Download - Dr.YoavMazor GIDepartment RambamMedicalCenter fileCT abdomen Small distal ... Susp: Hypersensitivity
Cirrhosis of liver, m/p due to NASHP t l h t i Portal hypertension: ▪ Gastric varices – no past bleeding▪ Portal hypertensive gastropathy▪ Portal hypertensive gastropathy▪ Hypersplenism (pancytopenia – PLT 50,000)
CHILD ‐A , MELD – 6CHILD A , MELD 6
GoutGout
Medications: Allopurinol, propranololp , p p
Main complaint: hematochezia and melena
Labs: Hgb 7 mg/dL, PLT 105,000, WBC 3840
INR normal
Treated with IV glipressin, omeprazole, erythromycin, ceftriaxone. y y
Urgent EGD preformed
Large conglomeration of gastric varices, with visible nipple sign no active bleedingvisible nipple sign, no active bleeding
No esophageal varices
Mosaic pattern of antral mucosap
Gastric varix treated with 2 cc *2 admixture Gastric varix treated with 2 cc 2 admixture of DERMABOND (2‐Octyl‐cyanoacrylate) and LIPIODOLLIPIODOL
New onset of ascites, SAAG>1.1, no SBP
Ongoing anemia, hematochezia
Packed cells X 12 units
Colonoscopy – hemorrhoids only Colonoscopy hemorrhoids only. Repeated EGD with no signs of active bleedingC bd CT abdomen
Small distal/ junctional esophageal varices Conglomeration of gastric varices Conglomeration of gastric varices
f bl d No sign of recent bleeding
Gastric varix treated with 2 cc X 2 admixture of DERMABOND (2‐Octyl‐cyanoacrylate) and of DERMABOND (2 Octyl cyanoacrylate) and LIPIODOL
Discharged after one month of hospitalization
Medications on discharge: Medications on discharge: Propanolol 10 mg*4/day Spironolactone 100 mg*1/dayp g y Allopurinol 100 mg*1/day
After discharge After discharge ‐ Continuous rectal bleeding –fresh blood after straining Cough and feverCough and fever
Re‐admitted to the surgical ward 1 week after di hdischarge
Cough, fever and rectal bleeding
Physical examination: Fever ‐ 38.8 C SAT 92% RA ‐‐‐ 72% RA9 7 Lungs: bilateral diffuse inspiratory crackles Rash buttocks hands and feet bilateral Rash – buttocks, hands and feet, bilateral, macular, does not resolve with local pressure and does not itch (biopsied) does not itch (biopsied).
pH 7.44, PCO2 32, HCO3 22‐‐‐‐ PO2 30
WBC 2900, Hgb 7.8 MCV 78, PLT 64,000
Creatinine, bilirubin, LFT ‐‐ normal
INR 1.32, fibrinogen 312. INR 1.32, fibrinogen 312.
Ceftriaxone and azithromycin started Supplement oxygen given Supplement oxygen given
On second day – ceftriaxone stopped and tazobactam‐ On second day ceftriaxone stopped and tazobactamampicillin started, IV furosamide, INH dexacort added
Patient transferred to ICU/internal ward
Repeated blood cultures negative. CMV Q fever mycoplasma rickettssia influenza CMV, Q fever, mycoplasma, rickettssia, influenza, legionella –neg.
Skin biopsy: Leukocytoclastic vasculitis
Ophthalmic: Diffuse hemorrhage around the optic disc, ‘flame’ shaped like and dot‐and‐blot hemorrhages, bilateral No bleeding into maculag DD includes DM, HTN and vasculitis.
49 years old patient with acute respiratory failurefailure
Feverh l k l l Rash ‐ leukocytoclastic vasculitis
Bilateral pulmonary infiltratesp y
PMH – liver cirrhosis, s/p histoacryl varices PMH liver cirrhosis, s/p histoacryl varices treatment.
A diagnostic procedure was preformed
Pneumonia – atypical
Acute respiratory distress syndrome (ARDS)
Systemic vasculitis – pulmonary hemorrhagey p y g
Embolic– septic ? Hystoacryl/dermabond?Embolic septic ? Hystoacryl/dermabond?
Hypersensitivity reaction Hypersensitivity reaction
Dense structures inside pulmonary vasculature bilateralvasculature, bilateral
l l d ff d l Bilateral, diffuse, ground glass opacities.
Sub‐pleural infracts, nodules.
ZN – negative
PCP – negative
Culture – Klebsiella oxytoca, enterobacter ycloacae
Characterization of Enterobacter cloacae pneumonia: a single-center retrospective analysis.Hennigs JK, et al. Lung. 2011 Dec;189(6):475-83
Transient bacteremia following endoscopic injection sclerotherapy of esophageal varices. Camara D, et al. Arch Intern Med. 1983 Jul;143(7):1350-2.
DERMABOND/LIPIODOL pulmonary embolism
Susp: Hypersensitivity reactionHypersensitivity reaction Leukocytoklastic vasculitis Interstitial pneumonitisInterstitial pneumonitis
Patient treated with IV hydrocortizone with ycomplete resolution of rash and respiratory symptoms.y p
Endoscopic sclerotherapy Tetradecyl sodium Tetradecyl sodium Sodium morrhuateEth l i l t Ethanolamine oleate Polidocanol
Endoscopic tissue adhesive injection Histoacryl ‐N‐butyl‐2‐cyanoacrylate Bucrylate ‐ isobutyl‐2‐cyanoacrylate
Since their discovery in 1949, cyanoacrylates have been used as a tissue adhesive, embolization material, and haemostatic agents in a broad range of medical and haemostatic agents in a broad range of medical specialties
T t f ti dh i Hi t l d Two types of tissue adhesives, Histoacryl and Bucrylate, have been used to treat variceal bleeding. These have proved effective in the control of bleeding ese a e p o ed e ect e t e co t o o b eed gwith a 90% success rate
Endoscopic obliterative therapy with Histoacryl is now Endoscopic obliterative therapy with Histoacryl is now the first‐choice treatment for emergency control of acute gastric variceal bleedingg g
SLEISENGER AND FORDTRAN’S GASTROINTESTINAL AND LIVER DISEASE: PATHOPHYSIOLOGY/DIAGNOSIS/MANAGEMENTCopyright © 2010by Saunders, an imprint of Elsevier Inc.
The fundamental technique of tissue adhesive b l l linjection using N‐butyl‐2‐cyanoacrylate (Histoacryl) is
the same as sclerotherapy
Polymerization occurs on contact with water to form a solid complex tightly bound to underlying tissue.
Polymerization is almost immediate in blood.
To prevent premature solidification during injection, Histoacryl is diluted with the oily contrast agent LipiodolLipiodol
Common: Transient fever and pain
Infectious: Bacteraemia Splenic abscessp Bacterial pericarditis
Prospective study of bacteremia rate after elective band ligation and sclerotherapy with cyanoacrylate for esophageal varices in patients with advanced liver disease.Bonilha DQ, et al. Arq Gastroenterol. 2011 Oct-Dec;48(4):248-51.
Septic complications after injection of N-butyl-2-cyanoacrylate: a report of 2 cases and review. Wahl P et al. Gastrointest Endosc 2004 ;59:911 –6.
Damage to endoscopic equipment due to premature hardening of cyanoacrylatepremature hardening of cyanoacrylate
l l l h Local mucosal ulceration at the injection site
Cementation and fixation of the injection needle in the glued varixneedle in the glued varix
C li ti f d i i l thComplications of endoscopic variceal therapy.Krige JE, Bornman PC, Shaw JM, Apostolou C.S Afr J Surg. 2005 Nov;43(4):177-88, 190-4. Review.
Emboli –
Portal and splenic vein thrombosis
Leakage through the gastro‐renal shunt into th l ft l i d i f i the left renal vein and inferior vena cava: Pulmonary Cerebral Coronary embolisationCoronary embolisation
Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices.Kang EJ et alKang EJ, et al. World J Gastroenterol. 2011 Mar 21;17(11):1494-500.
753 patients treated 51 patients with complications 51 patients with complications – 10 sepsis (1.3%) 5 distant embolisms (0.7%)‐ 1 pulmonary, 1 brain, 3 splenic
Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate.Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AE, Jin B.Clin Gastroenterol Hepatol. 2010 Sep;8(9):760-6.
In 140 patients who had Histoacryl injection for bleeding gastric varices, radiographically evident
l b li b d i 6 ( %) pulmonary emboli were observed in 6 (4.3%)
Chest radiographs and CT scans showed unusual Chest radiographs and CT scans showed unusual tubular or nodular, radiopaque pulmonary emboli along the pulmonary vessels
In 5 of 6 patients the radiographic abnormalities showed complete or partial resolution. p p
There were no fatalities directly associated with pulmonary embolipulmonary emboli
Hwang SS, Kim HH, Park SH, Kim SE, Jung JI, Ahn BY, etAl.. J Comput Assist Tomogr 2001;25:16–22
The reported severity of nbutyl‐ 2‐cyanoacrylate pulmonary embolism (PE) following EIS has varied from asymptomatic g y pto fatal.
Wh f h h di l i i h i When fever, cough, tachycardia, pleuritic chest pain, or dyspnea develop after endoscopic injectio therapy with cyanoacrylate chest radiography or non–contrast‐enhanced cyanoacrylate, chest radiography or non contrast enhanced computed tomography frequently allows diagnosis of pulmonary emboli
Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli.Alexander S, Korman MG, Sievert W. Intern Med J. 2006 Jul;36(7):462-5.emboli.Alexander S, Korman MG, Sievert W. Intern Med J. 2006 Jul;36(7):462 5.
N-butyl-2-cyanoacrylate and lipoidol pulmonary embolism (glue embolism).Javed A, Salamat A. Source J Ayub Med Coll Abbottabad. 2008 Apr-Jun;20(2):143-5.
Large injection volume 8 l i th ti t ( ) 4.2 vs. 1.8 ml in the patients (p < 0.0011).
Dilution of radiolucent Histoacryl with radiopaque Lipiodol p q p
Existence of porto‐systemic shuntsExistence of porto systemic shunts
Hwang SS, Kim HH, Park SH, Kim SE, Jung JI, Ahn BY, etAl.. J Comput Assist Tomogr 2001;25:16–22
The volume should be limited to minimal (2 (CC ?)
Damage to the endoscope is preventable if ifi ti t kspecific precautions are taken
131 I‐Labeled Lipiodol‐Induced Interstitial Pneumonia ‐A Series of 15 Cases
131 I‐labeled lipiodol is used as internal radiotherapy for unresectable hepatocellular carcinoma
From 1994 to 2009, interstitial pneumonia developed in 15 patients following 131 I‐labeled lipiodol administration
Most patients were admitted for acute respiratory failure with hypoxemia and hypocapnia.yp yp p
Chest CT scan revealed bilateral ground‐glass opacities with septal thickening, retraction, or both. No linear high‐density shadow.thickening, retraction, or both. No linear high density shadow.
Majority occurred after the second injection suggests that immunoallergic pathways could be the driving forceimmunoallergic pathways could be the driving force
CHEST 2011; 139(6):1463–1469
3 patients underwent embolization with n‐BCA before a planned, staged surgical resection of the embolized AVMs. p , g g
In all three patients, surgical and autopsy specimens showed i fl i hi h b li d l an inflammatory response within the embolized vasculature
with a prominent eosinophilic infiltrate.
The eosinophilic vasculitis seen in the pathology specimens may represent a previously undocumented hypersensitivity y p p y yp yreaction following exposure to n‐BCA.
Vascular inflammation with eosinophils after the use of n-butyl cyanoacrylate liquid embolic system.Quinn J, et al. Prestigiacomo CJ. J Neurointerv Surg. 2011 Mar;3(1):21-4.
SummarySummary
DERMABOND/LIPIODOL pulmonary embolismembolism
d h Suspected hypersensitivity reaction: Leukocytoklastic vasculitisy Interstitial pneumonitis