Introduction The optimal therapy for gastric variceal bleeding remains unclear. Endoscopic Human Thrombin injection appears a technically simple and efficacious alternative to cyanoacrylate with fewer complications, but data remains limited. This study evaluated patient outcomes following thrombin injection for gastric varices.
Methods Retrospective review of patients receiving endoscopic human thrombin injection for active bleeding or prevention of bleeding from gastric varices at a UK tertiary centre from December 2008 to November 2011. Thrombin injection (Tisseel 250 IU/ml, Baxter Int. Inc.) was repeated at intervals until varices eradicated.
Results 23 patients (65% male, mean age 53.1 (SD 14.0)), received human thrombin injection for gastric varices. Mechanism of portal hypertension was cirrhosis 17 patients (74%), extra-hepatic 6 (26%). Cirrhosis was due to alcohol (10), viral (2), PBC (2), other (3); 4 had additional portal vein thrombosis. TIPSS was felt not feasible in 8 (35%). Mean MELD was 13 (SD 5). Childs grade A, B, C in 39%, 35% and 26% respectively. Varices were classified: IGV1 19 (83%), IGV2 3 (13%), GOV2 1 (4%). 14 patients (61%) were actively bleeding or had signs of recent bleeding; of these haemostasis was achieved in 12 (86%). Mean thrombin dose/injection was 1168 IU (range 400–2500); median number of sessions 2 (range 1–7) with no reported complications. Median follow-up was 476 days (IQR 193–931). No patient underwent liver transplantation. Rebleeding occurred in 9 (39%) patients, 5 (56%) within the first week (range 1–1008 days), 1 yr rebleeding rate 35%. Rebleeding was successfully managed in 78%, by salvage TIPSS (5 patients) and thrombin injection (2). Two patients died following rebleeding. Six deaths (26%) occurred in total all within 12 months; the remainder were due to uncontrolled bleeding (1), liver failure (1), MOF following OV bleed banded (1), and hepatocellular carcinoma (1). Cumulative survival at 1, 6, 12 months was 82%, 78%, and 74% respectively. Where TIPSS was precluded, 75% (6 of 8 patients) were managed successfully with thrombin.
Conclusion Thrombin in our series appears to be a safe and effective endoscopic therapy for gastric varices, achieving good haemostasis with low medium to long term rebleeding rates. It may have particular utility in salvaging patients not suitable for TIPSS.
Competing interests None declared.
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