Glue Injection

Gastric varices are enlarged veins found in the stomach. They mainly occur in patients with portal hypertension. While gastric varices bleed less frequently than esophageal varices, the severity of bleeding and associated mortality is greater. Cyanoacrylate glue is a liquid substance with the consistency of water that transforms into a solid state when added to a physiological medium such as blood. When instilled into a varix using the standard method of intravariceal injection, the glue undergoes an instantaneous polymerization reaction and hardens to a rock hard substance, thereby plugging the lumen of the varix. This enables rapid hemostasis of active bleeding and prevents rebleeding.

A therapeutic gastroscope with a large working channel is used for injection. Variceal injection is performed with a 23-gauge disposable sclerotherapy needle. The varix is punctured under direct visualization and approximately 1cc of the glue is injected intravariceally. After injection, the patency of the varix is assessed with blunt catheter palpation and additional glue injected until the varices are obliterated.

Cyanoacrylate compounds are routinely used in different medical and surgical subspecialties for embolization of aneurysms, arteriovenous malformations and fistulae, and as a wound or tissue adhesive. The safety profile of cyanoacrylate glue for varix obliteration is excellent. A minority of patients develop transient fever and pain after injection. There have been rare case reports of complications related to embolization, which include cerebral stroke and pulmonary embolism. Visceral fistulas have also been reported, probably due to misguided injections.

When to use Histoacryl glue

It is used to inject in the gastric varix to achieve haemostasis in case of acute bleeding.

Gastric varix occur in 20% patients of portal hypertension and risk of gastric variceal bleeding varies from 55% to 78% with a bleeding related mortality rate of 45%

It is tissue glue and can be issued to glue cut surface e.g. small incised wound in place of steristrip.

How to prepare the glue

Wear protective eye goggles and gloves.
Draw 1ml of Lipiodol in a 2ml Luer lock syringe ( Lipiodol comes in 10ml ampoule)
Use of Luer lock syringe is preferable as it is quite hard to push the glue through the injection needle and there is a chance that the syringe can come loose from the injection needle spraying the glue everywhere.
Before you snap open the tip of the Histoacryl ampoule hold it vertically and tap the narrowed tip so that the solution settles in the bottom
Next draw the whole ampoule (0.5ml of Histoacryl® ) of glue in the same syringe and gently shake
The glue has to be freshly made immediately before the injection into the varix.
Keep acetone handy as it is only dissolvable in acetone.

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