The use of thrombin injections in the management of bleeding gastric varices: a single-center experience

Background: There is a relative dearth of literature on the definitive endoscopic management of bleeding gastric varices. Variceal ligation with bands and detachable snares, sclerosants, cyanoactylate glue, and thrombin injections have been used with variable success. Objective: To report our experience with bovine thrombin injection for the treatment of bleeding gastric varices. Design: A retrospective review. Setting: Tertiary-referral hospital. Patients: Forty-two cases of gastric varices were identified from our endoscopy database between July 1998 and July 2003. Thirteen patients had thrombin injection. Intervention: Thrombin injection therapy for bleeding gastric varices. Main Outcome Measurements: Control of hemorrhage, risk of rebleeding, and mortality. Results: Of the 13 patients who underwent thrombin injections, hemostasis in the acute setting was successful in 92% of cases. Patients received 1 to 4 sessions of thrombin, with a mean total dose of 10.8 mL for variceal eradication. One patient continued to bleed and needed a transjugular intrahepatic portosystemic shunt as a rescue procedure. The patient with hepatocellular carcinoma died within 30 days, and 4 more patients died after a median follow-up of 22 months; none died because of bleeding. There was no rebleeding in the remaining patients at a median follow-up of 25 months. Limitations: The retrospective nature and small number. Conclusions: In our series, injection with thrombin proved to be an effective endoscopic treatment in the majority of patients with bleeding gastric varices. The overall mortality, after controlling bleeding, was 38% (5/13), subsequent to a median follow-up of 22 months. (Gastrointest Endosc 2008;68:877-82.)