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.

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.

Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study

BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis.The current standard treatment is endoscopic variceal ligation(EVL),and Western guidelines recom-mend antibiotic prophylaxis following hemostasis.However,given the impro-vements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria,there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals.Patients were divided into the prophylaxis group(received antibiotics on admission or the next day)and the non-prophylaxis group(did not receive antibiotics within one day of admission).The primary outcome was composed of 6-wk mortality,4-wk rebleeding,and 4-wk spontaneous bacterial peritonitis(SBP).The secondary outcomes were each individual result and in-hospital mortality.A logistic regression with inverse probability of treatment weighting was used.A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures,while sensitivity analyses for antibiotic type and duration were also performed.RESULTS Among 980 patients,790 were included(prophylaxis:232,non-prophylaxis:558).Most patients were males under the age of 65 years with a median Child-Pugh score of 8.The composite primary outcomes occurred in 11.2%of patients in the prophylaxis group and 9.5%in the non-prophylaxis group.No significant differences in outcomes were observed between the groups(adjusted odds ratio,1.11;95%confidence interval,0.61-1.99;P=0.74).Individual outcomes such as 6-wk mortality,4-wk rebleeding,4-wk onset of SBP,and in-hospital mortality were not significantly different between the groups.The primary outcome did not differ between the Child-Pugh subgroups.Similar results were observed in the sensitivity analyses.CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study.Global reassessment of routine antibiotic prophylaxis is imperative.

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.

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.

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.

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.

Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding:A meta-analysis

AIM: To systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate (BB + ISMN) and endoscopic band ligation (EBL) on prophylaxis of esophageal variceal rebleeding. METHODS: Randomized controlled trials (RCTs) comparing the efficacy and safety of BB + ISMN and EBL on prophylaxis of esophageal variceal rebleeding were gathered from Medline, Embase, Cochrane Controlled Trial Registry and China Biological Medicine database between January 1980 and August 2007. Data from five trials were extracted and pooled. The analyses of the available data using the Revman 4.2 software were based on the intention-to-treat principle. RESULTS: Four RCTs met the inclusion criteria. In comparison with BB + ISMN with EBL in prophylaxis of esophageal variceal rebleeding, there was no significant difference in the rate of rebleeding [relative risk (RR), 0.79; 95% CI: 0.62-1.00; P = 0.05], bleeding-related mortality (RR, 0.76; 95% CI: 0.31-1.42; P = 0.40), overall mortality (RR, 0.81; 95% CI: 0.61-1.08; P = 0.15) and complications (RR, 1.26; 95% CI: 0.93-1.70; P = 0.13). CONCLUSION:In the prevention of esophageal variceal rebleeding, BB + ISMN are as effective as EBL. There are few complications with the two treatment modalities. Both BB + ISMN and EBL would be considered as the first-line therapy in the prevention of esophageal variceal rebleeding.

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.

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.

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.

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.

Multiple esophageal variceal ruptures with massive ascites due to myelofibrosis-induced portal hypertension

A 75-year old man had been diagnosed at 42 years of age as having polycythemia vera and had been monitored at another hospital. Progression of anemia had been recognized at about age 70 years, and the patient was thus referred to our center in 2008 where secondary myelofibrosis was diagnosed based on bone marrow biopsy findings. Hematemesis due to rupture of esophageal varices occurred in January and February of 2011. The bleeding was stopped by endoscopic variceal ligation. Furthermore, in March of the same year, hematemesis recurred and the patient was transported to our center. He was in irreversible hemorrhagic shock and died. The autopsy showed severe bone marrow fibrosis with mainly argyrophilic fibers, an observation consistent with myelofibrosis. The liver weighed 1856 g the spleen 1572 g, indicating marked hepatosplenomegaly. The liver and spleen both showed extramedullary hemopoiesis. Myelofibrosis is often complicated by portal hypertension and is occasionally associated with gastrointestinal hemorrhage due to esophageal varices. A patient diagnosed as having myelofibrosis needs to be screened for esophageal/gastric varices. Myelofibrosis has a poor prognosis. Therefore, it is necessary to carefully decide the therapeutic strategy in consideration of the patient's concomitant conditions, treatment invasiveness and quality of life.

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.

Lateral position intubation followed by endoscopic ultrasoundguided angiotherapy in acute esophageal variceal rupture: A case report

BACKGROUND Massive esophageal variceal bleeding can be catastrophic,leading to high morbidity and mortality.Patients experiencing massive esophageal variceal bleeding are at high risk of aspiration and hemorrhagic shock in acute episodes.Intubation and bleeding control are the two essential steps for resuscitation of these patients.CASE SUMMARY A 47-year-old male patient was admitted to our hospital with upper digestive tract bleeding.He was diagnosed with alcohol-induced liver cirrhosis and consequent esophagogastric varices.As he did not show a good response to somatostatin and Sengstaken-Blakemore tube placement,the patient was scheduled for endoscopic angiotherapy under anesthesia.Preoperative assessment showed an ASA physical status of III and Child-Pugh classification B.However,massive hemorrhage occurred just after induction of anesthesia.Intubation by video-guided laryngoscopy in the lateral decubitus position was attempted twice and was successful.After that,an experienced endoscopic ultrasound(EUS)specialist performed angiotherapy and occluded the culprit vessel.An ultra-thin gastroscope was then inserted into the endotracheal tube to extract the blood observed in the lobar bronchi.The patient suffered hemorrhagic shock with an estimated blood loss of 1500 mL in 20 min and remained in the intensive care unit for two days.The patient was discharged from our hospital eight days later without major complications.CONCLUSION Intubation in the lateral decubitus position and EUS-guided treatment can be lifesaving procedures in patients with massive upper gastrointestinal hemorrhage.

Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: A proposal for developing countries

AIM:To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions. METHODS:This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication. RESULTS:A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the programm. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%. CONCLUSION:EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.

Self-expanding metal stent for relieving the stricture after endoscopic injection for esophageal varices

BACKGROUND Esophageal stricture is one of the complications after esophageal varices sclero-therapy injection(ESI),and the incidence rate is between 2%-10%.AIM To explore the efficacy of self-expanding metal stent(SEMS)for the stricture after endoscopic injection with cyanoacrylate(CYA)and sclerotherapy for esophageal varices.METHODS We retrospectively analyzed the efficacy of SEMS to improve the stricture after endoscopic injection with CYA and sclerotherapy for esophageal varices in 4 patients from February 2023 to June 2023.RESULTS The strictures were improved in four patients after stenting.The stent was removed after two weeks because of chest pain with embedding into esophageal mucosa in one patient.The stent was removed after one month,however,the stent was reinserted because of the strictures happening again in two patients.The stent was removed after three months,however,the stent was reinserted because of the strictures happening again in one patient.The stent embedded into esophageal mucosa in three patients.There were 3 patients suffered reflux esophagitis,and the acid reflux was relieved by taking hydrotalcite.There was no other complication of esophageal perforation,bleeding from varices or infection.CONCLUSION SEMS may relieve the stricture which happened after endoscopic injection with CYA and sclerotherapy for esophageal varices.However,when we should remove the stent still needs to be explored.

Transparent cap adjusted the stent placed for stenosis after endoscopic injection of esophageal varices:A case report

BACKGROUND The stent embedded in the esophageal mucosa is one of the complications after stenting for esophageal stricture.We present a case of stent adjustment with the aid of a transparent cap after endoscopic injection of an esophageal varices stent.CASE SUMMARY A 61-year-old male patient came to the hospital with discomfort of the chest after the stent implanted for the stenosis because of endoscopic injection of esophageal varices.The gastroscopy was performed,and the stent embedded into the esophageal mucosa.At first,we pulled the recycling line for shrinking the stent,however,the mucosa could not be removed from the stent.Then a forceps was performed to remove the mucosa in the stent,nevertheless,the bleeding form the mucosa was obvious.And then,we used a transparent cap to scrape the mucosa along the stent,and the mucosa were removed successfully without bleeding.CONCLUSION A transparent cap helps gastroscopy to remove the mucosa embedded in the stent after endoscopic injection of the esophageal varices stent.

Biopsy forceps are useful for measuring esophageal varices in vitro

BACKGROUND To avoid acute variceal bleeding in cirrhosis,current guidelines recommend screening for high-risk esophageal varices(EVs)by determining variceal size and identifying red wale markings.However,visual measurements of EV during routine endoscopy are often inaccurate.AIM To determine whether biopsy forceps(BF)could be used as a reference to improve the accuracy of binary classification of variceal size.METHODS An in vitro self-made EV model with sizes ranging from 2 to 12 mm in diameter was constructed.An online image-based survey comprising 11 endoscopic images of simulated EV without BF and 11 endoscopic images of EV with BF was assembled and sent to 84 endoscopists.The endoscopists were blinded to the actual EV size and evaluated the 22 images in random order.RESULTS The respondents included 48 academic and four private endoscopists.The accuracy of EV size estimation was low in both the visual(13.81%)and BF-based(20.28%)groups.The use of open forceps improved the ability of the endoscopists to correctly classify the varices by size(small≤5 mm,large>5 mm)from 71.85%to 82.17%(P<0.001).CONCLUSION BF may improve the accuracy of EV size assessment,and its use in clinical practice should be investigated.

Non-invasive assessment of esophageal varices:Status of today

With increasing burden of compensated cirrhosis,we desperately need noninvasive methods for assessment of clinically significant portal hypertension.The use of liver and spleen stiffness measurement helps in deferring unnecessary endoscopies for low risk esophageal varices.This would reduce cost and patient discomfort.However,these special techniques may not be feasible at remote areas where still we need only biochemical parameters.More prospective studies validating the non-invasive risk prediction models are definitely needed.