Endoscopic use of human thrombin in bleeding gastric varices

The management of gastric variceal hemorrhage remains a clinical challenge. Bovine thrombin has been reported to be effective in two small series. We report our experience with human thrombin in the treatment of bleeding gastric varices.

We reviewed the case records of 12 patients presenting over a 2-yr period with gastric variceal bleeding requiring endoscopic injection of human thrombin. Ten were male and the mean age was 52 yr (range = 26-83). The underlying diagnoses were cirrhosis in nine, portal vein thrombosis in two, and liver metastasis in one. The majority had fundal gastric varices, and none were thought to have bled from their esophageal varices. Eight received thrombin as primary treatment, whereas four had thrombin only after failing transjugular intrahepatic portosystemic shunts. Patients received one to four sessions (mean = 1.9) of thrombin with a mean total dose of 1833 U (range = 800-4000). Mean follow-up was 17.8 months for those still alive (range = 7-33).

Hemostasis in the acute setting was successful in nine patients all of whom received thrombin within 48 hours of the bleed. In the longer term, nine of the 12 had no further bleeding. Of these, five patients did well with thrombin alone, one died of cancer, and the other three went on electively to more definitive shunt procedures. Three patients rebled from their gastric varices of which one was successfully retreated with thrombin. Only one death was related to variceal bleeding (8%). No adverse reactions were noted.

Our experience demonstrates that endoscopic therapy with thrombin appears safe and can be effective in the management of gastric variceal bleeding.