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.

Coil-assisted retrograde transvenous obliteration for gastric varices in a Chinese case

Gastric varices are a major complication of portal hypertension in patients with liver cirrhosis and are associated with more massive bleeding events and higher mortality rate.Transjugular intrahepatic portosystemic shunt(TIPS)and balloon-occluded retrograde transvenous obliteration(BRTO)have been well documented as effective therapies for portal hypertensive gastric variceal bleeding.In China,TIPS are well accepted but BRTO is not well recieved due to the increase risk of complications associated with traditional BRTO.However,modified-BRTO,known as coil-assisted and plug-assisted retrograde transvenous obliteration(CARTO and PARTO,respectively),is receiving increased attention due to devoid of BRTO’s shortcomings.No CARTO case from China has been reported in literature thus far.Here,we present a Chinese case of CARTO to treat gastric varices bleeding.

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.