Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Endoscopic ultrasound using ultrasound probes for the diagnosis of early esophageal and gastric cancers

Endoscopic ultrasound (EUS) devices were first designed and manufactured more than 30 years ago, and since then investigators have reported EUS is effective for determining both the staging and the depth of invasion of esophageal and gastric cancers. We review the present status, the methods, and the findings of EUS when used to diagnose and stage early esophageal and gastric cancer. EUS using high-frequency ultrasound probes is more accurate than conventional EUS for the evaluation of the depth of invasion of superficial esophageal carcinoma. The rates of accurate evaluation of the depth of invasion by EUS using high-frequency ultrasound probes were 70%-88% for intramucosal cancer, and 83%-94% for submucosal invasive cancer. But the sensitivity of EUS using high-frequency ultrasound probes for the diagnosis of submucosal invasive cancer was relatively low, making it difficult to confirm minute submucosal invasion. The accuracy of EUS using high-frequency ultrasound probes for early gastric tumor classification can be up to 80% compared with 63% for conventional EUS, although the accuracy of EUS using high-frequency ultrasound probes relatively decreases for those patients with depressed-type lesions, undifferentiated cancer, concomitant ulceration, expanded indications, type 0-I?lesions, and lesions located in the upper-third of the stomach. A 92% overall accuracy rate was achieved when both the endoscopic appearance and the findings from EUS using high-frequency ultrasound probes were considered together for tumor classification. Although EUS using high-frequency ultrasound probes has limitations, it has a high depth of invasion accuracy and is a useful procedure to distinguish lesions in the esophagus and stomach that are indicated for endoscopic resection.

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices(GV)represent a common and severe complication in patients with portal hypertension,commonly seen in patients with cirrhosis and severe pancreatic disease.Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa,portal vein and its tributaries,and collateral circulations during direct endoscopic observation.Recently,various studies have been published about endoscopic ultrasound(EUS)-guided management of GV,mainly including diagnosis,treatment,and prognostic analysis.This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

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.

Percutaneous transsplenic embolization of esophageal and gastrio-fundal varices in 18 patients

AIM: Clinical application and potential complication of percutaneous transsplenic varices embolization (PTSVE) of esophageal or gastrio-fundal varices in patients with hepatocellular carcinoma (HCC) complicated with portal vein cancerous thrombosis (PVCT).METHODS: 18 patients with HCC complicated with PVCT and esophageal or gastrio-fundal varices who underwent PTSVE were collected. The rate of success, complication, mortality of the procedure and postoperative complication were recorded and analyzed.RESULTS: PTSVE were successfully performed in 16 of 18cases, and the rate of success was 89%. After therapy erythrocyte counts decreased in all of the natunts. 5 of patients needed blood transfusion, 2 patients requiredsurgical intervention because of and 11 patients with ascites were alleviated by diuresis. Among these 18patients, the procedure-related mortality was 11% (2/18),one died of acute hepatic failure on the forth day after procedure, another died of acute renal failure on the fifth day. The patients were follow up for 112 mon exceptone. 13of them died of their tumors but none of them experienced variceal bleeding.CONCLUSION: PTSVE is a relatively safe and effective method to treat esophageal or gastrio-fundal varices in HCCpatients with PVCT when percutaneous transhepatic varices embolization (PTHVE) of varices is impossible.

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.

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

New methods for the management of gastric varices

Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.

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.

Drug-induced mucosal alterations observed during esophagogastroduodenoscopy

Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract,i.e.,the esophagus,stomach,and duodenum.These include pill-induced esophagitis,desquamative esophagitis,worsening of gastroesophageal reflux,chemotherapy-induced esophagitis,proton pump inhibitor-induced gastric mucosal changes,medication-induced gastric erosions and ulcers,pseudomelanosis of the stomach,olmesartan-related gastric mucosal inflammation,lanthanum deposition in the stomach,zinc acetate hydrate tabletinduced gastric ulcer,immune-related adverse event gastritis,olmesartan-associated sprue-like enteropathy,pseudomelanosis of the duodenum,and lanthanum deposition in the duodenum.For endoscopists,acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions.This minireview aims to provide essential information on druginduced mucosal alterations observed on esophagogastroduodenoscopy,along with representative endoscopic images.

Is there an alternative therapy to cyanoacrylate injection for safe and effective obliteration of bleeding gastric varices?

TO THE EDITORWe read with interest the article entitled ＂Bleeding gastric varices： Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital＂ by Noophun et al. They performed n-butyl-2-cyanoacrylate （CA） injection therapy for bleeding gastric varices in twentyfour patients, and hemostasis was achieved in seventeen （71%） patients. They concluded that CA injection therapy was effective and safe for bleeding gastric varices. However, we disagreed with the author＇s conclusion.

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.

Update on the management of gastrointestinal varices

Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.

Use of shear wave elastography for the diagnosis and follow-up of biliary atresia: A meta-analysis

BACKGROUND Timely differentiation of biliary atresia(BA)from other infantile cholestatic diseases can impact patient outcomes.Additionally,non-invasive staging of fibrosis after Kasai hepatoportoenterostomy has not been widely standardized.Shear wave elastography is an ultrasound modality that detects changes in tissue stiffness.The authors propose that the utility of elastography in BA can be elucidated through meta-analysis of existing studies.AIM To assess the utility of elastography in:(1)BA diagnosis,and(2)post-Kasai fibrosis surveillance.METHODS A literature search identified articles that evaluated elastography for BA diagnosis and for post-Kasai follow-up.Twenty studies met criteria for meta-analysis:Eleven for diagnosis and nine for follow-up post-Kasai.Estimated diagnostic odds ratio(DOR),sensitivity,and specificity of elastography were calculated through a random-effects model using Meta-DiSc software.RESULTS Mean liver stiffness in BA infants at diagnosis was significantly higher than in non-BA,with overall DOR 24.61,sensitivity 83%,and specificity 79%.Post-Kasai,mean liver stiffness was significantly higher in BA patients with varices than in patients without,with DOR 16.36,sensitivity 85%,and specificity 76%.Elastography differentiated stage F4 fibrosis from F0-F3 with DOR of 70.03,sensitivity 96%,and specificity 89%.Elastography also differentiated F3-F4 fibrosis from F0-F2 with DOR of 24.68,sensitivity 85%,and specificity 81%.CONCLUSION Elastography has potential as a non-invasive modality for BA diagnosis and surveillance post-Kasai.This paper’s limitations include inter-study method heterogeneity and small sample sizes.Future,standardized,multi-center studies are recommended.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose:We aimed to compare treatment efficacy,safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt(TIPS).Materials&Methods:This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017.Patients were divided into three groups according to embolic agents used in variceal embolization:tissue gel group(Group A),combination group(Group B),and coil group(Group C).The primary endpoint was 1-year rebleeding rate after TIPS creation.The secondary endpoints included shunt dysfunction,overt hepatic encephalopathy,liver function,and embolic agents-related expense.Results:A total of 60 patients(30,10,and 20 in Group A,B,and C)were included.Variceal rebleeding occurred in3(10%),0(0%),and 4(20%)patients within one year after TIPS creation in Group A,B,and C,respectively.Stent dysfunction occurred in 2(3.3%)patients and 9(15.0%)patients experienced overt hepatic encephalopathy.No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense,with a significantly lower cost in Group A when compared to the other two groups.Stent dysfunction occurred in two patients,with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.Conclusions:Compares to coil alone or combines with coil,tissue gel has similar treatment efficacy and safety,but with significantly lower cost for variceal bleeding during TIPS.

门脉高压性胃病患者中医证型分布特点及其与胃镜下黏膜病变的相关性

目的:明确门脉高压性胃病(portal hypertension gastropathy,PHG)患者中医证型分布特点,探究PHG中医证型与胃镜下黏膜病变特点之间的相关性。方法:采用临床调查方式对符合标准的180例PHG患者中医证型、胃黏膜病变特点等资料进行统计学分析。结果:PHG患者中医证型主要为湿热蕴结证、瘀血阻络证;胃黏膜糜烂、充血、水肿、出血以湿热蕴结证患者多见,瘀血阻络证以PHG重度患者多见;肝气郁结证及瘀血阻络证与肝肾阴虚证、水湿内阻证及脾肾阳虚证相比,食管静脉曲张发病率差异有统计学意义(P<0.05)。结论:PHG中医证型与胃黏膜病变相关,湿热、瘀血是其主要病理因素。

金属夹辅助内镜超声引导组织胶注射治疗合并胃肾分流的肝硬化胃静脉曲张患者的效果初探

目的探讨金属夹辅助内镜超声引导组织胶注射治疗合并胃肾分流的胃静脉曲张患者的效果及安全性。方法纳入2023年2月—2023年6月因肝硬化伴胃静脉曲张于首都医科大学附属北京地坛医院就诊,证实存在胃肾分流(GRS),并接受金属夹辅助内镜超声引导组织胶注射治疗的患者。主要的评价指标是术后曲张静脉减轻或消失情况,次要评价指标为手术完成情况及并发症。结果共11例合并GRS的胃静脉曲张患者纳入研究,男7例,女4例;中位年龄55岁;肝功能Child-Pugh A级1例,Child-Pugh B级7例,Child-Pugh C级3例;分流道最大直径(中位)8 mm,最小直径(中位)4 mm。治疗前靶血管血流中位流速11 cm/s,金属夹阻断后靶血管中位流速5 cm/s;中位组织胶使用量2 mL,聚桂醇使用量均为1 mL。所有患者手术结束后血流信号100%消失,手术成功率100%。随访6周患者均无再出血发生。术后1个月复查胃镜示静脉曲张根除或基本消失9例,静脉曲张改善2例。结论对于合并GRS的胃静脉曲张肝硬化患者,金属夹辅助内镜超声引导组织胶注射治疗是一种可行,安全,有效的方法。

脾硬度及血小板计数联合脾脏大小在肝硬化食管胃底静脉曲张诊断中的应用

目的探讨脾硬度(SSM)、血小板计数(PLT)联合脾脏大小对肝硬化食管胃底静脉曲张(GOV)的诊断价值。方法选取109例在我院就诊的乙型肝炎肝硬化病人,超声测量其脾脏厚径(ST)和脾脏长径(SD),应用瞬时弹性扫描仪测量其SSM,并进行血清学检测及胃镜检查。以胃镜检查结果为标准,采用Logistic回归分析乙型肝炎肝硬化中-重度GOV与SSM、PLT/SD、PLT/ST的关系,建立回归模型。结果有、无GOV组SSM、PLT/ST、PLT/SD比较差异有统计学意义(Z=3.03~5.53,P<0.05)。建立判断中-重度GOV的回归模型Logit(P)=-6.373+0.298×SSM-0.443×PLT/ST。SSM、PLT/ST、PLT/SD及回归模型诊断中-重度GOV的受试者工作特征曲线下面积分别为0.94、0.79、0.77、0.95。结论SSM、PLT/ST、PLT/SD对肝硬化是否存在GOV有一定的诊断价值,且SSM诊断中度以上GOV的价值比PLT/ST和PLT/SD更高;SSM及PLT联合脾脏大小建立的无创诊断模型也可用于诊断中-重度GOV。

血清sCD163对食管胃静脉曲张内镜下治疗后再出血风险的预测价值

目的通过对食管胃静脉曲张内镜下治疗患者术前血清可溶性血红蛋白清道夫受体163(sCD163)进行检测,结合治疗达标后18个月随访期内有无再出血情况,分析术前血清sCD163水平对食管胃静脉曲张内镜下治疗后再出血风险的预测价值。方法选取2019年1月至2022年6月在南通市第三人民医院进行肝硬化食管胃静脉曲张二级预防内镜下治疗的203例患者作为研究对象,在患者首次内镜下治疗前进行血清sCD163检测,经过1~3次内镜下治疗后复查胃镜,确认治疗达标后进入随访阶段,随访期内确认有无再出血情况,并根据出血情况分为出血组和未出血组。采用多因素Logistic回归分析再出血的危险因素。采用受试者工作特征(ROC)曲线分析血清sCD163对再出血风险的预测价值。结果未出血组和出血组患者血小板计数(PLT)、凝血酶原时间(PT)、门静脉宽度、sCD163水平比较,差异均有统计学意义(P<0.05);出血组和未出血组患者性别、年龄、丙氨酸转氨酶(ALT)、总胆红素(TBIL)、清蛋白(ALB)、有无腹水等临床资料比较,差异均无统计学意义(P>0.05)。将单因素分析差异有统计学意义的4项指标(PLT、PT、门静脉宽度、sCD163)纳入多因素Logistic回归分析,结果显示,仅血清sCD163水平升高是再出血的危险因素(P<0.05),其OR值为3.684。ROC曲线分析结果显示,血清sCD163预测治疗后再出血风险的最佳截断值为3.66 mg/L,灵敏度为0.746,特异度为0.833,曲线下面积为0.840。高、低sCD163组性别、年龄、PLT、ALT、TBIL、ALB等临床资料比较,差异均无统计学意义(P>0.05)。结论术前血清sCD163是肝硬化食管胃静脉曲张内镜下治疗后再出血风险的独立预测因子,术前血清sCD163水平检测对二级预防治疗方式的选择有一定指导意义。

内镜治疗肝硬化患者上消化道早癌的风险及处理策略

肝硬化患者患上消化道肿瘤风险增加,尤其是酒精性肝硬化患者.随着内镜检查的推广及普及,越来越多的上消化道早癌得以早期发现及治疗.内镜治疗已成为上消化道早癌的首选治疗方式,肝硬化患者由于可能存在血小板减少、凝血功能障碍、合并食管胃静脉曲张等情况,内镜治疗过程中出血、感染等风险较大.近年来国内外已有部分研究探讨内镜治疗肝硬化伴上消化道早癌的安全性及有效性.本文总结了近年来发表的内镜治疗肝硬化伴上消化道早癌的研究结果,简要综述其风险及防治策略,为临床提供指导.