Portal and splenic vein occlusion complicating Histoacryl injection therapy in bleeding gastric varices.

tyl−2−cyanoacrylate (NBCA) (Histoacryl , B. Braun, Melsungen, Germany) is an ef− fective hemostatic treatment for gastric variceal bleeding [1]. In this report we de− scribe a case of portal and splenic vein oc− clusion after injection therapy with NBCA. A 48−year−old woman with liver cirrhosis was admitted with fundic variceal bleed− ing. Endoscopic injection therapy with NBCA was initiated and hemostasis was achieved. Following this treatment, the patient developed ascites and pleural ef− fusion. A computed tomography (CT) scan showed massive ascites and an NBCA embolus in the portal vein (l" Fig. 1). The patient developed renal failure, metabolic acidosis, massive leu− cocytosis, and an ileus. Intestinal isch− emia was suspected. This clinical picture was compatible with an abdominal compartment syndrome. The femoral venous pressure, which can be regarded as a surrogate marker for intra−abdominal pressure, was high (30 mm Hg), supporting the diagnosis of abdominal compartment syndrome. Be− cause of her poor condition and liver cir− rhosis it was decided not to perform a laparotomy, and the patient died. Post− mortem examination showed an NBCA embolus in both portal and splenic veins. The small bowel was necrotic. No NBCA emboli were found in the mesenteric ar− teries. Injection treatment with NBCA in variceal bleeding is effective and relatively safe [1]. Several complications have been re− ported, among which are pulmonary em− bolism [2], pericarditis [3], and intra−ab− dominal arterial embolization [4]. In our patient, the treatment of the bleeding fundic varices was complicated by portal and splenic vein embolization. To our knowledge, this complication has only been described once in the literature [5]. This resulted in tense ascites and pleural effusion, giving rise to an abdominal compartment syndrome. The intestinal ischemia can also be regarded as a result of this syndrome. Portal vein occlusion following treatment with NBCA, although rare, should be con− sidered in patients who develop massive ascites following this endoscopic inter− vention.