Endoscopic treatment of gastric varices using N-butyl- 2-cyanoacrylate glue: experience from Ethiopia, sub- Saharan Africa

Endoscopic treatment of gastric varices using N-butyl- 2-cyanoacrylate glue: experience from Ethiopia, sub- Saharan Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endoscopic treatment of gastric varices using N-butyl- 2-cyanoacrylate glue: experience from Ethiopia, sub- Saharan Africa Abate Bane Shewaye, Kaleb Assefa Berhane This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4183362/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Gastro-esophageal varices (GV) are the major clinical manifestations of cirrhotic and non-cirrhotic portal hypertension. Although less frequent than esophageal varices (EV), They pose a significant clinical challenge due to their propensity for severe bleeding, associated with high morbidity and mortality rates. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) has emerged as a promising treatment modality for GV, offering effective hemostasis and low rebleeding rates. This study aims to investigate the practice and outcomes of NBCA injection therapy for gastric varices in Ethiopia. Methods A cross sectional study was conducted on patients who received NBCA injection treatment at Adera Medical and Surgical (AMS) Center from December 2022 to January 2024.Data regarding socio-demographics, clinical characteristics, indications, endoscopic findings, procedure details, complication and outcome were collected from patients’ medical records and through a phone call interview using structured checklist. The acquired data was examined for accuracy, cleaned up and validated before analysis using SPSS 26.0. Descriptive statistics were employed as a statistical data analysis technique for categorical variables, and the results were expressed as frequencies and percentages. Tables and figures were utilized to provide a concise summary of the findings. Categorical data were presented as frequencies, while continuous variables were expressed as means, standard deviations, and minimum and maximum values. Results: The study investigated the use of NBCA injection for treating gastric varices in 49 patients. The mean [± SD] age was 39.92 ± 16.05 years with M: F of 2.5 respectively. IGV1 was the commonest GV type (46.9%). Thirty-Five (71.4%) patients had active bleeding and received NBCA within 12 hours, while the rest received it prophylactically for large varices. Initial bleeding control was achieved in all patients. One patient with active bleeding experienced re-bleeding 25 hours post NBCA glue injection but stopped spontaneously. No procedure-related complications, bleeding, organ embolism, or death were reported. Conclusion: NBCA glue injection demonstrably achieved effective bleeding control in all patients with gastric varices in this study. These findings offer valuable insights for optimizing gastric varices management and reducing the burden of upper gastrointestinal bleeding in Ethiopia, Sub-Saharan Africa. To ensure successful implementation, enhancing healthcare providers' expertise in interventional endoscopic techniques, including NBCA glue injection, is crucial. Further wider research is recommended to explore long-term outcomes and compare the efficacy of NBCA glue injection with other treatment options for gastric varices in Ethiopia and sub Saharan Africa at large. Gastric varices N-butyl-2-cyanoacrylate glue Ethiopia Sub-Saharan Africa Figures Figure 1 Background Gastric varices (GV) are dilated submucosal collateral veins that arise in the context of portal hypertension. ( 1 ) They are estimated to occur between 17% and 25% among patients with portal hypertension (PHTN), which is much less frequent compared to esophageal varices (EV). The incidence of GV bleeding at 3 years is reported to be 16–45%, and comparable rates of hemorrhage and mortality from GV are observed among patients with cirrhotic and noncirrhotic PHTN. ( 2 , 3 , 4 ) Despite their lower incidence of bleeding compared to EV, GV pose a significant clinical concern due to their propensity for severe hemorrhage and poor patient outcomes ( 1 , 2 ). Sarin's classification categorizes (GV) into four types based on their location within the stomach and their relationship with esophageal varices (EV). Gastro-esophageal varices type 1 (GOV1) are a continuation of EV into the lesser curvature of the stomach. Gastro-esophageal varices type 2 (GOV2) represents a continuation of EV into the fundus of the stomach. Isolated gastric varices type 1 (IGV1) are those located in the fundus of the stomach, and isolated gastric varices type 2 (IGV2) refers to GV located anywhere in the stomach. GOV1 accounts for approximately 75% of GV types ( 2 ). Although limited data exist on the optimal management of GV hemorrhage, current guidelines recommend endoscopic therapy as the preferred definitive modality for GV bleeding. N-Butyl-2-Cyanoacrylate (NBCA) injection remains a primary treatment option where endoscopists are proficient in the technique. It involves the injection of cyanoacrylate glue mixed with lipiodol into the varix, leading to rapid polymerization and hemostasis ( 5 , 6 ). Since its introduction in the 1980s, it has been shown to be effective at initial control of bleeding (90–100%), preventing late rebleeding (< 15%), and fewer complications compared with alcohol-based sclerotherapy or band ligation ( 7 – 10 ). The best method of NBCA injection is highly debated, with multiple studies supporting various techniques. The success of any method of NBCA injection for GV is influenced by the choice of cyanoacrylate formulation, use of co-mixture agents, preparation of materials, and steady, uniform injection delivery. Distant embolization of the glue thrombus is the most feared complication, although the rates of clinically significant embolization leading to symptoms needing anticoagulant therapy or death are rare (0.7%). Similarly, exacerbations of bleeding, portal and splenic vein thrombosis, and infections are infrequently reported. Instances of injector needle impaction into GV have only been documented in case reports, suggesting a possible association with endoscopist experience, highlighting the need for specific training. Follow-up of endoscopic management of GV should mimic that of endoscopic management for EV ( 7 ). Combination therapy with nonselective beta-blockers (NSBB) is recommended to prevent rebleeding in GV patients ( 11 ). Esophagogastric varices are common cause of UGIB in sub-Saharan Africa (SSA) ( 12 – 16 ). In this region, where access to advanced endoscopic therapies is limited, managing gastric varices and associated bleeding episodes becomes particularly challenging. The scarcity of resources and expertise in performing endoscopic interventions confounds the management dilemma surrounding gastric varices in the region ( 17 , 18 ). Despite the growing interest in cyanoacrylate glue injection, data regarding its utilization and outcomes in the management of gastric varices in Sub-Saharan Africa remain limited. Therefore, this study aims to investigate the practice and outcomes of NBCA injection for gastric varices treatment in Ethiopia. Material and methods A retrospective cross-sectional study was conducted on patients with gastric varices who received NBCA injection treatment at Adera Medical and Surgical (AMS) Center, the only center where this procedure is done in Ethiopia to date. The procedure is performed by a senior gastroenterologist (1,2*) with a technique of cyanoacrylate injection into 1-1.5 ml aliquots following the needle puncture of the varix lumen. The glue is then flushed into the varix using sterile normal saline (approximately 0.8-1.0 mL, corresponding to the dead space). A continuous stream of the flush solution is directed toward the puncture site as the needle is removed from varix. Up till the varix is "hard" to forceps palpation, more glue is injected. The mucosa covering the glue cast sloughs off weeks to months after the injection, allowing the plug to be extruded into the stomach. All patients who had the procedure from December, 2022 to January 2024 were included in the study. Data on socio-demographics, indications, clinical characteristics, endoscopic findings, procedure details, complications and outcome were collected from patients’ medical records and through phone call using a structured check-list. The acquired data was examined for accuracy, cleaned up, and validated before analysis using SPSS 26.0. For categorical variables, descriptive statistics were utilized and expressed as frequencies and percentages. Tables and figures were used to summarize the results. Categorical data were represented as frequencies, whereas continuous variables were represented as means, standard deviations, and minimum and maximum values. Spurting or oozing of blood from a gastric varix or clotted blood in the stomach fundus was defined as GV bleeding, while new-onset hematemesis, a systolic blood pressure drop of ≥ 20 mmHg, a hemoglobin drop of ≥ 2 g/dL, or transfusion of ≥ 2 units after 24 hours post-procedure were considered criteria for rebleeding. Successful initial hemostasis was declared upon cessation of bleeding with no recurrence for 24 hours. Outcome measures included intra-procedural bleeding, hypotension, allergic reactions, systemic embolic events, fever, bacteremia, duration of hospital stay, need for salvage therapy (balloon tamponade, transjugular intrahepatic portosystemic shunt, surgery), rebleeding, and 6-week all-cause mortality. Follow-up was conducted via clinical evaluation and telephone calls. Results A total of 49 patients with gastric varices treated by NBCA injection were analyzed. Thirty-five (71.4%) of the patients presented with gastric variceal bleeding and NBCA injection was carried out within 12 hours of active bleeding on emergency basis while the rest of the patients with large (> 10mm) gastric varices without bleeding episodes were treated in the same way for primary prophylactic reasons. The majority of the patients were male (n = 35, 71.4%). The mean [± SD] age was 39.92 ± 16.05 (range: 11–70) years. Twenty-four patients (41.5%) presented with hematemesis and melena, while hematemesis was observed in 20.4% of cases, hematochezia in 14.3%, and melena in 16.3%. Nearly half of the patients (47%) exhibited concomitant tachycardia and hypotension. According to the Child-Pugh classification, 51.0% of patients had class A, 34.7% class B, and 14.3% class C liver status. The median Model of End-Stage Liver Disease (MELD) score for all patients was 13, ranging from 8 to 28. Two patients experienced hepatic encephalopathy and fully recovered within a few days. The majority of patients (58.5%) had non-cirrhotic etiologies of PHTN, such as chronic portal vein thrombosis (CPVT) in 34.1% of cases, hepatosplenic schistosomiasis (HSS) in 22.4%, and splenic vein thrombosis (SVT) in 2.0%, while chronic hepatitis B (22.4%) was the most common cirrhotic cause of PHTN. Three patients had concurrent hepatocellular carcinoma (HCC). (Table 1 ) Table 1 Demographic and clinical profile of GV patients visiting AMS Center, December, 2022 to January 2024 variable Total (n = 49) Frequency Percent (%) Gender Male 35 71.4 Female 14 28.6 Age(years) mean 39.92 Std. Deviation (SD) 16.05 Clinical presentation Hematemesis 10 20.4 Melena 8 16.3 Hematemesis and Melena 24 49.0 Hematochezia 7 14.3 Vital Signs Normal 11 22.4 Tachycardia 5 10.2 Hypotension 10 20.4 Tachycardia and Hypotension 23 47.0 Child Pugh Child score A 17 34.7 Child score B 25 51.0 Child score C 7 14.3 MELD score Median 13 Causes of PTH HBV 11 22.4 ALD 3 6.1 Autoimmune 2 4.1 MASLD 2 4. HSS 11 22.4 CPVT 17 34.7 SVT 1 2.0 Concurrent HCC 3 6.1 unspecified 1 2.0 Isolated GOV1, GOV2, IGV1 were reported in 17.1%, 12.2% and 46.9% of the endoscopic results while there was no IGV2 reported. Six reports indicated the presence of both GOV1 and GOV2, while three reports indicated the presence of both IGV1 and GOV2 (Fig. 1 ). Thirty-eight (77.5%) of the patients had large gastric varices while 7 had medium (5-10mm) and 4 had small (< 5mm) GV. All patients who presented with actively bleeding GV were initially optimized and resuscitated. A restrictive packed red blood cell (PRBC) and platelets transfusion aimed at maintaining a hemoglobin level of 7 to 9 g/dL and platelet count greater than 50 × 10⁹/L was employed for hemodynamic stabilization. Nearly half (49%) of the patients with GV required 2 ± 0.64 units of PRBC transfusion on average for initial hemodynamic stabilization. The majority of patients (83.7%) had concurrent esophageal varices without evidence of active bleeding, and endoscopic variceal ligation (EVL) was performed for three-fourths (78.0%) of these patients following NBCA glue injection for gastric varices. (Table 2 ) Table 2 Treatment and outcome of GV patients visiting AMS Center, December 2022 to January 2024 Frequency Percentage Blood transfusion for initial hemodynamic stabilization Yes 24 49 No 25 51 Type of blood product n = 24 PRBC 20 FFP 5 Unit of PRBC n = 24 1 4 16.7 2 14 58.3 3 6 25 Prior use of NSBB Yes 37 75.5 No 12 24.5 Presence of red signs Yes 18 36.7 No 31 63.3 Presence of concomitant EV Yes 41 83.7 No 8 16.3 Classification EV n = 41 F1 8 16.3 F2 18 36.7 F3 15 30.6 Was EVL done n = 41 Yes 32 78.0 No 9 22.0 Hemostasis achieved immediately n = 35 Yes 35 100 No 0 0 Rebleeding n = 35 Yes 1 2.9 No 34 97.1 Post procedure PPI Yes 30 61.2 No 19 38.8 Post procedure NSBB Yes 46 93.9 No 3 6.1 The average hospital stay of the patients was 1.88 days. With mean volume of 1.07 NBCA glue solution delivered per procedure, initial hemostasis was achieved in all patients who presented with active gastric variceal bleeding with one session. No patient required salvage therapy. Among the 35 patients who presented with active gastric variceal bleeding and underwent NBCA glue injection, re-bleeding occurred in one patient (2.9%) with IGV1 of CPVT cause and child class C liver status approximately 25 hours post-procedure, which was managed conservatively and resolved spontaneously. Post-procedure, more than half (61.2%) of the patients received proton pump inhibitor (PPI) therapy, and 93.9% continued NSBB treatment. (Table 2 ). Follow up abdominal ultrasound or computed tomography was done for all patients 6 weeks after NBCA and no thrombosis was reported. Moreover, no procedure-related complications, bleeding, organ embolism, or deaths from any cause were reported immediately or within six weeks after the procedure for any of the patients. Discussion Gastric variceal hemorrhage is a serious complication of PHTN accounting for approximately 20% of all variceal bleedings ( 19 , 20 ). Bleeding from GV is related to their size, wall thickness, and the presence of red color signs. The treatment options for GV bleeding include pharmacological therapy, endoscopic NCBA injection, and endovascular intervention ( 7 ). Currently, NCBA glue injection is recommended as the primary treatment option. More than 90% of hemostasis rates have been achieved with an NCBA injection with 70–90% of variceal obliteration and depends upon the technique and experience of the endoscopist. ( 7 , 9 ) Likewise, our first experience from Ethiopia revealed NCBA injection for GV to be very effective and safe in our cohort. A randomized controlled trial comparing endoscopic cyanoacrylate injection (ECI) with NSBBs for primary prophylaxis in 89 patients with GOV2s or IGV1s showed lower rebleeding rates (13%) in ECI patients compared to those treated with NSBBs (28%; P = .039) or no treatment (45%; P = .003) after a median follow-up of 26 months. (21) In a similar retrospective study of patients with large GOV1s, GOV2s, or IGV1s undergoing ECI compared to observation alone, bleeding rates were lower in ECI patients (19.4%) versus observation alone (35.1%; P = .001) after a median follow-up of 35 months. (22). In our study, all patients with large (> 10mm) GV undergoing prophylactic ECI experienced no bleeding during the observation period. In a prospective study of 568 patients with GV, IGV1s were the least common (6%) but had a high bleeding incidence (78%) and mortality rate (29%). IGV2 represented 15% of GVs with a bleeding risk of 9%. GOV1 was the most common (75%) GV with a bleeding rate of 12%, while GOV2 represented 21% of GV with a relatively higher bleeding rate of 55% ( 2 ). Managing bleeding GOV1 is usually similar to esophageal variceal bleeding management, whereas managing bleeding GOV2 or IGV1 is challenging due to high blood flow. ( 23 ) In our study cohort, IGV1 was the most common (46.9%) GV type and all GV types were successfully managed with NBCA injection. In the current study, complete obliteration of gastric varices leading to initial hemostasis was attained in all patients presenting with active gastric variceal bleeding. This outcome mirrors findings from a retrospective study involving 455 patients, where a success rate of 96.9% was reported ( 24 ). Similar success rates ranging from 90–97% have also been documented in smaller-scale studies ( 3 , 25 , 26 ). Another study assessing the safety of NBCA for gastric fundal varices treatment using standardized injection technique reported achieving initial hemostasis and variceal obliteration in all patients without early rebleeding, procedure-related complications, or bleeding-related deaths. The cumulative rebleeding-free rates at 1, 3, and 5 years were 94.5%, 89.3%, and 82.9%, respectively. ( 27 ) This study was also in line with our findings demonstrating that NBCA is safe and effective with the use of a standardized injection technique. A meta-analysis of 43 studies involving 3484 patients demonstrated a technical success rate of 94.1% (95% CI: 91.6–96.1%), a 30-day rebleeding rate of 24.2% (18.9–29.9%), and a 30-day overall and major complications occurrence of 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively ( 28 ). Consistent with these findings, a separate study reported a rebleeding rate of 12.7% within 4 weeks post-NBCA sclerotherapy. ( 24 ). Furthermore, mortality rates of 12.5% and 6.8% due to rebleeding immediately after NBCA sclerotherapy and after initial hemostasis were reported ( 24 , 29 ). Our study showed a lower rebleeding rate of 2.9% and no occurrence of overall complications or deaths within a 6-week follow-up period. In a study from a developing country, Pakistan, involving 31 patients, 87% of patients achieved hemostasis after the initial injection and reported a 9.7% overall mortality rate, unlike our study, which demonstrated a 100% success rate in achieving initial hemostasis and no death 6 weeks post-procedure. ( 30 ) Our findings, in alignment with existing literature, underscore the safety and efficacy of NBCA injection in achieving successful outcomes, including complete variceal obliteration and no procedure related complication or mortality within a six-week follow-up period. Despite variations in outcomes reported across different studies and regions, the overall evidence supports NBCA injection as a valuable intervention for managing gastric variceal bleeding, offering hope for improved patient outcomes and reduced mortality in managing GV. Further research and broader adoption of standardized techniques are warranted to optimize the use of NBCA injection and enhance its accessibility and effectiveness in diverse healthcare settings especially in resource limited regions where other advanced endoscopic and radiologic interventions are not readily available or accessible. Conclusion This study demonstrates the successful and safe application of NBCA injection for treating all types of GV, achieving effective bleeding control without significant complications. Early identification and referral of patients with gastric varices for prompt intervention, including during active bleeding episodes, is crucial to improve treatment effectiveness and reduce mortality. To ensure safe and successful treatment delivery in resource-limited settings, enhancing healthcare providers' training and expertise in interventional endoscopic techniques, including NBCA injection, is essential. Further wider prospective studies are needed to evaluate long-term outcomes and compare the efficacy of NBCA injection with other treatment options for gastric varices in Ethiopia and SSA at large. Declarations Ethics approval and informed consent The ethical clearance of the present study was obtained from the institutional review board of AMSC. Consent was obtained from all participants. All the information obtained was held with confidentiality and used only for the intended purpose. Availability of data and materials The datasets used and/or analyzed during the current study are available from the principal investigator up on reasonable request. Conflicts of interest The authors report no conflicts of interest related to this work. Acknowledgment We are grateful to the patients and colleagues who were involved in the care of the patients. Funding no funding was obtained. References Goral V, Yılmaz N. 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Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160–167 Mansoor-Ul-Haq M, Latif A, Asad M, Aziz Memon F. Treatment of Bleeding Gastric Varices by Endoscopic Cyanoacrylate Injection: A Developing-country Perspective. Cureus. 2020 Feb 20;12(2): e7062. doi: 10.7759/cureus.7062. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4183362","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286190667,"identity":"f94a6e71-ec21-42ab-bc59-7e26d2c0aac8","order_by":0,"name":"Abate Bane Shewaye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACCSBmbACxmA+AuDLEaGFsgGhhSwBxeUjRwmMAJgnq4J/d/PzBxx12efz8Zz6/ulFjwcPAfvjoBryW3Dlm2DjzTHKx5IzcbdY5x4AO40lLu4HXmhsJhs28bcyJG27wbjPOYQNqkeAxw6tF/kb6x+a/bfWJ+8+feWac848ILQY3cgybGdsOJ25gyGF+nNtGhBbDO2cKZ/aeOZ4440aaGXNunwQPGyG/yN1u3/Dh547qxP7+w48/53yrk+NnP3wMv/eRAJsEmCRWOQgwfyBF9SgYBaNgFIwcAAD39U4h2vb5mgAAAABJRU5ErkJggg==","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Abate","middleName":"Bane","lastName":"Shewaye","suffix":""},{"id":286190670,"identity":"9a807dac-7f1c-414a-b2d1-887dbc40935b","order_by":1,"name":"Kaleb Assefa Berhane","email":"","orcid":"","institution":"Adera Medical and Surgical Center","correspondingAuthor":false,"prefix":"","firstName":"Kaleb","middleName":"Assefa","lastName":"Berhane","suffix":""}],"badges":[],"createdAt":"2024-03-28 15:44:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4183362/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4183362/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54160979,"identity":"7a683a03-5e93-4e89-b1f2-82b325c786ab","added_by":"auto","created_at":"2024-04-05 13:03:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6072,"visible":true,"origin":"","legend":"\u003cp\u003eSarin classification of GV of patients visiting AMS Center, December 2022 to January 2024\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4183362/v1/893ccf8645fcd2c2eb53929f.png"},{"id":77904357,"identity":"326bb29f-6fcf-4b73-8bff-c698bb77dede","added_by":"auto","created_at":"2025-03-06 16:16:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":527750,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4183362/v1/9f87206b-0626-4d02-8ac0-e9320f405b77.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic treatment of gastric varices using N-butyl- 2-cyanoacrylate glue: experience from Ethiopia, sub- Saharan Africa","fulltext":[{"header":"Background","content":"\u003cp\u003eGastric varices (GV) are dilated submucosal collateral veins that arise in the context of portal hypertension. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) They are estimated to occur between 17% and 25% among patients with portal hypertension (PHTN), which is much less frequent compared to esophageal varices (EV). The incidence of GV bleeding at 3 years is reported to be 16\u0026ndash;45%, and comparable rates of hemorrhage and mortality from GV are observed among patients with cirrhotic and noncirrhotic PHTN. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Despite their lower incidence of bleeding compared to EV, GV pose a significant clinical concern due to their propensity for severe hemorrhage and poor patient outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSarin's classification categorizes (GV) into four types based on their location within the stomach and their relationship with esophageal varices (EV). Gastro-esophageal varices type 1 (GOV1) are a continuation of EV into the lesser curvature of the stomach. Gastro-esophageal varices type 2 (GOV2) represents a continuation of EV into the fundus of the stomach. Isolated gastric varices type 1 (IGV1) are those located in the fundus of the stomach, and isolated gastric varices type 2 (IGV2) refers to GV located anywhere in the stomach. GOV1 accounts for approximately 75% of GV types (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Although limited data exist on the optimal management of GV hemorrhage, current guidelines recommend endoscopic therapy as the preferred definitive modality for GV bleeding. N-Butyl-2-Cyanoacrylate (NBCA) injection remains a primary treatment option where endoscopists are proficient in the technique. It involves the injection of cyanoacrylate glue mixed with lipiodol into the varix, leading to rapid polymerization and hemostasis (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince its introduction in the 1980s, it has been shown to be effective at initial control of bleeding (90\u0026ndash;100%), preventing late rebleeding (\u0026lt;\u0026thinsp;15%), and fewer complications compared with alcohol-based sclerotherapy or band ligation (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The best method of NBCA injection is highly debated, with multiple studies supporting various techniques. The success of any method of NBCA injection for GV is influenced by the choice of cyanoacrylate formulation, use of co-mixture agents, preparation of materials, and steady, uniform injection delivery.\u003c/p\u003e \u003cp\u003eDistant embolization of the glue thrombus is the most feared complication, although the rates of clinically significant embolization leading to symptoms needing anticoagulant therapy or death are rare (0.7%). Similarly, exacerbations of bleeding, portal and splenic vein thrombosis, and infections are infrequently reported. Instances of injector needle impaction into GV have only been documented in case reports, suggesting a possible association with endoscopist experience, highlighting the need for specific training. Follow-up of endoscopic management of GV should mimic that of endoscopic management for EV (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Combination therapy with nonselective beta-blockers (NSBB) is recommended to prevent rebleeding in GV patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEsophagogastric varices are common cause of UGIB in sub-Saharan Africa (SSA) (\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In this region, where access to advanced endoscopic therapies is limited, managing gastric varices and associated bleeding episodes becomes particularly challenging. The scarcity of resources and expertise in performing endoscopic interventions confounds the management dilemma surrounding gastric varices in the region (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the growing interest in cyanoacrylate glue injection, data regarding its utilization and outcomes in the management of gastric varices in Sub-Saharan Africa remain limited. Therefore, this study aims to investigate the practice and outcomes of NBCA injection for gastric varices treatment in Ethiopia.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eA retrospective cross-sectional study was conducted on patients with gastric varices who received NBCA injection treatment at Adera Medical and Surgical (AMS) Center, the only center where this procedure is done in Ethiopia to date.\u003c/p\u003e \u003cp\u003eThe procedure is performed by a senior gastroenterologist (1,2*) with a technique of cyanoacrylate injection into 1-1.5 ml aliquots following the needle puncture of the varix lumen. The glue is then flushed into the varix using sterile normal saline (approximately 0.8-1.0 mL, corresponding to the dead space). A continuous stream of the flush solution is directed toward the puncture site as the needle is removed from varix. Up till the varix is \"hard\" to forceps palpation, more glue is injected. The mucosa covering the glue cast sloughs off weeks to months after the injection, allowing the plug to be extruded into the stomach.\u003c/p\u003e \u003cp\u003eAll patients who had the procedure from December, 2022 to January 2024 were included in the study. Data on socio-demographics, indications, clinical characteristics, endoscopic findings, procedure details, complications and outcome were collected from patients\u0026rsquo; medical records and through phone call using a structured check-list. The acquired data was examined for accuracy, cleaned up, and validated before analysis using SPSS 26.0. For categorical variables, descriptive statistics were utilized and expressed as frequencies and percentages. Tables and figures were used to summarize the results. Categorical data were represented as frequencies, whereas continuous variables were represented as means, standard deviations, and minimum and maximum values.\u003c/p\u003e \u003cp\u003eSpurting or oozing of blood from a gastric varix or clotted blood in the stomach fundus was defined as GV bleeding, while new-onset hematemesis, a systolic blood pressure drop of \u0026ge;\u0026thinsp;20 mmHg, a hemoglobin drop of \u0026ge;\u0026thinsp;2 g/dL, or transfusion of \u0026ge;\u0026thinsp;2 units after 24 hours post-procedure were considered criteria for rebleeding. Successful initial hemostasis was declared upon cessation of bleeding with no recurrence for 24 hours. Outcome measures included intra-procedural bleeding, hypotension, allergic reactions, systemic embolic events, fever, bacteremia, duration of hospital stay, need for salvage therapy (balloon tamponade, transjugular intrahepatic portosystemic shunt, surgery), rebleeding, and 6-week all-cause mortality. Follow-up was conducted via clinical evaluation and telephone calls.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 49 patients with gastric varices treated by NBCA injection were analyzed. Thirty-five (71.4%) of the patients presented with gastric variceal bleeding and NBCA injection was carried out within 12 hours of active bleeding on emergency basis while the rest of the patients with large (\u0026gt;\u0026thinsp;10mm) gastric varices without bleeding episodes were treated in the same way for primary prophylactic reasons. The majority of the patients were male (n\u0026thinsp;=\u0026thinsp;35, 71.4%). The mean [\u0026plusmn;\u0026thinsp;SD] age was 39.92\u0026thinsp;\u0026plusmn;\u0026thinsp;16.05 (range: 11\u0026ndash;70) years.\u003c/p\u003e \u003cp\u003eTwenty-four patients (41.5%) presented with hematemesis and melena, while hematemesis was observed in 20.4% of cases, hematochezia in 14.3%, and melena in 16.3%. Nearly half of the patients (47%) exhibited concomitant tachycardia and hypotension.\u003c/p\u003e \u003cp\u003eAccording to the Child-Pugh classification, 51.0% of patients had class A, 34.7% class B, and 14.3% class C liver status. The median Model of End-Stage Liver Disease (MELD) score for all patients was 13, ranging from 8 to 28. Two patients experienced hepatic encephalopathy and fully recovered within a few days.\u003c/p\u003e \u003cp\u003eThe majority of patients (58.5%) had non-cirrhotic etiologies of PHTN, such as chronic portal vein thrombosis (CPVT) in 34.1% of cases, hepatosplenic schistosomiasis (HSS) in 22.4%, and splenic vein thrombosis (SVT) in 2.0%, while chronic hepatitis B (22.4%) was the most common cirrhotic cause of PHTN. Three patients had concurrent hepatocellular carcinoma (HCC). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical profile of GV patients visiting AMS Center, December, 2022 to January 2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStd. Deviation (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMelena\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHematemesis and Melena\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHematochezia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eVital Signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTachycardia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTachycardia and Hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Pugh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild score A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild score B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild score C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eCauses of PTH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHBV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMASLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcurrent HCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eunspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIsolated GOV1, GOV2, IGV1 were reported in 17.1%, 12.2% and 46.9% of the endoscopic results while there was no IGV2 reported. Six reports indicated the presence of both GOV1 and GOV2, while three reports indicated the presence of both IGV1 and GOV2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thirty-eight (77.5%) of the patients had large gastric varices while 7 had medium (5-10mm) and 4 had small (\u0026lt;\u0026thinsp;5mm) GV.\u003c/p\u003e \u003cp\u003eAll patients who presented with actively bleeding GV were initially optimized and resuscitated. A restrictive packed red blood cell (PRBC) and platelets transfusion aimed at maintaining a hemoglobin level of 7 to 9 g/dL and platelet count greater than 50 \u0026times; 10⁹/L was employed for hemodynamic stabilization. Nearly half (49%) of the patients with GV required 2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64 units of PRBC transfusion on average for initial hemodynamic stabilization.\u003c/p\u003e \u003cp\u003eThe majority of patients (83.7%) had concurrent esophageal varices without evidence of active bleeding, and endoscopic variceal ligation (EVL) was performed for three-fourths (78.0%) of these patients following NBCA glue injection for gastric varices.\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment and outcome of GV patients visiting AMS Center, December 2022 to January 2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion for initial hemodynamic stabilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of blood product n\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePRBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFFP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eUnit of PRBC n\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePrior use of NSBB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of red signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePresence of concomitant EV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eClassification EV n\u0026thinsp;=\u0026thinsp;41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWas EVL done n\u0026thinsp;=\u0026thinsp;41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHemostasis achieved immediately n\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRebleeding n\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost procedure PPI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost procedure NSBB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average hospital stay of the patients was 1.88 days. With mean volume of 1.07 NBCA glue solution delivered per procedure, initial hemostasis was achieved in all patients who presented with active gastric variceal bleeding with one session. No patient required salvage therapy.\u003c/p\u003e \u003cp\u003eAmong the 35 patients who presented with active gastric variceal bleeding and underwent NBCA glue injection, re-bleeding occurred in one patient (2.9%) with IGV1 of CPVT cause and child class C liver status approximately 25 hours post-procedure, which was managed conservatively and resolved spontaneously.\u003c/p\u003e \u003cp\u003ePost-procedure, more than half (61.2%) of the patients received proton pump inhibitor (PPI) therapy, and 93.9% continued NSBB treatment. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Follow up abdominal ultrasound or computed tomography was done for all patients 6 weeks after NBCA and no thrombosis was reported.\u003c/p\u003e \u003cp\u003eMoreover, no procedure-related complications, bleeding, organ embolism, or deaths from any cause were reported immediately or within six weeks after the procedure for any of the patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGastric variceal hemorrhage is a serious complication of PHTN accounting for approximately 20% of all variceal bleedings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Bleeding from GV is related to their size, wall thickness, and the presence of red color signs. The treatment options for GV bleeding include pharmacological therapy, endoscopic NCBA injection, and endovascular intervention (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Currently, NCBA glue injection is recommended as the primary treatment option. More than 90% of hemostasis rates have been achieved with an NCBA injection with 70\u0026ndash;90% of variceal obliteration and depends upon the technique and experience of the endoscopist. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Likewise, our first experience from Ethiopia revealed NCBA injection for GV to be very effective and safe in our cohort.\u003c/p\u003e \u003cp\u003eA randomized controlled trial comparing endoscopic cyanoacrylate injection (ECI) with NSBBs for primary prophylaxis in 89 patients with GOV2s or IGV1s showed lower rebleeding rates (13%) in ECI patients compared to those treated with NSBBs (28%; P\u0026thinsp;=\u0026thinsp;.039) or no treatment (45%; P\u0026thinsp;=\u0026thinsp;.003) after a median follow-up of 26 months. (21) In a similar retrospective study of patients with large GOV1s, GOV2s, or IGV1s undergoing ECI compared to observation alone, bleeding rates were lower in ECI patients (19.4%) versus observation alone (35.1%; P\u0026thinsp;=\u0026thinsp;.001) after a median follow-up of 35 months. (22). In our study, all patients with large (\u0026gt;\u0026thinsp;10mm) GV undergoing prophylactic ECI experienced no bleeding during the observation period.\u003c/p\u003e \u003cp\u003eIn a prospective study of 568 patients with GV, IGV1s were the least common (6%) but had a high bleeding incidence (78%) and mortality rate (29%). IGV2 represented 15% of GVs with a bleeding risk of 9%. GOV1 was the most common (75%) GV with a bleeding rate of 12%, while GOV2 represented 21% of GV with a relatively higher bleeding rate of 55% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Managing bleeding GOV1 is usually similar to esophageal variceal bleeding management, whereas managing bleeding GOV2 or IGV1 is challenging due to high blood flow. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e23\u003c/span\u003e) In our study cohort, IGV1 was the most common (46.9%) GV type and all GV types were successfully managed with NBCA injection.\u003c/p\u003e \u003cp\u003eIn the current study, complete obliteration of gastric varices leading to initial hemostasis was attained in all patients presenting with active gastric variceal bleeding. This outcome mirrors findings from a retrospective study involving 455 patients, where a success rate of 96.9% was reported (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Similar success rates ranging from 90\u0026ndash;97% have also been documented in smaller-scale studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother study assessing the safety of NBCA for gastric fundal varices treatment using standardized injection technique reported achieving initial hemostasis and variceal obliteration in all patients without early rebleeding, procedure-related complications, or bleeding-related deaths. The cumulative rebleeding-free rates at 1, 3, and 5 years were 94.5%, 89.3%, and 82.9%, respectively. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e27\u003c/span\u003e) This study was also in line with our findings demonstrating that NBCA is safe and effective with the use of a standardized injection technique.\u003c/p\u003e \u003cp\u003eA meta-analysis of 43 studies involving 3484 patients demonstrated a technical success rate of 94.1% (95% CI: 91.6\u0026ndash;96.1%), a 30-day rebleeding rate of 24.2% (18.9\u0026ndash;29.9%), and a 30-day overall and major complications occurrence of 15.9% (11.2\u0026ndash;21.3%) and 5.3% (3.3\u0026ndash;7.8%) of patients, respectively (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Consistent with these findings, a separate study reported a rebleeding rate of 12.7% within 4 weeks post-NBCA sclerotherapy. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Furthermore, mortality rates of 12.5% and 6.8% due to rebleeding immediately after NBCA sclerotherapy and after initial hemostasis were reported (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Our study showed a lower rebleeding rate of 2.9% and no occurrence of overall complications or deaths within a 6-week follow-up period.\u003c/p\u003e \u003cp\u003eIn a study from a developing country, Pakistan, involving 31 patients, 87% of patients achieved hemostasis after the initial injection and reported a 9.7% overall mortality rate, unlike our study, which demonstrated a 100% success rate in achieving initial hemostasis and no death 6 weeks post-procedure. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur findings, in alignment with existing literature, underscore the safety and efficacy of NBCA injection in achieving successful outcomes, including complete variceal obliteration and no procedure related complication or mortality within a six-week follow-up period. Despite variations in outcomes reported across different studies and regions, the overall evidence supports NBCA injection as a valuable intervention for managing gastric variceal bleeding, offering hope for improved patient outcomes and reduced mortality in managing GV. Further research and broader adoption of standardized techniques are warranted to optimize the use of NBCA injection and enhance its accessibility and effectiveness in diverse healthcare settings especially in resource limited regions where other advanced endoscopic and radiologic interventions are not readily available or accessible.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates the successful and safe application of NBCA injection for treating all types of GV, achieving effective bleeding control without significant complications. Early identification and referral of patients with gastric varices for prompt intervention, including during active bleeding episodes, is crucial to improve treatment effectiveness and reduce mortality. To ensure safe and successful treatment delivery in resource-limited settings, enhancing healthcare providers' training and expertise in interventional endoscopic techniques, including NBCA injection, is essential. Further wider prospective studies are needed to evaluate long-term outcomes and compare the efficacy of NBCA injection with other treatment options for gastric varices in Ethiopia and SSA at large.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical clearance of the present study was obtained from the\u0026nbsp;institutional review board of AMSC. Consent was obtained from all participants.\u0026nbsp;All the information obtained was held with confidentiality and used only for the intended purpose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the principal investigator up on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the patients and colleagues who were involved in the care of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eno funding was obtained.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGoral V, Yılmaz N. 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Korean J Intern Med. 2014;29(4):437\u0026ndash;444. doi: 10.3904/kjim.2014.29.4.437.\u003c/li\u003e\n\u003cli\u003eKind R, Guglielmi A, Rodella L, et al. Bucrylate treatment of bleeding gastric varices: 12 years\u0026rsquo; experience. Endoscopy 2000; 32:512-519.\u003c/li\u003e\n\u003cli\u003eNguyen AJ, Baron TH, Burgart LJ, Leontovich O, Rajan E, Gostout CJ. 2-Octyl-cyanoacrylate (Dermabond), a new glue for variceal injection therapy: results of a preliminary animal study. Gastrointest Endosc 2002; 55:572- 575.\u003c/li\u003e\n\u003cli\u003eSeewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, Seitz U, Zhong Y, Thonke F, Soehendra N. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices. Gastrointest Endosc. 2008 Sep;68(3):447-54.\u003c/li\u003e\n\u003cli\u003eChevallier O, Guillen K, Comby PO, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Gl\u0026eacute;l\u0026eacute; LS, Loffroy R. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med. 2021 May 25;10(11):2298. doi: 10.3390/jcm10112298. \u003c/li\u003e\n\u003cli\u003eHuang YH, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000;52:160\u0026ndash;167\u003c/li\u003e\n\u003cli\u003eMansoor-Ul-Haq M, Latif A, Asad M, Aziz Memon F. Treatment of Bleeding Gastric Varices by Endoscopic Cyanoacrylate Injection: A Developing-country Perspective. Cureus. 2020 Feb 20;12(2): e7062. doi: 10.7759/cureus.7062. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gastric varices, N-butyl-2-cyanoacrylate glue, Ethiopia, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-4183362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4183362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGastro-esophageal varices (GV) are the major clinical manifestations of cirrhotic and non-cirrhotic portal hypertension. Although less frequent than esophageal varices (EV), They pose a significant clinical challenge due to their propensity for severe bleeding, associated with high morbidity and mortality rates. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) has emerged as a promising treatment modality for GV, offering effective hemostasis and low rebleeding rates. This study aims to investigate the practice and outcomes of NBCA injection therapy for gastric varices in Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross sectional study was conducted on patients who received NBCA injection treatment at Adera Medical and Surgical (AMS) Center from December 2022 to January 2024.Data regarding socio-demographics, clinical characteristics, indications, endoscopic findings, procedure details, complication and outcome were collected from patients\u0026rsquo; medical records and through a phone call interview using structured checklist. The acquired data was examined for accuracy, cleaned up and validated before analysis using SPSS 26.0. Descriptive statistics were employed as a statistical data analysis technique for categorical variables, and the results were expressed as frequencies and percentages. Tables and figures were utilized to provide a concise summary of the findings. Categorical data were presented as frequencies, while continuous variables were expressed as means, standard deviations, and minimum and maximum values.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe study investigated the use of NBCA injection for treating gastric varices in 49 patients. The mean [\u0026plusmn;\u0026thinsp;SD] age was 39.92\u0026thinsp;\u0026plusmn;\u0026thinsp;16.05 years with M: F of 2.5 respectively. IGV1 was the commonest GV type (46.9%). Thirty-Five (71.4%) patients had active bleeding and received NBCA within 12 hours, while the rest received it prophylactically for large varices. Initial bleeding control was achieved in all patients. One patient with active bleeding experienced re-bleeding 25 hours post NBCA glue injection but stopped spontaneously. No procedure-related complications, bleeding, organ embolism, or death were reported.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eNBCA glue injection demonstrably achieved effective bleeding control in all patients with gastric varices in this study. These findings offer valuable insights for optimizing gastric varices management and reducing the burden of upper gastrointestinal bleeding in Ethiopia, Sub-Saharan Africa. To ensure successful implementation, enhancing healthcare providers' expertise in interventional endoscopic techniques, including NBCA glue injection, is crucial. Further wider research is recommended to explore long-term outcomes and compare the efficacy of NBCA glue injection with other treatment options for gastric varices in Ethiopia and sub Saharan Africa at large.\u003c/p\u003e","manuscriptTitle":"Endoscopic treatment of gastric varices using N-butyl- 2-cyanoacrylate glue: experience from Ethiopia, sub- Saharan Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-05 13:03:11","doi":"10.21203/rs.3.rs-4183362/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a5376ea-5443-4d4d-be42-561880158b93","owner":[],"postedDate":"April 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-06T16:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-05 13:03:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4183362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4183362","identity":"rs-4183362","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}