec, APTT 29 sec, fibrinogen 1.80 g/L. His chest x-ray was normal.
The patient continued to have melaena, although there was no further haematemesis. His Hb dropped further to 7.8 g/L and thrombocytopenia developed (PLT: 82x109/L). He was transfused 3 units of red blood cells, 3 units of Fresh Frozen Plasma (FFP) and 1 unit of platelets. Oesophagogastroduodenoscopy (OGD) showed large oesophageal varices, which were banded and injected with sclerosant agent (sodium tetradecyl sulphate). Further management included intravenous glypressin and cephalosporin antibiotics. For twenty-four hours he remained haemodynamically stable with no further episodes of haematemesis or melaena. Abdominal ultrasound scan showed shrunken liver and enlarged spleen with moderate ascites; findings consistent with chronic liver disease with portal hypertension.
Thirty hours post-endoscopic therapy, the patient complained of acute onset right sided pleuritic chest pain. He was tachycardic and tachypnoeic and his oxygen saturation dropped to 82% on inhaled room air. The chest auscultation was otherwise normal. ECG showed atrial fibrillation with ventricular rate of 143/min. His PT was 17 sec, APTT 26 sec and fibrinogen 4.00 g/L. A repeat chest x-ray showed atelectasis on both lung bases and bilateral small pleural effusions.
A CT pulmonary angiogram (Figure 1) confirmed suspected pulmonary embolism. The patient was started on enoxaparin. His further stay in the hospital was complicated by antibiotic related diarrhea. A repeat OGD showed grade 2 oesophageal varices (Figures 2,3) and evidence of ulceration secondary to sclerotherapy. The patient was discharged home on proton pump inhibitor (PPI) and enoxaparin; he is currently waiting for his first follow-up clinic visit.
Discussion
Up to 30% of cirrhotic patients with portal hypertension will bleed from the upper gastrointestinal varices at 2 years; esophageal varices account for three-quarters of these bleeds. Sclerotherapy has been established as very effective and life-saving modality for the treatment of acute variceal bleed. Radiographically evident pulmonary embolisms (PE) are uncommonly observed following endoscopic sclerotherapy and it appears to be more common in patients receiving a higher volume of sclerosant agent (Table I).1-5
Case reports of pulmonary embolism due to variceal sclerotherapy.
| Publication reference | Title of the report | Authors | Sclerosant used |
|---|---|---|---|
| Endoscopy 988;20:91-4 | Scintigraphic detection of pulmonary embolization of esophageal variceal sclerosant | DePuey EG, Richards WO, Millikan WJ, Henderson JM | Sodium morrhuate |
| Ugeskr Laeger 1989;151:1249 | Pulmonary embolism as a complication of sclerosing treatment of esophageal varices | Fruergaard P, Launbjerg J | |
| Nihon Kyobu Shikkan Gakkai Zasshi 1993;31:833-9 | Pulmonary circulatory disturbance following endoscopic injection sclerotherapy | Uchibori S | 5% ethanolamine oleate (EO) |
| Eur Respir J 1998;11:560-4 | Prognostic factors in restoration of pulmonary flow after submassive pulmonary embolism: a multiple regression analysis | Menéndez R, Nauffal D, Cremades MJ | |
| Dtsch Med Wochenschr 1998;123:691-5 | Fatal pulmonary embolism after endoscopic embolization of downhill esophageal varix | Tsokos M, Bartel A, Schoel R, Rabenhorst G, Schwerk WB | Cyanoacrylate |
| Endoscopy 1998;30:S89-90 | Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices | Roesch W, Rexroth G | Bucrylate |
| Gastroenterol Clin Biol 1999;23:1095-6 | Severe pulmonary embolism after obturation of gastric varices with a butylcyanoacrylate and lipoidol combination | Kull E, Hernandez M, Richer JP, Borderie C, Silvain C, Beauchant M | Butylcyanoacrylate lipoidol |
| Endoscopy 2000;32:S1-2 | Multiple pulmonary glue emboli following gastric variceal obliteration | Palejwala AA, Smart HL, Hughes M | |
| J Comput Assist Tomogr 2001;25:16-22 | N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding | Hwang SS, Kim HH, Park SH, Kim SE, Jung JI, Ahn BY, Kim SH, Chung SK, Park YH, Choi KH | n-butyl-2-cyanoacrylate |
| J Radiol 2001;82:583-5 | Pulmonary embolization from migration of sclerotherapy material | Nassif A, Coevoet V, Resten A, Aikem N, Maitre S, Musset D | |
| Z Gastroenterol 2004;42:383-6 | Massive pulmonary embolism after endoscopic therapy for gastric variceal bleeding | Witthöft T, Homann N, Dodt C, Ludwig D | n-butyl-2-cyanoacrylate and lipiodol |
| Endoscopy 2005;37:687 | Fatal N-butyl-2-cyanoacrylate pulmonary embolism after sclerotherapy for variceal bleeding | van Beek AP, van Erpecum KJ | Cyanoacrylate |
| Gastroenterol Hepatol 2006;29:60 | Massive pulmonary embolism after endoscopic sclerosis with N-butyl-2-cyanoacrylate | Felipe V, Forner A, Mata A, Llach J, Bordas JM | N-butyl-2-cyanoacrylate |
| Rev Gastroenterol Mex 2006;71:350 | Clinical images in gastroenterology. Pulmonary embolism secondary to endoscopic application of cyanoacrylate | Chávez-Tapia NC, Cervantes-Solís C, Ramírez-Arias F | Cyanoacrylate |
| Endoscopy 2007 Feb 7; [Epub ahead of print] | Pulmonary embolism after sclerotherapy treatment for variceal bleeding | Escardo JC, Cosenza SJ, Alvarez JH, Pratesi P, Parra GG, Hita A | 4% polidocanol |
Pulmonary Embolism as complication of scelrotherapy is thought to occur from the migration of the sclerosant into the pulmonary vasculature5 causing an acute inflammatory reaction or chemical injury of the vessel wall resulting in an embolism.6 In a retrospective study by Hwang et al., the volume of injected mixture was shown to be a predictor of embolisation.6 Six out of 140 patients (4.3%) with pulmonary emboli were given a mean volume of more than 4.2 mL as opposed to 1.8 mL for those without pulmonary emboli. Four of these six patients had respiratory symptoms, although there were no direct deaths as a result of pulmonary embolization. Other factors implicated are the area injected and the use of repeated injections.
