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.

Computed tomography for the prediction of oesophageal variceal bleeding:A surrogate or complementary to the gold standard?

In this editorial we comment on the in-press article in the World Journal of Gastrointestinal endoscopy about the role of computed tomography(CT)for the prediction of esophageal variceal bleeding.The mortality and morbidity are much increased in patients with chronic liver diseases when complicated with variceal bleeding.Predicting the patient at a risk of bleeding is extremely important and receives a great deal of attention,paving the way for primary prophylaxis either using medical treatment including carvedilol or propranolol,or endoscopic band ligation.Endoscopic examination and the hepatic venous pressure gradient are the gold standards in the diagnosis and prediction of variceal bleeding.Several non-invasive laboratory and radiological examinations are used for the prediction of variceal bleeding.The contrast-enhanced multislice CT is a widely used non-invasive,radiological examination that has many advantages.In this editorial we briefly comment on the current research regarding the use of CT as a non-invasive tool in predicting the variceal bleeding.

Future directions of noninvasive prediction of esophageal variceal bleeding:No worry about the present computed tomography inefficiency

In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.

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.

Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy

BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent than esophageal varices bleeding(EVB),but the former is a more critical illness and has a higher mortality rate.At present,endoscopic variceal histoacryl injection therapy(EVHT)is safe and effective,and it has been recommended by relevant guidelines as the primary method for the treatment of GVB.However,gastric varices after endoscopic treatment still have a high rate of early rebleeding,which is mainly related to complications of its treatment,such as bleeding from drained ulcers,rebleeding of varices etc.Therefore,preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.AIM To assess the efficacy of aluminium phosphate gel(APG)combined with proton pump inhibitor(PPI)in preventing early rebleeding after EVHT in individuals with GVB.METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021.Based on the selection criteria,101 patients were sorted into the PPI alone treatment group,and 95 patients were sorted into the PPI combined with the APG treatment group.The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups.Statistical methods were performed by two-sample t-test,Wilcoxon rank sum test andχ2 test.RESULTS No major variations were noted between the individuals of the two groups in terms of age,gender,Model for End-Stage Liver Disease score,coagulation function,serum albumin,hemoglobin,type of gastric varices,the dose of tissue glue injection and EV that needed to be treated simultaneously.The early rebleeding rate in PPI+APG group was 3.16%(3/95),which was much lower than that in the PPI group(12.87%,13/101)(P=0.013).Causes of early rebleeding:the incidence of gastric ulcer bleeding in the PPI+APG group was 2.11%(2/95),which was reduced in comparison to that in the PPI group(11.88%,12/101)(P=0.008);the incidence of venous bleeding in PPI+APG group and PPI group was 1.05%(1/95)and 0.99%(1/101),respectively,and there was no significant difference between them(0.999).The early mortality rate was 0 in both groups within 6 wk after the operation,and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding.The overall incidence of complications in the PPI+APG group was 12.63%(12/95),which was not significantly different from 13.86%(14/101)in the PPI group(P=0.800).of abdominal pain in the PPI+APG group was 3.16%(3/95),which was lower than that in the PPI group(11.88%,12/101)(P=0.022).However,due to aluminum phosphate gel usage,the incidence of constipation in the PPI+APG group was 9.47%(9/95),which was higher than that in the PPI group(1.98%,2/101)(P=0.023),but the health of the patients could be improved by increasing drinking water or oral lactulose.No patients in either group developed spontaneous peritonitis after taking PPI,and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.

Antiviral therapy delays esophageal variceal bleeding in hepatitis B virus-related cirrhosis

AIM:To investigate the effect of antiviral therapy with nucleoside analogs in hepatitis B virus(HBV)-related cirrhosis and esophageal varices.METHODS:Eligible patients with HBV-related cirrhosis and esophageal varices who consulted two tertiary hospitals in Beijing,China,the Chinese Second Artillery General Hospital and Chinese PLA General Hospital,were enrolled in the study from January 2005 to December 2009. Of 117 patients,79 received treatment with different nucleoside analogs and 38 served as controls. Bleeding rate,change in variceal grade and non-bleeding duration were analyzed. Multivariate Cox proportional hazard regression was used to identify factors related to esophageal variceal bleeding.antiviral group compared to the control group(29.1%vs 65.8%,P < 0.001). Antiviral therapy was an independent factor related to esophageal bleeding in multivariate analysis(HR = 11.3,P < 0.001). The mean increase in variceal grade per year was lower in the antiviral group(1.0 ± 1.3 vs 1.7 ± 1.2,P = 0.003). Nonbleeding duration in the antiviral group was prolonged in the Kaplan-Meier model. Viral load rebound was observed in 3 cases in the lamivudine group and in 1 case in the adefovir group,all of whom experienced bleeding. Entecavir and adefovir resulted in lower bleeding rates(17.2% and 28.6%,respectively) than the control(P < 0.001 and P = 0.006,respectively),whereas lamivudine(53.3%) did not(P = 0.531).CONCLUSION:Antiviral therapy delays the progression of esophageal varices and reduces bleeding risk in HBV-related cirrhosis,however,high-resistance agents tend to be ineffective for long-term treatment.

Predictors of esophageal varices and first variceal bleeding in liver cirrhosis patients

To assess “predictors” of esophageal varices (EV) and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis. METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis. Model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), platelet count to spleen diameter (PC/SD), fibrosis-4-index (FIB-4), fibrosis index (FI) and King’s Score were measured for all participants. All patients underwent endoscopic assessment within two days of hospitalization. The major end point was the first esophageal variceal bleeding (EVB) event. The diagnostic performance of “predictors” for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure. RESULTSFIB-4 was the only strong and significant “predictor” of esophageal varices (multivariable-adjusted OR = 1.57 for one unit increment; 95%CI: 1.15-2.14). Furthermore, a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices, with a sensitivity of 72%, a specificity of 58% and a proportion of area under the curve (AUC) of 66% (P = 0.01). During the follow-up (median: 31.5 mo; interquartile range: 11-59 mo), 34 patients (24%) experienced a first EVB. FIB-4 was a poor predictor of EVB (the AUC was only 51%) for a cut-off value of 5.02. Furthermore, the AUC of AST/ALT, APRI, PC/SD, FI, MELD and King’s Score ranged from 45% to 55%. None of the non-invasive markers turned out to be a useful predictor of EVB. CONCLUSIONDespite the low diagnostic accuracy, FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.

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.

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.

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.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND Liver cirrhosis is the main cause of portal hypertension.The leading cause of death in patients with liver cirrhosis is its most common complication,esophageal variceal bleeding(EVB).Endoscopic variceal ligation(EVL)is recommended by many guidelines to treat EVB and prevent rebleeding;however,esophageal ulcers occur after treatment.Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates.Thus,the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.AIM To evaluate the efficacy of aluminum phosphate gel(APG)plus a proton pump inhibitor(PPI)in the prevention of early rebleeding after EVL in patients with EVB.METHODS The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital,Guangdong Province,China from January 2015 to December 2020 were collected.According to the study inclusion and exclusion criteria,401 cases were included in a PPI-monotherapy group(PPI group),and 377 cases were included in a PPI and APG combination therapy(PPI+APG)group.We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups.The two-sample t-test,Wilcoxon rank-sum test,and chisquared test were adopted for statistical analyses.RESULTS No significant differences in age,sex,model for end-stage liver disease score,coagulation function,serum albumin level,or hemoglobin level were found between the two groups.The incidence of early rebleeding in the PPI+APG group(9/337;2.39%)was significantly lower than that in the PPI group(30/401;7.48%)(P=0.001).Causes of early rebleeding in the PPI group were esophageal ulcer(3.99%,16/401)and esophageal varices(3.49%,14/401),while those in the PPI+APG group were also esophageal ulcers(5/377;1.33%)and esophageal varices(4/377;1.06%);such causes were significantly less frequent in the PPI+APG group than in the PPI group(P=0.022 and 0.024,respectively).The early mortality rate within 6 wk in both groups was 0%,which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy.The incidence of adverse events other than early bleeding in the PPI+APG group(28/377;7.43%)was significantly lower than that in the PPI group(63/401;15.71%)(P<0.001).The incidence of chest pain in the PPI+APG group(9/377;2.39%)was significantly lower than that in the PPI group(56/401;13.97%)(P<0.001).The incidence of constipation in the PPI+APG group(16/377;4.24%)was significantly higher than that in the PPI group(3/401;0.75%)(P=0.002)but constipation was relieved after patients drank more water or took lactulose.In the PPI and PPI+APG groups,the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50%(2/401)and 0.53%(2/377),respectively,and those of hepatic encephalopathy were 0.50%(2/401)and 0.27%(1/377),respectively,presenting no significant difference(P>0.999).CONCLUSION PPI+APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Behcet’s disease manifesting as esophageal variceal bleeding: A case report

BACKGROUND Behcet’s disease(BD)is a chronic disease characterized by oral and vulvar ulcers as well as eye and skin damage and involves multiple systems.It presents as an alternating process of repeated attacks and remissions.Esophageal venous rupture and bleeding caused by BD is rarely reported at home and abroad.This paper reports a case of bleeding from oesophageal varices caused by BD,aiming to provide an additional dimension for considering the cause of bleeding from esophageal varices in the future.CASE SUMMARY A 38-year-old female patient was admitted due to a gradual increase in shortness of breath and chest tightness after the activity,and was admitted to our hospital for treatment.After admission,relevant examinations showed that the patient had multiple blood clots.Four days after admission,she suddenly experienced massive hematemesis.Emergency esophagogastroduodenoscopy revealed bleeding from esophageal and gastric varices.The patient had no history of viral hepatitis or drinking habits,and no history of special genetic diseases or congenital vascular diseases.There is no obvious abnormality in liver function.After reviewing the medical history,it was found that the patient had recurred oral ulcers since childhood,ulcers were visible in the perineum during menstruation,and there was an intermittent red nodular rash and uveitis.The current skin acupuncture reaction is positive,combined with the evaluation of the external hospital and our hospital,the main diagnosis is BD.She received methylprednisolone,cyclophosphamide,immunomodulation,acid suppression,gastric protection,and anticoagulation and anti-infection treatments,and was discharged from the hospital.During the 1-year follow-up period,the patient did not vomit blood again.CONCLUSION This case highlights bleeding from esophageal varices caused by BD, aiming toprovide an additional dimension concerning the cause of bleeding fromesophageal varices in the future.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Restrictive versus Liberal Blood Transfusion Strategies in Egyptian Patients with Esophageal Variceal Bleeding

Background and Study Aim: Esophageal variceal bleeding is a major medical emergency and one of the most important indications for hospital admission and for blood transfusion. However, the safest and the effective blood transfusion strategy is controversial. Here, we studied the safety and the effectiveness of the restrictive versus liberal transfusion strategies in patients with esophageal variceal bleeding. Patients and Methods: The study included 342 patients with esophageal variceal bleeding. Patients were divided into 2 groups: group I (Restrictive strategy) transfusion when the hemoglobin level is ≤7 g/dl and group II (Liberal strategy): transfusion when the hemoglobin level is ≤9 g/dl. All patients were subjected to complete blood counts, liver and kidney profiles, coagulation profile, pelvi-abdominal ultrasonography and upper GI endoscopy. Clinical outcome measures include rebleeding, infection, allergic transfusion reactions thromboembolic events, and mortality. Results: Of all patients admitted to hospital with esophageal variceal bleeding, the number of transfused RBCs units and hospital stay were more in the liberal transfusion strategy. Also, the overall rate of complications was higher in the liberal transfusion strategy (49.7% versus 38.5% in the restrictive transfusion strategy). The most common complications were rebleeding (26.9%) and infection (21.6%). As regard the death rate, 13 cases (7.6%) died in the restrictive transfusion strategy versus 25 cases (14.6%) in the liberal transfusion one. Conclusions: For esophageal variceal bleeding, restrictive transfusion strategy is better than the liberal one as regard cost-effectiveness, risk of complications and hospital stay with no harm and less mortality as compared to liberal strategy.

Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding

AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. METHODS:In this retrospective study,the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA(EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed.Patient demographics,rebleeding rate,survival rate,and complications were compared between the two groups(PTVE and EVO).All results were expressed as mean±SD,or as a percentage.Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or theχ 2 test(with Yates correction)where appropriate.A P value less than 0.05 was considered significant.Statistical computation was performed using SPSS 13.0 software. RESULTS:A total of 77 patients were included;45 patients who underwent EVO and 32 patients who received PTVE.During the follow-up(19.78±7.70 mo in the EVO group,vs 21.53±8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group(37.78%vs 12.5%, P=0.028).The cumulative rebleeding-free rate was 75%,59%,and 49%in 1,2,and 3 years respectively for EVO,and 93%,84%,and 84%for PTVE(P=0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment.Variables including age,gender,cause,Child-Pugh classification, size of gastric varices(GV),location of GV,and treatment methods were analyzed.It was revealed that Child-Pugh classification[risk ratio(RR)2.10,95%CI:1.03-4.28,P=0.040],choice of treatment(RR 0.25, 95%CI:0.08-0.80,P=0.019),and size of GV(RR 2.14, 95%CI:1.07-4.28,P=0.032)were the independent factors for predicting rebleeding.Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up,eight patients in the EVO group and four patients in the PTVE group died.The cumulative survival rates at 1,2,and 3 years were 93%,84%, and 67%respectively in the EVO group,and 97%, 88%,and 74%respectively in the PTVE group.The survival rates were not significantly different between the two groups(P=0.432).Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival(RR 2.77,95%CI:1.12-6.80,P=0.027).The incidence of complications was similar in both groups. CONCLUSION:With extensive and permanent obliteration of gastric varices and its feeding veins,PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.

Repeated pancreatitis-induced splenic vein thrombosis leads to intractable gastric variceal bleeding: A case report and review

Gastric varices(GV) are one of the most common complications for patients with portal hypertension. Currently, histoacryl injection is recommended as the initial treatment for bleeding of GV, and this injection has been confirmed to be highly effective for most patients in many studies. However, this treatment might be ineffective for some types of GV, such as splenic vein thrombosis-related localized portal hypertension(also called left-sided, sinistral, or regional portal hypertension). Herein, we report a case of repeated pancreatitis-induced complete splenic vein thrombosis that led to intractable gastric variceal bleeding, which was treated by splenectomy. We present detailed radiological and pathological data and blood rheology analysis(the splenic artery- after a short gastric vein or stomach vein- gastric coronary vein- portal vein). The pathophysiology can be explained by the abnormal direction of blood flow in this patient. To our knowledge, this is the first reported case for which detailed patho-logy and blood rheology data are available.

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.

Prognosis of hepatic cirrhosis patients with esophageal or gastric variceal hemorrhage: multivariate analysis

Objective: To study the effect of bacterial infection, use of antibiotics, active bleeding at endoscopy, and the severity of liver disease as prognostic factors in hepatic cirrhotic patients during the first 5 days after the episode of esophageal or gastric variceal hemor- rhage. Methods: Seventy-six hepatic cirrhosis patients with esophageal or gastric variceal bleeding were enrolled. Bleeding was managed in a standardized protocol u- sing octreotide and vasopressin in sclerotherapy or band ligation for active bleeding at endoscopy. The screening protocol for bacterial infection consisted of chest radiograph; blood, urine and ascitic fluid cul- tures; the severity of liver disease shown by Child- Pugh score. Results: Active bleeding was observed at endoscopy in 40 patients (53%). Failure to control bleeding Within 5 days occurred in 36 patients (45%). Empir- ical antibiotic treatment was used in 53 patients (67%), whereas bacterial infections were documen- ted in 43 patients (57%). Multivariate analysis showed that proven bacterial infection (P<0.01) or antibiotic use (P<0.05) as well as active bleeding at endoscopy (P<0.01) and Child-Pugh score (P< 0.01) were independent prognostic factors of failure to control bleeding. Conclusion: Bacterial infection is associated with fai- lure to control esophageal or gastric variceal bleeding in hepatic cirrhotic patients.

EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis:A meta-analysis

AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis.METHODS: Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios(ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed.RESULTS: Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95% CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95% CI: 3.61-70.68). The pooled HR of survival was 1.26(95% CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. CONCLUSION: The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.