So Near, Yet So Far…

Tropical Gastroenterology 104 are the endoscopic treatment of choice for IGV1,2 and GOV2. Endoscopic glue is associated with a significant risk of complications such as embolisation, bleeding, ulceration and extrusion.2-4 Also, it is difficult to see varices properly in the presence of an active bleed or a large blood clot or food residue in the fundus by a conventional gastroscope. Endoscopic ultrasound (EUS) overcomes the limitations of conventional endoscopy. EUS-guided delivery of cyanoacrylate (CYA) glue enables realtime precise delivery of the glue directly into the varix lumen. Moreover, EUS also enables the use of Doppler evaluation to confirm varix obliteration simultaneously. The various EUS-guided therapies used for gastric varices include glue injection, coil placement and combination of both the above. While glue placement carries a risk of embolisation, coils larger than the size of the varix are costly. Thus, a combination of EUS-guided coil and glue decreases the cost (lesser numbers of coils are needed) and reduces the risk of embolisation (lesser amount of glue is needed and the coils act as a scaffold to retain the glue, thereby decreasing the chances of glue embolization). In a retrospective study of 152 patients, EUS-guided combined coil and glue injection of high-risk gastric varices appears to be highly effective for hemostasis in active bleeding and primary and secondary bleeding prophylaxis.5 Once obliteration was achieved, post-treatment bleeding from varices occurred in only 3% of patients during long-term follow-up.5 While asymptomatic glue embolization in the glue-alone group is very common,6 combination therapy appears safe and may reduce the risk of glueembolisation. EUS-guided coil and glue has been shown to be effective in several other studies also.6,7 To summarise, we present a series of 3 cases where endoscopy failed and IR-guided intervention was not possible/feasible. EUS-guided therapy achieved variceal obliteration in all these cases.