FATAL PULMONARY EMBOLUS AFTER ENDOSCOPIC EMBOLIZATION OF A DOWN-HILL ESOPHAGEAL VARIX

History and clinical findings: A 79-year-old man was admitted with a h istory of recent haematemesis and tarry stools. 4 years before he had undergone a subtotal thyroidectomy for hyperthyroidism. Investigations : He was anaemic (haemoglobin 7.2 g/dl, haematocrit 23%). At the trans ition between the upper and middle third of the oesophagus gastroscopy revealed a bleeding oesophageal varix. Treatment and course: The blee ding varix was sclerosed with polidocanol. 3 erythrocyte concentrates were administered. Massive bleeding 2 days later was controlled with i ntravaricose injection of cyanoacrylate (Histoacryl(R)). The patient d ied 6 weeks later from progressive cardiovascular failure. Autopsy rev ealed the cause of death as right heart failure with extensive foreign -body pulmonary emboli identified.as thrombotic material containing po lymerized cyanoacrylate found in the previously injected oesophageal v arix. Also discovered was a retrosternal goitre which had compressed t he brachiocephalic vein. Cause of the >>washing-out<< of the cyanoacry late embolus from the varix into the systemic circulation was an oesop hagovaricose collateral circulation in a cranio-caudal direction; this had been formed by the pressure of the retrosternal goitre on the bra chiocephalic vein. Conclusion: Cyanoacrylate injection into a varix ab ove the lower third of the oesophagus should only be done under strict indication. A similar risk as that described in this case potentially exists in the treatment of acute bleeding from a portosystemic varico se circulation.