Digestive Diseases and Sciences

, Volume 62, Issue 11, pp 3091–3099 | Cite as

Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience

  • Tom D. Catron
  • George B. SmallfieldEmail author
  • Le Kang
  • Richard K. Sterling
  • Mohammad S. Siddiqui
Original Article


Background and Aims

Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy.


We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique.


Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance.


ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.


Gastric varices Cyanoacrylate Gastric variceal hemorrhage Audible Doppler Endoscopic Doppler Doppler probe 



Audible Doppler assessment


Balloon-occluded retrograde transvenous obliteration




Esophageal variceal hemorrhage


Endoscopic variceal ligation


Gastric varices


Gastric variceal hemorrhage


Hepatocellular carcinoma


Hepatic encephalopathy


Model for end-stage liver disease


Nonalcoholic steatohepatitis




Non-cirrhotic portal hypertension


Portal vein thrombosis


Transjugular intrahepatic portosystemic shunt




Author’s contribution

Tom D. Catron—Acquisition, analysis, and interpretation of data, drafting of manuscript. George B. Smallfield—Study concept and design, critical revision of the manuscript for intellectual content, administrative and material support, study supervision. Le Kang—Statistical Analysis. Richard K. Sterling—Critical revision of the manuscript for intellectual content. Mohammad S. Siddiqui—Critical revision of the manuscript for intellectual content.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to disclose.


  1. 1.
    Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16:1343–1349.CrossRefPubMedGoogle Scholar
  2. 2.
    Kim T, Shijo H, Kokawa H, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology. 1997;25:307–312.CrossRefPubMedGoogle Scholar
  3. 3.
    Laine Loren, Cook Deborah. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleedinga meta-analysis. Ann Intern Med. 1995;123:280–287.CrossRefPubMedGoogle Scholar
  4. 4.
    Chey WD, Elta GH. Natural history of gastric varices. Gastroenterology. 1993;105:599–602.CrossRefPubMedGoogle Scholar
  5. 5.
    Mehta G, Abraldes JG, Bosch J. Developments and controversies in the management of oesophageal and gastric varices. Gut. 2010;59:701–705.CrossRefPubMedGoogle Scholar
  6. 6.
    Boyer TD, Haskal Ziv J. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology. 2010;51:306.CrossRefPubMedGoogle Scholar
  7. 7.
    Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol. 2002;97:1010–1015.CrossRefPubMedGoogle Scholar
  8. 8.
    Cheng L-F, Wang ZQ, Li CZ, et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol. 2010;8:760–766.CrossRefPubMedGoogle Scholar
  9. 9.
    Sarin SK, Kumar A. Endoscopic treatment of gastric varices. Clin Liver Dis. 2014;18:809–827.CrossRefPubMedGoogle Scholar
  10. 10.
    Irisawa A, Obara K, Sato Y, et al. EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension. Gastrointest Endosc. 1999;50:374–380.CrossRefPubMedGoogle Scholar
  11. 11.
    Gubler C, Bauerfeind P. Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection. Scand J Gastroenterol. 2014;49:1136–1142.CrossRefPubMedGoogle Scholar
  12. 12.
    Salah W, Dumot JA, Wong RCK. Through-the-scope Doppler US-guided cyanoacrylate injection: a new technique for the treatment of gastric variceal hemorrhage. Gastrointest Endosc. 2013;78:574.CrossRefPubMedGoogle Scholar
  13. 13.
    Wong RCK, Farooq FT, Chak A. Endoscopic Doppler US probe for the diagnosis of gastric varices (with videos). Gastrointest Endosc. 2007;65:491–496.CrossRefPubMedGoogle Scholar
  14. 14.
    Wood RF, Nasmyth DG. Doppler ultrasound in the diagnosis of vascular occlusion in renal transplantation. Transplantation. 1982;33:547–551.CrossRefPubMedGoogle Scholar
  15. 15.
    Matjasko MJ, Williams JP, Fontanilla M. Intraoperative use of Doppler to detect successful obliteration of carotid-cavernous fistulas: Technical note. J Neurosurg. 1975;43:634–636.CrossRefPubMedGoogle Scholar
  16. 16.
    Beppu K, Inokuchi K, Koyanagi N, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc. 1981;27:213–218.CrossRefPubMedGoogle Scholar
  17. 17.
    Hou M-C, Lin HC, Tiau Kuo B, Lee FY, Lee SD, Schmidt CM, et al. (1996) Clinical implications of the white nipple sign and its role in the diagnosis of esophageal variceal hemorrhage. Am J Gastroenterol 91.Google Scholar
  18. 18.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–938.CrossRefPubMedGoogle Scholar
  19. 19.
    Seewald S, Sriram PVJ, Naga M, et al. Cyanoacrylate glue in gastric variceal bleeding. Endoscopy. 2002;34:926–932.CrossRefPubMedGoogle Scholar
  20. 20.
    Türler A, Wolff M, Dorlars D, Hirner A, et al. Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate. Gastrointest Endosc. 2001;53:228–230.CrossRefPubMedGoogle Scholar
  21. 21.
    Jun CH, Kim KR, Yoon JH, et al. Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage. Korean J Intern Med. 2014;29:437–444.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kahloon A, Chalasani N, DeWitt J, et al. Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices. Dig Dis Sci. 2014;59:2178–2183. doi: 10.1007/s10620-014-3148-9.CrossRefPubMedGoogle Scholar
  23. 23.
    Franco MC, Gomes GF, Nakao FS, de Paulo GA, Ferrari AP Jr, Della Libera Jr E. Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices. World J Gastrointest Endosc. 2014;6:254.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Mishra SR, Sharma BC, Kumar A, Sarin SK, et al. Endoscopic cyanoacrylate injection versus β-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut. 2010;59:729–735.CrossRefPubMedGoogle Scholar
  25. 25.
    Chang YJ, Park JJ, Joo MK, et al. Long-term outcomes of prophylactic endoscopic histoacryl injection for gastric varices with a high risk of bleeding. Dig Dis Sci. 2010;55:2391–2397. doi: 10.1007/s10620-009-1023-x.CrossRefPubMedGoogle Scholar
  26. 26.
    Kochhar GS, Navaneethan U, Hartman J, et al. Comparative study of endoscopy versus transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding. Gastroenterol Rep. 2015;3:75–82.CrossRefGoogle Scholar
  27. 27.
    Hou M-C, Lin HC, Lee HS, Liao WC, Lee FY, Lee SD. A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL. Gastrointest Endosc. 2009;70:668–675.CrossRefPubMedGoogle Scholar
  28. 28.
    Marques P, Maluf-Filho F, Kumar A, et al. Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate. Dig Dis Sci. 2008;53:544–550. doi: 10.1007/s10620-007-9882-5b.CrossRefPubMedGoogle Scholar
  29. 29.
    Akahoshi T, Hashizume M, Shimabukuro R, et al. Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience. Surgery. 2002;131:S176–S181.CrossRefPubMedGoogle Scholar
  30. 30.
    Lo G-H, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001;33:1060–1064.CrossRefPubMedGoogle Scholar
  31. 31.
    Paik CN, Kim SW, Lee IS, et al. The therapeutic effect of cyanoacrylate on gastric variceal bleeding and factors related to clinical outcome. J Clin Gastroenterol. 2008;42:916–922.CrossRefPubMedGoogle Scholar
  32. 32.
    Kind R, Guglielmi A, Rodella L, et al. Bucrylate treatment of bleeding gastric varices: 12 years’ experience. Endoscopy. 2000;32:512–519.CrossRefPubMedGoogle Scholar
  33. 33.
    Huang Y-H, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc. 2000;52:160–167.CrossRefPubMedGoogle Scholar
  34. 34.
    Procaccini NJ, Al-Osaimi AM, Northup P, Argo C, Caldwell SH, et al. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center US analysis. Gastrointest Endosc. 2009;70:881–887.CrossRefPubMedGoogle Scholar
  35. 35.
    Cheng L, Wang ZQ, Li CZ, et al. Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years’ experience of 635 cases. Chin Med J. 2007;120:2081–2085.PubMedGoogle Scholar
  36. 36.
    Seewald S, Ang TL, Imazu H, et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc. 2008;68:447–454.CrossRefPubMedGoogle Scholar
  37. 37.
    Mumtaz K, Majid S, Shah HA, et al. Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding. World J Gastroenterol. 2007;13:1247–1251.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Tan P-C, Hou MC, Lin HC, et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-Butyl-2-Cyanoacrylate injection versus band ligation. Hepatology. 2006;43:690–697.CrossRefPubMedGoogle Scholar
  39. 39.
    Al-Bawardy B, Gorospe EC, Saleem A, Buttar NS, Song LMWK, et al. Outcomes and predictors of rebleeding after 2-octyl cyanoacrylate injection in acute gastric variceal hemorrhage. J Clin Gastroenterol. 2016;50:458–463.CrossRefPubMedGoogle Scholar
  40. 40.
    Bhat YM, Weilert F, Fredrick RT, et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large US experience over 6 years (with video). Gastrointest Endosc. 2016;83:1164–1172.CrossRefPubMedGoogle Scholar
  41. 41.
    Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc. 2013;78:711–721.CrossRefPubMedGoogle Scholar
  42. 42.
    Binmoeller KF, Weilert F, Shah JN, Kim J, et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc. 2011;74:1019–1025.CrossRefPubMedGoogle Scholar
  43. 43.
    Tantau M, Crisan D, Popa D, Vesa S, Tantau A, et al. Band ligation versus N-Butyl-2-cyanoacrylate injection in acute gastric variceal bleeding: a prospective follow-up study. Ann Hepatol. 2013;13:75–83.PubMedGoogle Scholar
  44. 44.
    Lo G-H, Liang HL, Chen WC, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39:679–685.CrossRefPubMedGoogle Scholar
  45. 45.
    Park JK, Saab S, Kee ST, et al. Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-analysis. Dig Dis Sci. 2015;60:1543–1553. doi: 10.1007/s10620-014-3485-8.CrossRefPubMedGoogle Scholar
  46. 46.
    Hong CH, Kim HJ, Park JH, et al. Treatment of patients with gastric variceal hemorrhage: Endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2009;24:372–378.CrossRefPubMedGoogle Scholar
  47. 47.
    Caldwell Stephen. Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era? Am J Gastroenterol. 2012;107:1784–1790.CrossRefPubMedGoogle Scholar
  48. 48.
    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65:310–335.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Tom D. Catron
    • 1
  • George B. Smallfield
    • 2
    Email author
  • Le Kang
    • 3
  • Richard K. Sterling
    • 2
  • Mohammad S. Siddiqui
    • 2
  1. 1.Tinsley Harrison Internal Medicine Residency Training ProgramUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Department of Internal Medicine, Division of Gastroenterology, Hepatology, and NutritionVCU Medical CenterRichmondUSA
  3. 3.Department of BiostatisticsVCU Medical CenterRichmondUSA

Personalised recommendations