[Massive pulmonary embolism after endoscopic therapy for gastric variceal bleeding]

A 60-year-old woman with alcoholic cirrhosis of the liver was admitted to the ICU because of haemodynamic instability, hematemesis and presumed acute variceal bleeding. An upper endoscopy was performed and varices of the distal esophagus and an actively bleeding varix of the gastric fundus were detected. The bleeding was successfully treated with 2 consecutive injections of 0.5 ml n-butyl-2-cyanoacrylate and 0.5 ml lipiodol. The patient was intubated prior to the endoscopy to avoid blood aspiration. However, severe hypoxaemia with a need for prolonged mechanical ventilation and signs of right heart strain developed after endoscopy. A chest X-ray and CT scan of the thorax documented an extensive embolisation of the pulmonary arteries. The patient's varices were retreated with band ligation but rebleeding occurred. Finally, a TIPS application was needed to stop recurrent haemorrhage. This case demonstrates that embolisation of the pulmonary arterial bed is a rare complication of endoscopic sclerotherapy for gastric variceal bleeding. The severity of this complication may depend on the volume of liquid acrylate being injected and pre-existing lung tissue alterations. Since histoacryl is not lysable, severe pulmonary emboli with lung tissue damage and pulmonary hypertension may occur. Factors contributing to this complication are analysed and therapeutic alternatives are discussed.