Recurrent bacteremia after injection of N-butyl-2-cyanoacrylate for treatment of bleeding gastric varices: a case report and review of the literature

Abstract

BackgroundBleeding from gastric varices has high mortality rate, and obliteration using N-butyl-2-cyanoacrylate is the treatment of choice. Recurrent bacteremia is rarely reported following the procedure. We aimed to report a case of recurrent bacteremia after N-butyl-2-cyanoacrylate treatment and to review published cases.Case presentation and reviewIn May 2014, a 43-year-old Brazilian male presented with lower gastrointestinal bleeding. Endoscopy showed active bleeding from gastric varix. Injection of N-butyl-2-cyanoacrylate was performed and the patient was discharged. Over the next 4 months he presented with three episodes of bacteremia with severe sepsis and no identifiable focus of infection. Oral prophylaxis was initiated in September 2014 and he has remained free of bacteremia. Six other cases of recurrent bacteremia following sclerosis with N-butyl-2-cyanoacrylate were reported in the literature. All patients had portal hypertension and bleeding from gastric varices. Average age of patients was 55.7 years and the median time from endoscopic procedure to the first episode of bacteremia was 105 days (range 14–365). The mean number of episodes of bacteremia per patient was 2.5.ConclusionRecurrent bacteremia associated with endoscopic treatment with N-2-butyl-cyanoacrylate is rare, but should be suspected in patients in which investigation shows no other focus of infection. Secondary prophylaxis should be considered after the first episode.

Bacteriemias Recorrentes após Escleroterapia de Varizes Ectópicas Duodenais com Cianoacrilato

“…O caso relatado descreve uma doente jovem, do sexo feminino, com hemorragia por varizes ectópicas duodenais, com cinco episódios de bacteriemia documentados, com início um mês após a escleroterapia com cianoacrilato (Tabela 2). 4 Destaca-se o caso por ser uma complicação muito rara da escleroterapia, que pode ocorrer por obliteração incompleta da variz com disseminação bacteriana para os tecidos moles ou formação de biofilme no material extrusado. 7 Considerando este último mecanismo como a provável etiologia das bacteriemias da doente apresentada, as opções terapêuticas disponíveis seriam aguardar pela expulsão do material, o que perpetuaria o foco infecioso durante alguns meses, ou a excisão cirúrgica, contraindicada nesta doente dado o elevado risco anestésico, comorbilidades e agressividade do procedimento.…”

Resección quirúrgica de tapón de cianoacrilato variceal infectado posterior a esclerosis endoscópica de várices gástricas. Caso clínico

“…En la literatura se describe que los riesgos de bacteriemias transitorias en pacientes cirróticos posterior a la escleroterapia de emergencia o electiva son diferentes 6 , alcanzando valores que oscilan entre 20% y 70% para aquellas que son de emergencia y entre 0 y 27% para las electivas [3][4][5] .…”

“…Sin embargo, la bacteriemia recurrente con repercusión clínica, tal como el síndrome febril prolongado, es una complicación rara posterior a la escleroterapia. Randi et al 6 reportan solo 7 casos publicados en la literatura.…”

“…En solo uno de los casos reportados por Randi et al 6 se realizó manejo quirúrgico resecando el foco infeccioso. Todos los demás fueron manejados con tratamiento antibiótico prolongado y algunos quedaron con profilaxis antibiótica indefinida.…”