Triplex operation for portal hypertension with esophageal variceal bleeding:report of 140 cases

BACKGROUND:Portal hypertension is a common dis ease. The surgical therapy of this disease focuses on the re sultant upper digestive tract bleeding, which can imperi patients' life directly. This study was to evaluate the effect of triplex operation ( mesocaval C shunt with artificia graft, ligation of the coronary vein and splenic artery) on portal hypertension and its associated upper digestive tract bleeding. METHODS: A retrospective study was made on clinical da- ta of 140 patients undergoing triplex operation, who had suffered from portal hypertension and upper digestive tract bleeding. RESULTS: Postoperative portal pressure was 25-43 cmH2 O ( preoperative portal pressure 27-45 cmH2 O ) with the average reduction of 10 cmH2O. One patient (0.7%) died of cerebrovascular disease. Five patients (3.5%) suffered from mild hepatic encephalopathy, which was ameliorated through conservative treatment. Lymphatic fistula occurred in 3 patients (2.1% ) who recovered without treatment 5, 10 days and 3 months after operation respectively. One hundred patients were followed up for 1 month to 6 years without recurrent hemorrhage or hepatic encephalopathy. Hypersplenism and ascites disappeared in 70 patients (70% ) and 80 patients (80% ) respectively. A significant reduction of ascites was seen in 12 patients(12% ). The arti- ficial vessels remained unblocking detected by B type ultra- sonography and Doppler sonography in 95 patients (95% ). CONCLUSION: Triplex operation is suitable for patients with the following portal hypertensions; portal hyperten- sion caused by simple occlusion of the hepatic vein (a patho- logical type of Budd-Chiari syndrome); thrombosis of the portal vein or prehepatic portal hypertension because of cavernous transformation; intrahepatic portal hypertension with rebleeding after splenectomy or non-operation, and those patients with liver function in grade A or B according to the Child-Pugh classification.

Acute upper gastrointestinal bleeding due to portal hypertension in a patient with primary myelofibrosis:A case report

BACKGROUND Acute upper gastrointestinal bleeding is a common medical emergency that has a 10%hospital mortality rate.According to the etiology,this disease can be divided into acute varicose veins and nonvaricose veins.Bleeding from esophageal varices is a life-threatening complication of portal hypertension.Portal hypertension is a clinical syndrome defined as a portal venous pressure that exceeds 10 mmHg.Cirrhosis is the most common cause of portal hypertension,and thrombosis of the portal system not associated with liver cirrhosis is the second most common cause of portal hypertension in the Western world.Primary myeloproliferative disorders are the main cause of portal venous thrombosis,and somatic mutations in the Janus kinase 2 gene(JAK2 V617F)can be found in approximately 90% of polycythemia vera,50% of essential thrombocyrosis and 50% of primary myelofibrosis.CASE SUMMARY We present a rare case of primary myelofibrosis with gastrointestinal bleeding as the primary manifestation that presented as portal-superior-splenic mesenteric vein thrombosis.Peripheral blood tests revealed the presence of the JAK2 V617F mutation.Bone marrow biopsy ultimately confirmed the diagnosis of myelofibrosis(MF-2 grade).CONCLUSION In patients with acute esophageal variceal bleeding due to portal hypertension and vein thrombosis without cirrhosis,the possibility of myeloproliferative neoplasms should be considered,and the JAK2 mutation test should be performed.

Computed tomography for prediction of esophageal variceal bleeding

This letter to the editor relates to the study entitled“The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives”.Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information,it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores,HVPG,and EGD.However,to date,evidence concerning the role of CT in this setting is still lacking,therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

Comprehensive approach to esophageal variceal bleeding:From prevention to treatment

Esophageal variceal bleeding is a severe complication often associated with portal hypertension,commonly due to liver cirrhosis.Prevention and treatment of this condition are critical for patient outcomes.Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging.Primary prophylaxis involves the use of non-selective beta-blockers,such as propranolol or nadolol,which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices.Endoscopic variceal ligation(EVL)may also be employed as primary prophylaxis to prevent initial bleeding episodes.Once bleeding occurs,immediate treatment is essential.Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding.Endoscopic intervention is the cornerstone of treatment,with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices.In cases where bleeding is refractory to endoscopic treatment,transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure.Long-term management after an acute bleeding episode involves secondary prophylaxis using betablockers and repeated EVL sessions to prevent rebleeding,complemented by monitoring and managing liver function to address the underlying disease.In light of new scientific evidence,including the findings of the study by Peng et al,this editorial aims to review available strategies for the prevention and treatment of esophageal varices.

Per rectal portal scintigraphy as a useful tool for predicting esophageal variceal bleeding in cirrhotic patients

AIM: To investigate potential roles of per rectal portal scintigraphy in diagnosis of esophageal varices and predicting the risk of bleeding.METHODS: Fifteen normal subjects and fifty cirrhotic patients with endoscopically confirmed esophageal varices were included. Patients were categorized into bleeder and non-bleeder groups according to history of variceal bleeding. All had completed per rectal portal scintigraphy using 99mTechnetium pertechnetate. The shunt index was calculated from the ratio of 99mTechnetium pertechnetate in the heart and the liver. Data were analyzed using Student’s t-test and receiver operating characteristics.RESULTS: Cirrhotic patients showed a higher shunt index than normal subjects (63.80 ± 25.21 vs 13.54 ± 6.46, P < 0.01). Patients with variceal bleeding showed a higher shunt index than those without bleeding (78.45 ± 9.40 vs 49.35 ± 27.72, P < 0.01). A shunt index of over 20% indicated the presence of varices and that of over 60% indicated the risk of variceal bleeding.CONCLUSION: In cirrhotic patients, per rectal portal scintigraphy is a clinically useful test for identifying esophageal varices and risk of variceal bleeding.

Portal hypertension and gastrointestinal bleeding:Diagnosis,prevention and management

Bleeding from esophageal varices is a life threatening complication of portal hypertension.Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal.Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol.Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method.Therapy of acute bleeding is based on three strategies:vasopressor drugs like terlipressin,antibiotics and endoscopic therapy.In refractory bleeding,self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt(TIPS).Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate.Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking.Therapy of refractory bleeding relies on shuntprocedures like TIPS.Bleeding from ectopic varices,portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common.Possible medical and endoscopic treatment options are discussed.

New index to predict esophageal variceal bleeding in cirrhotic patients

AIM: To develop a safe, simple, noninvasive and affordable system to predict esophageal variceal bleeding (EVB) in decompensated cirrhosis patients.

Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding

AIM： To study the prevalence, predictors and control of bleeding following N-butyl 2 cyanoacrylate （NBC） sclerotherapy of gastric varix （GV）. METHODS： We analyzed case records of 1436 patients with portal hypertension, who underwent endoscopy during the past five years for variceal screening or upper gastrointestinal （GI） bleeding. Fifty patients with bleeding GV underwent sclerotherapy with a mean of 2 mL NBC for control of bleeding. Outcome parameters were primary hemostasis （bleeding control within the first 48 h）, recurrent bleeding （after 48 h of esophagogastro-duodenoscopy） and in-hospital mortality were analyzed. RESULTS： The prevalence of GV in patients with portal hypertension was 15% （220/1436） and the incidence of bleeding was 22.7% （50/220）. Out of the 50 bleeding GV patients, isolated gastric varices （IGV-Ⅰ） were seen in 22 （44%）, gastro-oesophageal varices （GOV） on lesser curvature （GOV-Ⅰ） in 16 （32%）, and GOV on greater curvature （GOV-Ⅱ） in 15 （30%）. IGV-Ⅰ was seen in 44% （22/50） patients who had bleeding as compared to 23% （39/170） who did not have bleeding （P 〈 0.003）. Primary hernostasis was achieved with NBC in all patients. Re-bleeding occurred in 7 （14%） patients after 48 h of initial sclerotherapy. Secondary hemostasis was achieved with repeat NBC sclerotherapy in 4/7 （57%）. Three patients died after repeat sclerotherapy, one during transjugular intrahepatic portosystemic stem shunt （TIPSS）, one during surgery and one due to uncontrolled bleeding. Treatment failure-related mortality rate was 6% （3/50）. CONCLUSION： GV can be seen in 15% of patients with portal hypertension and the incidence of bleeding is 22.7%. NBC is highly effective in controlling GV bleeding. In hospital mortality of patients with bleeding GV is 6%.

Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding

AIM:To investigate glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding and to evaluate the long-term efficacy and safety of this therapy.METHODS:A total of 148 cirrhotic patients in our hospital with esophagogastric variceal bleeding(EGVB) were included in this study.N-butyl-2-cyanoacrylate was mixed with lipiodol in a 1:1 ratio and injected as a bolus of 1-3 mL according to variceal size.Patients underwent endoscopic follow-up the next week,fourth week,second month,fourth month,and seventh month after injection and then every 6 mo to determine the cast shape.An abdominal X-ray fi lm and ultrasound or computed tomographic scan were also carried out in order to evaluate the time of variceal disappearance and complete extrusion of the cast.The average follow-up time was 13.1 mo.RESULTS:The instantaneous hemostatic rate was 96.2%.Early re-bleeding after injection in 9 cases(6.2%) was estimated from rejection of adhesive.Late re-bleeding occurred in 12 patients(8.1%) at 2-18 mo.The glue cast was extruded into the lumen within one month in 86.1% of patients and eliminated within one year.Light erosion was seen at the injection position and mucosa edema in the second week.The glue casts were extruded in 18 patients(12.1%) after one week and in 64 patients(42.8%) after two weeks.All kinds of glue clumping shapes and colors on endoscopic examination were observed in 127 patients(86.1%) within one month,including punctiform,globular,pillar and variform.Forty one patients(27.9%) had glue extrusion after 3 mo and 28 patients(28.9%) after six months.The extrusion time was not related to the injection volume of histoacryl.Obliteration was seen in 70.2%(104 cases) endoscopically.The main complication was re-bleeding resulting from extrusion.The prognosis of the patients depended on the severity of the underlying liver disease.CONCLUSION:Endoscopic injection of cyanoacrylate is highly effective for gastric varices bleeding.The glue clump shape is correlated with anatomic structure of vessels.The time of extrusion was not related to dosage of the glue.

The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives

Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.Although CT is only a diagnostic modality,thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data,it could potentially assist liver disease scores,HVPG,and EGD in a more effective prediction of EVB.However,to date,evidence concerning the role of CT in this setting is still lacking.Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

Role of endoscopy in management of gastrointestinal complications of portal hypertension

The management of patients with gastrointestinal complications of portal hypertension is often complex and challenging. The endoscopy plays an important role in the management of these patients. The role of endoscopy is both diagnostic and interventional and in the last years the techniques have undergone a rapid expansion with the advent of different and novel endoscopic modalities, with consequent improvement of investigation and treatment of these patients. The choice of best therapeutic strategy depends on many factors: baseline disease, patient's clinical performance and the timing when it is done if in emergency or a prophylactic approaches. In this review we evaluate the endoscopic management of patients with the gastrointestinal complications of portal hypertension.

Computed tomography combined with gastroscopy for assessment of pancreatic segmental portal hypertension

BACKGROUND Pancreatic segmental portal hypertension(PSPH) is the only type of portal hypertension that can be completely cured. However, it can easily cause varicose veins in the esophagus and stomach and hemorrhage in the digestive tract.AIM To explore the application of computed tomography(CT) to examine the characteristics of PSPH and assess the risk level.METHODS This was a retrospective analysis of CT images of 22 patients diagnosed with PSPH at our center. Spearman correlation analysis was performed using the range of esophageal and gastric varices(measured by the vertical gastric wall), the ratio of the width of the splenic portal vein to that of the compression site(S/C ratio), the degree of splenomegaly, and the stage determined by gastroscopy. This study examined whether patients experienced gastrointestinal bleeding within 2 wk and combined CT and gastroscopy to explore the connection between bleeding and CT findings.RESULTS The range of esophageal and gastric varices showed the best correlation in the diagnosis of PSPH(P < 0.001), and the S/C ratio(P = 0.007) was correlated with the degree of splenomegaly(P = 0.021) and PSPH(P < 0.05). This study revealed that male patients were more likely than females to progress to grade 2 or grade 3 as determined by gastroscopy. CT demonstrated excellent performance, with an area under the curve of 0.879.CONCLUSION CT can be used to effectively analyze the imaging signs of PSPH, and CT combined with gastroscopy can effectively predict the risk level of gastrointestinal bleeding.

Predictors of early rebleeding and mortality after acute variceal haemorrhage in patients with cirrhosis

The upper gastrointestinal bleeding from esophageal or gastric varices is the most dangerous complication of portal hypertension. The purpose of this study was to identify the predictors of early rebleeding and mortality after a bleeding episode. Patients and Methods: It was a retrospective study including 215 patients admitted in our department of hepatology and gastroenterology at the Hassan II University Hospital of Fez, from January 2001 to January 2010. Results: The mean age of our patients was 51 years. Thirty percent of patients had cirrhosis due to virus (B or C). The majority of patients (79%) had only esophageal varices. Fifty patients (23%) had a bleeding recurrence. Twenty-five patients (11.5%) died during the first ten days, of which 52% had presented rebleeding (p = 0.01). In 30% of cases, the rebleeding was secondary to a fall of pressure ulcers. Univariate analysis showed that early mortality of patients was significantly associated with advanced age (p = 0.018), low prothrombin time (PT) (p = 0.022), low serum sodium (p = 0.03), low platelet count (p = 0.05), and elevated transaminases (p = 0.02). Conclusion: The survival of cirrhotic patients after a bleeding episode was influenced by advanced age, a low rate of PT, of serum sodium, and of the platelet count, and elevated transaminases.

Torsion of spleen and portal hypertension: Pathophysiology and clinical implications

The displacement of spleen from its normal location to other places is known as wandering spleen(WS)and is a rare disease.The repeated torsion of WS is due to the presence of long pedicle and absence/laxity of anchoring ligaments.A WS is an extremely rare cause of left-sided portal hypertension(PHT)and severe gastric variceal bleeding.Left-sided PHT usually occurs as a result of splenic vein occlusion caused by splenic torsion,extrinsic compression of the splenic pedicle by enlarged spleen,and splenic vein thrombosis.There is a paucity of data on WSrelated PHT,and these data are mostly in the form of case reports.In this review,we have analyzed the data of 20 reported cases of WS-related PHT.The mechanisms of pathogenesis,clinico-demographic profile,and clinical implications are described in this article.The majority of patients were diagnosed in the second to third decade of life(mean age:26 years),with a strong female preponderance(M:F=1:9).Eleven of the 20 WS patients with left-sided PHT presented with abdominal pain and mass.In 6 of the 11 patients,varices were detected incidentally on preoperative imaging studies or discovered intraoperatively.Therefore,pre-operative search for varices is required in patients with splenic torsion.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension.

Endoscopic management of esophageal varices

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary

Acute pancreatitis associated left-sided portal hypertension with severe gastrointestinal bleeding treated by transcatheter splenic artery embolization:a case report and literature review

Left-sided portal hypertension(LSPH)followed by acute pancreatitis is a rare condition with most patients being asymptomatic.In cases where gastrointestinal(GI)bleeding is present,however,the condition is more complicated and the mortality is very high because of the difficulty in diagnosing and selecting optimal treatment.A successfully treated case with severe GI bleeding by transcatheter splenic artery embolization is reported in this article.The patient exhibited severe uncontrollable GI bleeding and was confirmed as gastric varices secondary to LSPH by enhanced computed tomography(CT)scan and CT-angiography.After embolization,the bleeding stopped and stabilized for the entire follow-up period without any severe complications.In conclusion,embolization of the splenic artery is a simple,safe,and effective method of controlling gastric variceal bleeding caused by LSPH in acute pancreatitis.

Portal hypertensive gastropathy:A systematic review of thepathophysiology,clinical presentation,natural history andtherapy

AIM: To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy(PHG) based on a systematic literature review.METHODS: Computerized search of the literature was performed via Pub Med using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. RESULTS: PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG.PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepaticportosystemic-shunt or liver transplantation is highly successful ultimate therapies because they reduce the underlying portal hypertension.CONCLUSION: PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Effects of propranolol or propranolol plus isosorbide-5-mononitrate on variceal pressure in schistosomiasis

AIM: To compare the effects of propranolol (PR) to that of PR plus isosorbide-5-mononitrate (ISMN) on variceal pressure in patients with schistosomiasis. METHODS: Forty-eight patients with schistosomiasis who had no previous variceal bleeding were treated with PR alone or PR plus ISMN. Seven patients refused variceal pressure manometry (3 receiving PR and 4 receiving PR plus ISMN). One patient withdrew from the trial due to headache after taking ISMN. At the time of termination, twenty patients were randomly assigned to treatment with PR plus ISMN or PR alone. The dose of PR was adjusted until the resting heart rate had been reduced by 25% or was less than 55 bpm. In the PR plus ISMN group, after PR was titrated to the same target, the dose of ISMN was increased up to 20 mg orally twice a day. Variceal pressure was measured using a noninvasive endoscopic balloon technique at the end of the 6-mo treatment period. RESULTS: In 40 patients (20 in the PR group and 20 in the PR plus ISMN group), variceal pressure was measured before treatment and at the end of the 6-mo treatment period. PR or PR plus ISMN treatment caused a significant reduction in variceal pressure (PR group: from 24.15 ± 6.05 mmHg to 22.68 ± 5.70 mmHg, P = 0.001; PR plus ISMN group: from 25.69 ± 5.26 mmHg to 20.48 ± 5.43 mmHg; P < 0.001). The percentage decrease in variceal pressure was significant after PR plus ISMN compared with that after PR alone (15.93% ± 8.37% vs 6.05% ± 3.67%, P = 0.01). One patient in the PR plus ISMN group and two patients in the PR group had variceal bleeding during follow-up. There were no significant differences between the two groups regarding the incidence of variceal bleeding. In the PR plus ISMN group, three patients had headache and hypotension. The headache was mild and transient and promptly disappeared after continuation of the relevant drug in two patients. Only one patient withdrew from the trial due to severe and lasting headache after taking ISMN. No side effects occurred in the PR group. CONCLUSION: PR plus ISMN therapy may be an alternative treatment for patients with schistosomiasis who have a high risk of bleeding.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration(BRTO) for ruptured gastric varices.METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool.The gastric varices were confirmed by endoscopy,and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography(CE-CT).A 6-Fr balloon catheter(Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein,or into the gastrocaval shunt via the right femoral vein,depending on the varices drainage route.The sclerosant,5% ethanolamine oleate iopamidol,was injected into the gastric varices through the catheter during balloon occlusion.In patients with incom plete thrombosis of the varices after the first BRTO,a second BRTO was performed the following day.Patients were followed up by endoscopy and CE-CT at 1 d,1 wk,and 1,3 and 6 mo after the procedure,and every 6 mo thereafter.RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices.These patients underwent a second BRTO on the next day,and additional sclerosant was injected through the catheter.Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients,while the remaining patient had incomplete thrombosis of the varices.None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d(range 8-2739 d).No major complications occurred after the procedure.However,esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.