|
1
|
Gao L, Bai J, Liu K, Wang L, Zhu S, Zhao X, Han Y, Liu Z. Hypertonic solution as an optimal submucosal injection solution for endoscopic resection of gastrointestinal mucosal lesions: Systematic review and network meta-analysis. Dig Endosc 2024; 36:657-669. [PMID: 37767724 DOI: 10.1111/den.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES Based on different physicochemical properties, common submucosal injection solutions could be classified into three categories: normal saline solution (NS), hypertonic solution (HS), and viscous solution (VS). We compared the efficacy and safety of various categories of solutions in this network meta-analysis of randomized controlled trials (RCTs) to identify the optimal submucosal injection fluid. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for RCTs that compared the efficacy and safety of NS, HS, and VS during endoscopic resection for gastrointestinal (GI) mucosal lesions. Pairwise and network analyses were conducted to determine the ranking of different fluids. RESULTS Thirteen RCTs were included in the final analysis with 1637 patients (1639 lesions). HS outperformed NS in rates of en bloc (pooled relative risk [RR] 1.50; 95% confidence interval [CI] 1.10-1.90), overall bleeding (pooled odds ratio [OR] 0.33; 95% CI 0.10-0.88; lesions >10 mm OR 4.65 × 10-2; 95% CI 1.10 × 10-3-0.46), and intraoperative bleeding (lesions >10 mm OR 7.10 × 10-6; 95% CI 4.30 × 10-18-0.26). HS showed the highest probability of ranking first in each outcome except for the volume of injection. Although VS was superior to NS in rates of en bloc, overall, and intraoperative bleeding in the lesions >10 mm subgroup, and required less fluid in pooled analysis, it ranked last in cost of submucosal injection solution. CONCLUSIONS Both HS and VS were superior to NS in comparisons of efficacy and safety. Considering the better performance and potentially low cost, HS might be an optimal choice during gastrointestinal endoscopic resection, especially for colorectal endoscopic mucosal resection.
Collapse
Affiliation(s)
- Li Gao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Jiawei Bai
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
- School of Medicine, Yan'an University, Yan'an, China
| | - Kai Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Lulu Wang
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Shaohua Zhu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Xin Zhao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Ying Han
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| |
Collapse
|
|
2
|
Shashi P, Kochhar G, Shen B. Endoscopic therapy of colorectal anastomotic hematoma with hypertonic dextrose. Gastroenterol Rep (Oxf) 2018; 7:455-458. [PMID: 31857908 PMCID: PMC6911995 DOI: 10.1093/gastro/goy026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/20/2018] [Accepted: 04/08/2018] [Indexed: 12/28/2022] Open
Abstract
Anastomotic dehiscence and leak are dreaded complications after a colorectal resection and can often present with rectal bleeding and pelvic abscess or sepsis. Although most cases of bleeding after gastrointestinal anastomoses are minor and self-limited, major bleeding, as defined by hemodynamic instability or the need for blood transfusions, poses a significant challenge for management. Here we report a case in which a patient presenting with profuse rectal bleeding and pelvic hematoma secondary to a colorectal anastomotic leak was treated endoscopically with 50% dextrose spray then enema.
Collapse
Affiliation(s)
- Preeti Shashi
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gursimran Kochhar
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
|
3
|
Tominaga K, Kamimura K, Takahashi K, Yokoyama J, Yamagiwa S, Terai S. Diversion colitis and pouchitis: A mini-review. World J Gastroenterol 2018; 24:1734-1747. [PMID: 29713128 PMCID: PMC5922993 DOI: 10.3748/wjg.v24.i16.1734] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/01/2018] [Accepted: 04/16/2018] [Indexed: 02/06/2023] Open
Abstract
Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.
Collapse
Affiliation(s)
- Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Satoshi Yamagiwa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| |
Collapse
|
|
4
|
Endoscopic Treatment of Bleeding Diversion Pouchitis with High-Concentration Dextrose Spray. ACG Case Rep J 2017; 4:e51. [PMID: 28377939 PMCID: PMC5371723 DOI: 10.14309/crj.2017.51] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/09/2017] [Indexed: 12/23/2022] Open
Abstract
Surgical closure of stoma with the reestablishment of gut continuity is the only curative intervention available for inflammatory bowel disease patients with diversion pouchitis, proctitis, or colitis. For patients who are not candidates for surgical reestablishment of bowel continuity, the alternative nonsurgical approaches, such as topical therapy with mesalamine, corticosteroids, or short-chain fatty acids, have only shown modest efficacy. The management of massive bleeding from diversion pouchitis has not been described. We present a patient with ulcerative colitis with severe hematochezia and diffuse mucosal bleeding in a diverted ileal pouch, which was successfully treated with endoscopic spray of hypertonic glucose.
Collapse
|
|
5
|
Hamerski C, Binmoeller KF, Shah JN. Hemostasis of Acute Gastric Variceal Bleeding. GI ENDOSCOPIC EMERGENCIES 2016:181-193. [DOI: 10.1007/978-1-4939-3085-2_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
6
|
Elwakil R, Montasser MF, Abdelhakam SM, Ibrahim WA. N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices. World J Gastrointest Endosc 2015; 7:411-416. [PMID: 25901221 PMCID: PMC4400631 DOI: 10.4253/wjge.v7.i4.411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/06/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices.
METHODS: Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I (n-butyl-2-cyanoacrylate; Histoacryl®), Group II (iso-amyl-2-cyanoacrylate; Amcrylate®) and Group III (mixture of 72% chromated glycerin; Scleremo® with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo.
RESULTS: 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference, (P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference, (P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments.
CONCLUSION: All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.
Collapse
|
|
7
|
Oh SH, Kim SJ, Rhee KW, Kim KM. Endoscopic cyanoacrylate injection for the treatment of gastric varices in children. World J Gastroenterol 2015; 21:2719-2724. [PMID: 25759541 PMCID: PMC4351223 DOI: 10.3748/wjg.v21.i9.2719] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/28/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of N-butyl-2-cyanoacrylate in treating acute bleeding of gastric varices in children.
METHODS: The retrospective study included 21 children with 47 episodes of active gastric variceal bleeding who were treated by endoscopic injection of N-butyl-2-cyanoacrylate at Asan Medical Center Children’s Hospital between August 2004 and December 2011. To reduce the risk of embolism, each injection consisted of 0.1-0.5 mL of 0.5 mL N-butyl-2-cyanoacrylate diluted with 0.5 or 0.8 mL Lipiodol. The primary outcome was incidence of hemostasis after variceal obliteration and the secondary outcome was complication of the procedure.
RESULTS: The 21 patients experienced 47 episodes of active gastric variceal bleeding, including rebleeding, for which they received a total of 52 cyanoacrylate injections. Following 42 bleeding episodes, hemostasis was achieved after one injection and following five bleeding episodes it was achieved after two injections. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1-0.5 mL). Injection achieved hemostasis in 45 of 47 (95.7%) episodes of acute gastric variceal bleeding. Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications such as distal embolism were noted with the exception of abdominal pain in one patient (4.8%). Among four mortalities, one patient died of variceal rebleeding.
CONCLUSION: Endoscopic variceal obliteration using a small volume of aliquots with repeated cyanoacrylate injection was an effective and safe option for the treatment of gastric varices in children.
Collapse
|
|
8
|
Endoscopic Therapy of Bleeding from Radiation Enteritis with Hypertonic Glucose Spray. ACG Case Rep J 2014; 1:181-3. [PMID: 26157869 PMCID: PMC4435317 DOI: 10.14309/crj.2014.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/13/2014] [Indexed: 12/23/2022] Open
Abstract
Non-variceal and non-ulcerative bleeding in the gastrointestinal (GI) tract, such as radiation enteritis with active and extensive oozing, is common, and management of these conditions can be challenging. We describe the first case in the literature to use hypertonic glucose spray in radiation enteritis-associated diffuse mucosal bleeding.
Collapse
|
|
9
|
Sofue K, Takeuchi Y, Shibamoto K, Sugimoto K, Sugimura K, Arai Y. Infusion of 50% glucose solution to occlude an intrahepatic portosystemic venous shunt before percutaneous transhepatic portal embolization: report of a case. Surg Today 2013; 44:2366-8. [PMID: 24091863 DOI: 10.1007/s00595-013-0745-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
A 68-year-old man with cholangiocarcinoma underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Selective right posterior portography revealed an intrahepatic portosystemic venous shunt (IPSVS) connecting the segment VII branch to the right hepatic venous branch. An infusion of 50 % glucose solution was given to occlude the shunt. This is novel management for IPSVSs when they are numerous, small, or torturous, and makes the subsequent procedures simpler, shorter, and less expensive.
Collapse
Affiliation(s)
- Keitaro Sofue
- Department of Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo, Tokyo, 104-0045, Japan,
| | | | | | | | | | | |
Collapse
|
|
10
|
Abstract
Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.
Collapse
Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, Institute of Liver and Biliary Sciences, New Delhi, India.
| | | |
Collapse
|
|
11
|
Akahoshi T, Hashizume M, Tomikawa M, Kawanaka H, Yamaguchi S, Konishi K, Kinjo N, Maehara Y. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol 2008; 23:1702-9. [PMID: 18713295 DOI: 10.1111/j.1440-1746.2008.05549.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Balloon-occluded retrograde transvenous obliteration (B-RTO) is a new alternative treatment for gastric varices (GVx), but the long-term efficacy is not known. We investigated the long-term effects of B-RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx). METHODS B-RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty-eight patients had varices likely to bleed, but no bleeding. After B-RTO, the recurrent bleeding, occurrence of EVx and mortality over the long-term were evaluated. RESULTS B-RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8-year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2-GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05). CONCLUSION B-RTO is beneficial over the long-term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B-RTO can become a first-choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.
Collapse
Affiliation(s)
- Tomohiko Akahoshi
- Departments of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
|
12
|
Abstract
Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.
Collapse
Affiliation(s)
- Nagib Toubia
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, MCV, Box 980341, Richmond, VA 23298-0341, USA
| | | |
Collapse
|
|
13
|
Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67:313-23. [PMID: 18226695 DOI: 10.1016/j.gie.2007.09.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/27/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
| | | | | |
Collapse
|
|
14
|
Yamagami T, Kato T, Hirota T, Yoshimatsu R, Matsumoto T, Nishimura T. Infusion of 50% glucose solution before injection of ethanolamine oleate during balloon-occluded retrograde transvenous obliteration. ACTA ACUST UNITED AC 2007; 51:334-8. [PMID: 17635469 DOI: 10.1111/j.1440-1673.2007.01746.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The feasibility of infusion of 50% glucose solution before balloon-occluded retrograde transvenous obliteration (BRTO) to occlude collateral vessels draining gastric varices other than gastrorenal shunt was evaluated. In five patients with such collateral vessels, 50% glucose solution was infused from the balloon catheter inflated within the gastrorenal shunt. The degree of collateral vessels had decreased when BRTO was carried out so that sclerotic agents sufficiently occupied the gastric varices in all patients. In three patients, embolization of collateral vessels with coils was unnecessary. There were no complications. In conclusion, retrograde infusion of 50% glucose solution assists in effectively carrying out BRTO.
Collapse
Affiliation(s)
- T Yamagami
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo, Kyoto 602-8566,
| | | | | | | | | | | |
Collapse
|
|
15
|
Sugimoto N, Watanabe K, Watanabe K, Ogata S, Shimoda R, Sakata H, Eguchi Y, Mizuta T, Tsunada S, Iwakiri R, Nojiri J, Mizuguchi M, Kudo S, Miyazaki K, Fujimoto K. Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate. J Gastroenterol 2007; 42:528-32. [PMID: 17653647 DOI: 10.1007/s00535-007-2041-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Accepted: 03/05/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices. METHODS Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary. RESULTS Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27). CONCLUSIONS This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.
Collapse
Affiliation(s)
- Nozomi Sugimoto
- Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
16
|
Croffie J, Somogyi L, Chuttani R, DiSario J, Liu J, Mishkin D, Shah RJ, Tierney W, Wong Kee Song LM, Petersen BT. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007; 66:1-6. [PMID: 17591465 DOI: 10.1016/j.gie.2007.02.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
|
17
|
Abstract
Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.
Collapse
Affiliation(s)
- Adil Habib
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University Medical Center, MCV Box 980341, Richmond, VA 23298-0341, USA
| | | |
Collapse
|
|
18
|
Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Rizos C, Beltsis A. Endoscopic mucosal resection of large sessile colorectal polyps with submucosal injection of hypertonic 50 percent dextrose-epinephrine solution. Dis Colon Rectum 2006; 49:1384-92. [PMID: 16897333 DOI: 10.1007/s10350-006-0611-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Before endoscopic mucosal resection of large sessile colorectal polyps, injection of solution into submucosa cushions and isolates the tumor, although there is little information as to which solution with optimal effect should be used. This study investigated the effectiveness of endoscopic mucosal resection by use of a hypertonic dextrose plus epinephrine solution for large sessile colorectal polyps. METHODS We removed 59 large sessile colorectal polyps in 59 patients by introducing an endoscopic submucosal hypertonic dextrose plus epinephrine injection technique. Endoscopic evaluations were repeated at 3, 6, and 12 months or longer. If no residual tumor was observed endoscopically and histologically at one year or more, the patient was considered to be "cured." The main outcome measurements were the mean amount of solution injected, mean disappearance time of solution, safety, complications, and recurrence at follow-up. RESULTS Of the 59 large sessile colorectal polyps, 23 (39 percent) were resected en bloc and 36 (61 percent) piecemeal. The mean amount of hypertonic dextrose plus epinephrine solution injected was 24.42 +/- 17.52 ml, and its mean disappearance time was 13.61 +/- 5.21 (range, 7-21) minutes. Of the 36 patients treated with piecemeal resection, 18 (50 percent) required additional endoscopic interventions. In patients who entered the follow-up surveillance protocol for one year or longer, the cure rate by en bloc resection was 100 percent (23/23) and that by piecemeal intervention was 96.78 percent (30/31). Four patients (6.8 percent) had local bleeding after endoscopic mucosal resection that was mainly controlled endoscopically. CONCLUSIONS Endoscopic mucosal resection after submucosal hypertonic dextrose plus epinephrine solution injection, with an intensive follow-up program, seems to be a safe and effective treatment for large sessile colorectal polyps.
Collapse
Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, Central Hospital, Thessaloniki, Macedonia 551 33, Greece
| | | | | | | | | | | |
Collapse
|
|
19
|
Abstract
Many advances have occurred in the management of varices over the years. Guidelines based on sound evidence have been developed to manage the esophageal variceal hemorrhage. Less is known about how best to manage some of the more difficult cases of bleeding related to portal hypertension. This article reviews evidence in the hypertensive gastropathy, ectopic varices, and management of patients who are intolerant of or have not responded to beta-blocker therapy. The goal of this article is to review the sparse available evidence and to suggest reasonable management options.
Collapse
Affiliation(s)
- Atif Zaman
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailcode PV310, Portland, OR 97210, USA.
| |
Collapse
|
|
20
|
Katsinelos P, Paroutoglou G, Beltsis A, Chatzimavroudis G, Papaziogas B, Katsinelos T, Rizos C, Tzovaras G, Vasiliadis I, Dimiropoulos S. Endoscopic Mucosal Resection of Lateral Spreading Tumors of the Colon Using a Novel Solution. Surg Laparosc Endosc Percutan Tech 2006; 16:73-7. [PMID: 16773004 DOI: 10.1097/00129689-200604000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Lateral spreading tumors (LSTs) of the colon are lesions over 10 mm in diameter that are low in height and grow superficially. They are increasingly being diagnosed in Western cohorts. The aim of this study was to investigate the safety and efficacy of dextrose 50% solution in the endoscopic mucosal resection (EMR) of LSTs. The study population consisted of 21 patients with LSTs of the colorectum. The mean size of the LSTs was 23.52+/-13.60 mm. Dextrose 50% solution was injected, via a variceal needle, into the submucosa to lift up the LST sufficiently from the proper muscle layer. Subsequently, a snare was positioned around the lesion and then closed while being pressed against the mucosa, with suction being applied to draw the lesion into the snare. Blended current was used for resection. If necessary, a piecemeal technique was used to achieve complete resection. Immediate and delayed complications were recorded. After the EMR, patients were followed up at 3, 6, and 12 months or later, using total colonoscopy. Endoscopic resection was completed in all LSTs. Of the 21 LSTs, 15 (71.4%) were resected en bloc and 6 (28.6%) piecemeal. The mean amount of injected dextrose 50% solution was 14.86+/-9.13 mL. One patient (4.78%) had immediate bleeding after EMR, which was stopped endoscopically. Histologic examination of resected LSTs showed adenoma with high-grade dysplasia 9 (42.9%), adenoma with low-grade dysplasia 10 (47.6%), and invasive carcinoma 2 (9.5%). Twenty patients were followed up for 37.9+/-24.03 months. Local recurrent disease was detected in 4 patients (20%), all within 6 months of the index EMR. These recurrent lesions were completely resected endoscopically. The contribution of submucosal injection of dextrose 50% is significant for a safe and efficient EMR of LSTs of the colorectum.
Collapse
|
|
21
|
Katsinelos P, Paroutoglou G, Mimidis K, Beltsis A, Papaziogas B, Gelas G, Kountouras Y. Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions. World J Gastroenterol 2005; 11:6022-6. [PMID: 16273618 PMCID: PMC4436728 DOI: 10.3748/wjg.v11.i38.6022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment.
METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding, and mortality rates were collected and analyzed retrospectively.
RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy’s lesion over a mean long-term follow-up of 29.8 mo.
CONCLUSION: Bleeding from Dieulafoy’s lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy’s lesions.
Collapse
Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, "G. Gennimatas" Hospital, Ethnikis Aminis 41, Thessaloniki 54635, Greece.
| | | | | | | | | | | | | |
Collapse
|
|
22
|
Farooq FT, Wong RC. Injection sclerotherapy for the management of esophageal and gastric varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005; 7:8-17. [DOI: 10.1016/j.tgie.2004.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
23
|
|
|
24
|
Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
| |
Collapse
|
|
25
|
Silvain C. [How to prevent and to treat bleeding from gastric or ectopic or from portal hypertension gastropathy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B218-26. [PMID: 15150516 DOI: 10.1016/s0399-8320(04)95259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Christine Silvain
- Service d'Hépato-Gastroentérologie et Assistance Nutritive, CHU La Milétrie, 86021 Poitiers Cedex
| |
Collapse
|
|
26
|
Abstract
Portal hypertension bleeding is a common and serious complication of cirrhosis. All patients with cirrhosis should undergo endoscopy and be evaluated for possible causes of current or future portal hypertensive bleeding. Possible causes of bleeding include esophageal varices, gastric varices, and PHG. Patients with esophageal varices at high risk of bleeding should be treated with nonselective beta-blockers for primary prevention of variceal hemorrhage. HVPG measurements represent the optimal way to monitor the success of pharmacologic therapy. EVL may be used in those with high-risk varices who do not tolerate beta-blockers. When active bleeding develops, simultaneous and coordinated attention must be given to hemodynamic resuscitation, prevention and treatment of complications, and active control of bleeding. In cases of acute esophageal variceal (Fig. 5) and PHG bleeding, terlipressin, somatostatin, or octreotide should be started. Endoscopic treatment is provided for those with bleeding esophageal varices. If first-line therapy fails, TIPS or surgery may need to be performed. Unlike esophageal variceal or PHG bleeding, there is no established optimal treatment for gastric variceal bleeding. Individual and specific treatment modalities for acute gastric variceal bleeding must be calculated carefully after considering side effects.
Collapse
Affiliation(s)
- Kevin M Comar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, MCV Box 980711, Sanger Hall 12011, Richmond, VA 23298-0711, USA
| | | |
Collapse
|
|
27
|
Greenwald BD, Caldwell SH, Hespenheide EE, Patrie JT, Williams J, Binmoeller KF, Woodall L, Haluszka O. N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study and cost analysis. Am J Gastroenterol 2003; 98:1982-8. [PMID: 14499775 DOI: 10.1111/j.1572-0241.2003.07637.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES N-butyl-2-cyanoacrylate has been reported to be effective for bleeding varices but is not available in the United States. We report the initial US experience with cyanoacrylate in this prospective trial and evaluate its safety, efficacy, and relative costs. METHODS Patients with active or recent gastric variceal bleeding were eligible. Cyanoacrylate therapy was performed until variceal occlusion was achieved. Rebleeding was assessed at 72 h (acute phase), 6 wk (subacute phase), and 1 yr (chronic phase). Survival was assessed at 3 months and 1 yr. Cost analysis was performed comparing the first 17 patients to historical control patients not treated with cyanoacrylate. RESULTS A total of 44 patients were enrolled, 37 with cirrhosis and seven with noncirrhotic portal hypertension (NCPH). In cirrhotic patients, rebleeding was seen in two of 37 (5%) at 72 h, one of 30 (3%) at 6 wk, and five of 28 (18%) at 1 yr. Survival without shunt at 3 months was 30 of 34 (88%) and at 1 yr was 24 of 31 (77%). In NCPH patients, rebleeding was seen in two of seven (29%) at 72 h. These patients received definitive therapy for NCPH after diagnosis. Mortality and costs were substantially higher in the non-cyanoacrylate group. The odds of death were greater by 7-fold in the non-cyanoacrylate group than within the cyanoacrylate group (95% CI = 1.18-41.36, p = 0.0318). At 3 months, there was a 3.18-fold difference (95% CI = 1.05-9.64, p = 0.0411) in accrued costs; at 1 yr, the difference was 2.55-fold (95% CI = 0.96-6.94, p = 0.0585). The cost-effective ratio was estimated as 108,237 US dollars/death averted, reflecting marked cost reduction with improved survival in the cyanoacrylate-treated group. This is believed to result largely from avoidance of shunt interventions. CONCLUSIONS Cyanoacrylate treatment of gastric varices is safe, clinically effective, and cost effective.
Collapse
Affiliation(s)
- Bruce D Greenwald
- Division of Gastroenterology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | |
Collapse
|
|
28
|
Conio M, Rajan E, Sorbi D, Norton I, Herman L, Filiberti R, Gostout CJ. Comparative performance in the porcine esophagus of different solutions used for submucosal injection. Gastrointest Endosc 2002. [PMID: 12297766 DOI: 10.1016/s0016-5107(02)70435-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Before endoscopic mucosal resection and polypectomy of sessile lesions, injection of fluid into the submucosa cushions and isolates the tissue and thereby reduces thermal injury and the risk for perforation and hemorrhage. This study investigated the performance of 5 different solutions when used to form submucosal fluid cushions in the porcine esophagus. METHODS Five groups of 5 pigs were studied. In each pig, 6 separate submucosal injections of 5 mL of a single test solution were performed within the distal third of the esophagus. The time required for the submucosal bleb to flatten completely was recorded after each injection. The solutions used were as follows: normal saline solution, normal saline plus epinephrine solution, 50% dextrose, 10% glycerine/5% fructose in normal saline solution, and 1% rooster comb hyaluronic acid. RESULTS The normal saline solution and normal saline plus epinephrine solutions had the shortest disappearance times (respectively, median 2.4 and 3.0 minutes), which were significantly shorter compared with the other test solutions. The mean disappearance times for 50% dextrose and 10% glycerine were, respectively, 4.7 and 4.2 minutes. The mean disappearance time for hyaluronic acid was 22.1 minutes. CONCLUSIONS A solution of hyaluronic acid appears to be ideal for producing a lasting submucosal cushion for prolonged procedures. Dextrose 50% is superior to normal saline solution and may serve as an alternative to hyaluronic acid in terms of availability and cost.
Collapse
Affiliation(s)
- Massimo Conio
- Developmental Endoscopy Unit, Center for Endoscopic Research and Development, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | | | | | | | |
Collapse
|
|
29
|
Heneghan MA, Byrne A, Harrison PM. An open pilot study of the effects of a human fibrin glue for endoscopic treatment of patients with acute bleeding from gastric varices. Gastrointest Endosc 2002; 56:422-6. [PMID: 12196788 DOI: 10.1016/s0016-5107(02)70054-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Optimal treatment for gastric variceal bleeding remains to be determined. The use of conventional sclerosing agents is associated with high rates of recurrent bleeding. Other agents, such as cyanoacrylate, have significant complication rates and can damage endoscopic equipment. The risk of prior-associated disease has caused concern regarding the use of bovine thrombin. METHODS Beriplast-P (human thrombin) forms a fibrin clot at the needle tip immediately upon injection through a double lumen needle. In 10 patients with gastric variceal bleeding, a median dose of 6 mL of Beriplast-P was injected into gastric varices. OBSERVATIONS Immediate hemostasis was achieved in 7 of 10 patients (70%) with a single injection. At a median follow-up of 8 months, there was no recorded episode of recurrent bleeding from gastric varices. CONCLUSIONS These results suggest that Beriplast-P is useful in the treatment of gastric variceal bleeding. Refinements in the design of the injection needle may improve the efficacy of this novel therapy.
Collapse
Affiliation(s)
- Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SF5 9PJ, England
| | | | | |
Collapse
|
|
30
|
Abstract
Gastric varices and portal hypertensive gastropathy (PHG) are an important complication of both generalized and segmental portal hypertension. The natural history and risk factors for bleed from GV are not extensively studied as that for esophageal varices. Recently, effective therapy for gastric variceal bleed in form of tissue adhesives, balloon-occluded retrograde transvenous obliteration of gastric varices (BRTO) has been developed. Further advances are still needed regarding natural history, risk factors, bleeding, and mechanism of GV rupture.
Collapse
Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India.
| | | |
Collapse
|
|
31
|
Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, Lien HC, Yang SS. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000; 52:160-7. [PMID: 10922085 DOI: 10.1067/mge.2000.104976] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The long-term efficacy and safety of the endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated to define its role as the initial treatment for bleeding gastric varices. METHODS Ninety patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis within a 6-year period. Histoacryl was injected intravariceally as a 1:1 mixture with Lipiodol. Among the 90 patients, 5 had active bleeding and 85 had recent bleeding. Most of the varices were large (F2 or F3, 85 cases). The most common locations were the fundus and the posterior wall of the proximal body (94.4%). After Histoacryl injection, patients were followed endoscopically with retreatment as necessary. RESULTS The rate of hemostasis at 1 week was 94.4%. Recurrent bleeding occurred in 23.3% of the patients from 3 days to 16 months after the initial injection. Recurrent bleeding was stopped with reinjections of Histoacryl in 16.7% of the patients. The rate of definitive hemostasis was 93.3% (84 of 90). The treatment failure-related mortality rate was 2.2% (2 of 90). To date, 35 patients have died, mostly as a result of malignancy or liver failure, and 55 are still alive. The determining factor for long-term survival was the underlying disease leading to portal hypertension. There were few long-term complications except for Histoacryl cast extrusion-related mucosal defects. CONCLUSIONS Endoscopic injection of Histoacryl is highly effective for the treatment of bleeding gastric varices, with rare complications both acutely and long term. This treatment modality is appropriate as the first choice for bleeding gastric varices.
Collapse
Affiliation(s)
- Y H Huang
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, and National Yang-Ming University, Taipei, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
|
32
|
Bohnacker S, Sriram PV, Soehendra N. The role of endoscopic therapy in the treatment of bleeding varices. Best Pract Res Clin Gastroenterol 2000; 14:477-94. [PMID: 10952810 DOI: 10.1053/bega.2000.0092] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.
Collapse
Affiliation(s)
- S Bohnacker
- Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany
| | | | | |
Collapse
|
|
33
|
de Franchis R, Primignani M. Endoscopic treatments for portal hypertension. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1997; 11:289-309. [PMID: 9395749 DOI: 10.1016/s0950-3528(97)90041-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Endoscopic treatments for bleeding gastro-oesophageal varices include injection sclerotherapy, variceal obturation with tissue adhesives and variceal rubber band ligation. Today, endoscopic treatments are not recommended for the primary prophylaxis of variceal bleeding. Acute injection sclerotherapy remains a quick and simple technique for the control of active bleeding from oesophageal varices. Its efficacy may be improved by the early administration of vasoactive drugs. Banding ligation is the optimal endoscopic treatment for the prevention of rebleeding from oesophageal varices. The use of tissue adhesives and thrombin as injectates to treat bleeding fundal gastric varices and oesophageal varices not responding to vasoactive drugs or sclerotherapy is promising but needs further assessment by means of randomized controlled trials.
Collapse
Affiliation(s)
- R de Franchis
- Gastroenterology and Gastrointestinal Endoscopy Service, Istituto di Medicina Interna, University of Milan, Italy
| | | |
Collapse
|