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Trikudanathan G, Rahimi EF, Bhatt A, Bucobo JC, Chandrasekhara V, Copland AP, Han S, Kahn A, Krishnan K, Kumta NA, Lichtenstein DR, Obando JV, Pannala R, Parsi MA, Saumoy M, Trindade AJ, Yang J, Law RJ. Endoscopic devices and techniques for the management of gastric varices (with videos). Gastrointest Endosc 2025; 101:496-510. [PMID: 39480369 DOI: 10.1016/j.gie.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 01/05/2025]
Abstract
BACKGROUND AND AIMS Gastric variceal bleeding occurs less commonly than bleeding from esophageal varices (EVs), although it is associated with higher morbidity and mortality. Bleeding from gastroesophageal varices type 1 (GOV1) is treated like EVs. In contrast, other forms of gastric variceal bleeding, including gastroesophageal varices type 2 (GOV2) and isolated gastric varices types 1 (IGV1) and 2 (IGV2), are treated with varying endoscopic approaches. Nonendoscopic methods include transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO). This technology report focuses on endoscopic management of gastric varices (GVs). METHODS The MEDLINE database was searched through August 2022 for relevant articles by using key words such as gastric varices, glue, cyanoacrylate, thrombin, sclerosing agents, band ligation, topical hemostatic spray, coils, EUS, TIPS, and BRTO. The article was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee and approved by the Governing Board of the ASGE. RESULTS Endoscopic injection with cyanoacrylate (CYA) glue has been the primary endoscopic method to treat GVs. EUS-guided angiotherapy with CYA glue and coil embolization has emerged as an alternative method enabling improved detection of GVs with a high technical success for targeting and obliterating GVs. Combining CYA glue with coil therapy allows the coil to act as a scaffold for the glue, reducing the risk of glue embolization and improving outcomes. Alternative injectates or topical treatments have been described but remain poorly studied. CONCLUSIONS The mainstay paradigm for the endoscopic management of gastric variceal bleeding is the injection of CYA glue. The published success of EUS-guided angiotherapy using CYA glue with or without embolization coils has increased our treatment armamentarium.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erik F Rahimi
- Department of Gastroenterology, Baylor Scott & White Health, Lakeway, Texas, USA
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Carlos Bucobo
- Gastroenterology Services, Northwell Health Gastroenterology Institute, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health Systems, Charlottesville, Virginia, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allon Kahn
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jorge V Obando
- Division of Gastroenterology, Duke University Health System, Raleigh, North Carolina, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Monica Saumoy
- Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Diehl DL. The four pillars of endohepatology. J Can Assoc Gastroenterol 2025; 8:S56-S61. [PMID: 39990516 PMCID: PMC11842896 DOI: 10.1093/jcag/gwae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2025] Open
Abstract
Over the past several years, there has been increasing interaction between Hepatology and Endoscopy, mainly facilitated by EUS-guided modalities. There are 4 main areas that have led to the emergence of what has been called "Endohepatology". The first is EUS-guided parenchymal liver biopsy (EUS-LB). An optimal technique EUS-LB has been developed using a 19G EUS fine needle biopsy needle with "wet suction." There are several advantages to EUS-LB. Another component of Endohepatology is the ability to directly measuring portal pressure gradient (PPG) under EUS guidance. A 25G needle can be inserted directly into branches of the hepatic vein and portal vein to measure PPG. Although this technique requires a sedated endoscopic procedure, it is technically easier and better tolerated than the traditional transjugular approach and is very safe. Newer techniques of endoscopic management of gastric varices using EUS-guided injection of glues and coils is another driver of Endohepatology. EUS-guided glue injection is safer than direct endoscopic injection, and the use of coils decreases the incidence of glue embolization. The fourth pillar is expanded use of EUS-guided gallbladder drainage (EUS-GB) with lumen apposing metal stents. This is beginning to revolutionize management of gallbladder disease in cirrhotic patients who are poor candidates for cholecystectomy. Endohepatology will grow as these 4 main applications become more widespread and Hepatologists become more comfortable with the role of Endohepatology in patient management.
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Affiliation(s)
- David L Diehl
- Geisinger Commonwealth School of Medicine, Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, United States
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Amalou K, Rekab R, Belloula A, Saidani K. Endoscopic ultrasound-guided treatment of isolated gastric varices. World J Gastrointest Endosc 2025; 17:100556. [PMID: 39989860 PMCID: PMC11843042 DOI: 10.4253/wjge.v17.i2.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 12/31/2024] [Accepted: 01/21/2025] [Indexed: 02/13/2025] Open
Abstract
In this letter we comment on the article by Zhang et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2024. We focus specifically on the management of gastric varices (GV), which is a significant consequence of portal hypertension, is currently advised to include beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt for secondary prophylaxis or active bleeding. Although it has been studied, direct endoscopic injection of cyanoacrylate glue has limitations, such as the inability to fully characterize GV endoscopically and the potential for distant glue embolism. In order to achieve this, endoscopic ultrasound has been used to support GV characterization, real-time therapy imaging, and Doppler obliteration verification.
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Affiliation(s)
- Khellaf Amalou
- Department of Gastroenterology, Mohamed Seghir Nekkache, Algiers 16000, Algeria
| | - Ryma Rekab
- Department of Gastroenterology, Mohamed Seghir Nekkache, Algiers 16000, Algeria
| | - Ahlem Belloula
- Department of Gastroenterology, Mohamed Seghir Nekkache, Algiers 16000, Algeria
| | - Khadidja Saidani
- Department of Gastroenterology, Mohamed Seghir Nekkache, Algiers 16000, Algeria
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Manolakis A, Tsagkidou K, Koumarelas KE. Endoscopic ultrasound-guided therapies in the treatment of gastric varices: An in-depth examination of associated adverse events. World J Gastrointest Endosc 2024; 16:640-646. [PMID: 39735397 PMCID: PMC11669960 DOI: 10.4253/wjge.v16.i12.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 10/01/2024] [Accepted: 10/28/2024] [Indexed: 12/12/2024] Open
Abstract
The Baveno VII consensus, released in 2023, recommends that the endoscopic treatment of choice for managing bleeding gastric varices (GV) is endoscopic ultrasound (EUS)-guided treatment, specifically EUS-guided cyanoacrylate (CYA) glue injection. This approach has been endorsed due to its efficacy in controlling bleeding while reducing rebleeding rates, compared to other endoscopic techniques. Despite its efficacy, CYA injection for GV has been linked to rare but serious adverse events, such as glue embolization leading to pulmonary embolism, infection/bacteremia, splenic infarction, intra-procedural and post-procedural complications. The technique for endoscopic obliteration of GV was subsequently refined using EUS guidance, aiming to more accurately direct the injection into the varix, reduce the volume of injected glue, target the perforating vein when possible, and confirm obliteration of GV via Doppler examination.
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Affiliation(s)
- Anastasios Manolakis
- Department of Gastroenterology, University of Thessaly School of Medicine, Larisa 41100, Greece
| | - Kyriaki Tsagkidou
- Department of Gastroenterology, General Hospital of Larisa, Larisa 41221, Greece
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Dragomir I, Pojoga C, Hagiu C, Seicean R, Procopet B, Seicean A. Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy. Gastroenterol Rep (Oxf) 2024; 12:goae082. [PMID: 39281269 PMCID: PMC11398876 DOI: 10.1093/gastro/goae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/23/2024] [Accepted: 06/07/2024] [Indexed: 09/18/2024] Open
Abstract
Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.
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Affiliation(s)
- Irina Dragomir
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Cristina Pojoga
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
- UBB Med, Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj Napoca, Romania
| | - Claudia Hagiu
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Radu Seicean
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- First Surgical Clinic, County Emergency Hospital, Cluj Napoca, Romania
| | - Bogdan Procopet
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Andrada Seicean
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
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Chi XT, Lian TT, Zhuang ZH. Advances in the endoscopic management of gastric varices. Dig Endosc 2024; 36:884-894. [PMID: 38404210 DOI: 10.1111/den.14770] [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: 08/07/2023] [Accepted: 01/25/2024] [Indexed: 02/27/2024]
Abstract
This review provides an overview of the treatment options available for gastric varices (GV) with a focus on endoscopic methods. Various minimally invasive techniques, including endoscopic band ligation, endoscopic cyanoacrylate injection, and transjugular intrahepatic portosystemic shunt, can be applied to the treatment of GV. Endoscopic cyanoacrylate injection is now recognized as a first-line treatment for GV. Endoscopic ultrasound-guided cyanoacrylate injection combined with coils has shown good security and effectiveness. Thrombin injection therapy is a promising treatment, with a similar hemostasis rate to cyanoacrylate injection but with fewer serious complications. With the deepening understanding of the hemodynamics of the GV system, various treatment methods and their combination are gradually evaluated to provide patients with safer and more effective treatment options.
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Affiliation(s)
- Xin-Tong Chi
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ting-Ting Lian
- Endoscopic Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ze-Hao Zhuang
- Department of Gastroenterology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Sarkis Y, Masuoka H, Ghabril M, Gutta A, Al-Haddad MA, Stainko S, Cohen L, Perkins A, DeWitt JM. Comparison of endoscopic ultrasound-guided primary and secondary prophylaxis for gastric variceal bleeding. Dig Endosc 2024; 36:710-718. [PMID: 37886793 DOI: 10.1111/den.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) for primary prophylaxis (PP) of gastric varices (GV) is controversial. This study evaluates the safety and efficacy of this intervention. METHODS Patients treated for PP of GV bleeding by EUS injection of CYA with or without coils were identified. Endoscopic techniques, outcomes, and adverse events (AEs) were reviewed and compared with a group treated for secondary prophylaxis (SP). Patients were followed until: (i) loss to follow-up; (ii) GV bleeding; (iii) interventional radiology or surgery decompression; (iv) liver transplant; or (v) death or comfort care. RESULTS One hundred and nineteen patients (61 men; mean 59 ± 12 years) underwent EUS for PP (n = 24) or SP (n = 95). The PP group was treated with CYA alone (n = 18) or with coils (n = 4). Eight (33%) mild (n = 6) or moderate (n = 2) AEs and no index GV bleeding occurred during a mean of 6.1 ± 5.9 months follow-up. Repeat EUS in 22 (92%) PP patients showed 7 (32%) residual GVs, which were retreated with CYA alone (n = 6) or with coils (n = 1). Two (29%) mild (n = 1) or moderate (n = 1) AEs occurred after repeat EUS and 1/22 (5%) index GV bleed occurred during a mean 23 ± 25 months follow-up. Compared to the SP group, the PP group had lower Model for End-stage Liver Disease (MELD) score (P = 0.03), fewer GV stigmata (P < 0.001), required less CYA (P = 0.019) during index EUS, and had a longer time between index and surveillance EUS (P = 0.014). The incidence of AEs and GV bleeding between the two groups were similar. CONCLUSION Posttreatment GV bleeding and AEs are similar following EUS-guided primary and secondary GV prophylaxis.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Howard Masuoka
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Aditya Gutta
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Lainna Cohen
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Anthony Perkins
- Department of Biostatistics and Health Data Science, Indiana University Health Medical Center, Indianapolis, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
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Gadour E, Awad A, Hassan Z, Shrwani KJ, Miutescu B, Okasha HH. Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis. World J Gastroenterol 2024; 30:742-758. [PMID: 38515947 PMCID: PMC10950627 DOI: 10.3748/wjg.v30.i7.742] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/19/2023] [Accepted: 01/16/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND In hepatology, the clinical use of endoscopic ultrasound (EUS) has experienced a notable increase in recent times. These applications range from the diagnosis to the treatment of various liver diseases. Therefore, this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases. AIM To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy. METHODS PubMed, Medline, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched until October 2023. The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool. In addition, statistical analyses were performed using the Comprehensive Meta-Analysis software. RESULTS Overall, 45 articles on EUS were included (28 on diagnostic role and 17 on therapeutic role). Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4% for focal liver lesions (FLL) and 96.6% for parenchymal liver diseases. EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases (3.1% and 8.7%, respectively). Analysis of data from four studies showed that EUS-guided liver abscess had high clinical (90.7%) and technical success (90.7%) without significant complications. Similarly, EUS-guided interventions for the treatment of gastric varices (GV) have high technical success (98%) and GV obliteration rate (84%) with few complications (15%) and rebleeding events (17%). CONCLUSION EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.
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Affiliation(s)
- Eyad Gadour
- Department of Gastroenterology and Hepatology, King Abdulaziz Hospital-National Guard, Ahsa 31982, Saudi Arabia
- Department of Internal Medicine, Faculty of Medicine, Zamzam University College, Khartoum 11113, Sudan
| | - Abeer Awad
- Department of Hepatogastroenterology, Kasar Alainy Hospital, Faculty of Medicine, Cairo University, Cairo 11451, Egypt
| | - Zeinab Hassan
- Department of Internal Medicine, Stockport Hospitals NHS Foundation Trust, Manchester SK2 7JE, United Kingdom
| | - Khalid Jebril Shrwani
- Public Health Authority, Saudi Center for Disease Prevention and Control, Jazan 45142, Saudi Arabia
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, School of Medicine and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Bogdan Miutescu
- Department of Gastroenterology and Hepatology, Victor Babes University of Medicine and Pharmacy, Timisoara 300041, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, Victor Babes University of Medicine and Pharmacy, Timisoara 30041, Romania
| | - Hussein Hassan Okasha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kasr Al-Aini School of Medicine, Cairo University, Cairo 11562, Egypt
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Wang Z, Zhang F, Zeng Z, Bai Y, Chen L, Shi C, Jin J, Zhang Q, Mei X, Kong D. Application of Indian ink markers for locating gastric varices under endoscopic ultrasonography. Surg Endosc 2024; 38:633-639. [PMID: 38012437 DOI: 10.1007/s00464-023-10532-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The present study aimed to investigate the accuracy of endoscopic ultrasonography (EUS) combined with Indian ink in locating target vessels of gastric varices (GVs) compared with conventional endoscopic techniques. Additionally, the characteristics of GVs under conventional endoscopy were also explored. METHODS All 50 cirrhotic patients with GVs between August 2021 and December 2022 were included in the study. Firstly, conventional endoscopy was employed to identify GVs and to record the expected injection sites. Subsequently, EUS was used to locate the perforated vessel and the injection site was them marked with India ink followed by injection with cyanoacrylate (CYA). Finally, conventional endoscopy was used to examine GVs, to identify the marker points of Indian ink and to compare whether the injection points under conventional endoscopy were consistent with those marked with Indian ink. Furthermore, patients with consistent and inconsistent distribution of endoscopic markers and injection sites were divided into two groups. RESULTS EUS could detect the perforating vessels in real time and intuitively. The distribution of markers using EUS was significantly different compared with the injection points obtained by conventional endoscopy (P < 0.001). Therefore, 20 cases were allocated to the consistent group and 30 cases to the non-consistent group. 16 patients who showed red wale signs were obtained in the consistent group and 11 patients in the non-consistent group (P = 0.048). The diameter of the largest GVs was 13.5 (10-15) mm in the consistent group compared with 10 (7.5-10) mm in the non-consistent group (P = 0.006). CONCLUSION EUS could provide the exact location of GVs, thus more accurately describing the endoscopic characteristics of the GVs. Furthermore, the red wale signs and diameter of the largest GVs obtained using conventional endoscopy were helpful in determining the location of target GVs.
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Affiliation(s)
- Zhihong Wang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Yuchuan Bai
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
| | - Derun Kong
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
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Bazarbashi AN, Aby ES, Mallery JS, El Chafic AH, Wang TJ, Kouanda A, Arain M, Lew D, Gaddam S, Mulki R, Kabir Baig KK, Satyavada S, Chak A, Faulx A, Glessing B, Evans G, Schulman AR, Haddad J, Tielleman T, Hollander T, Kushnir V, Shah J, Ryou M. EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video). Gastrointest Endosc 2024; 99:31-37. [PMID: 37532106 DOI: 10.1016/j.gie.2023.07.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 07/06/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND AND AIMS Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. METHODS This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. RESULTS A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. CONCLUSIONS This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.
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Affiliation(s)
- Ahmad Najdat Bazarbashi
- Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine/Barnes Jewish Hospital, St. Louis, Missouri, USA.
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - J Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | | | - Thomas J Wang
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Abdul Kouanda
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Mustafa Arain
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Kondal Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Sagarika Satyavada
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ashley Faulx
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Brooke Glessing
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gretchen Evans
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - James Haddad
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas, USA
| | - Thomas Tielleman
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas, USA
| | - Thomas Hollander
- Division of Gastroenterology and Hepatology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Vladimir Kushnir
- Division of Gastroenterology and Hepatology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Janak Shah
- Division of Gastroenterology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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12
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Lesmana CRA. Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management. Artif Intell Gastrointest Endosc 2023; 4:12-17. [DOI: 10.37126/aige.v4.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/14/2023] [Accepted: 12/04/2023] [Indexed: 12/07/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta 12950, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta 12930, Indonesia
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13
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Wang Z, Zeng Z, Chen L, Shi C, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Endoscopic ultrasonography-guided injection of cyanoacrylate in the treatment of gastroesophageal varices type 1: a single-center randomized study. Surg Endosc 2023; 37:8277-8284. [PMID: 37674054 DOI: 10.1007/s00464-023-10342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND AIM First, it has been demonstrated that endoscopic ultrasonography (EUS)-guided cyanoacrylate (CYA) injection (EUS-CYA) has greater efficacy than direct endoscopic injection of cyanoacrylate (DEI-CYA) for treating type 1-isolated gastric varices. However, it is necessary to conduct further studies to determine whether EUS has any advantage over the current guidelines for treating gastroesophageal varices type 1 (GOV1). Second, liver function is an important prognostic factor in patients with liver cirrhosis. Therefore, we evaluated the liver function of patients treated with EUS-CYA. METHODS In a single-center study, a prospective cohort from February 2021 to September 2022 involving 89 patients with cirrhosis with GOV1 were assigned to undergo EUS-CYA (n = 45) or DEI-CYA (n = 44). The success rate of CYA injection, the rate of overall rebleeding, the rate of reintervention, the complications during the follow-up period, and the liver function were compared. RESULTS In both groups, 100% of the operations were successful. The follow-up time of the two groups was 290 (153-398) days and 267 (177-416) days, respectively. In the EUS group, the perforating veins had an average diameter of 7.0 ± 2.7 mm, and they had a 100% occlusion rate. A statistically significant difference was found between the two groups regarding the number of sessions needed to eradicate GV (p = 0.005, pairwise comparisons were conducted using the Bonferroni correction method.), the late rebleeding rate after EUS-CYA [n = 3 (6.7%) vs n = 10 (22.7%); p = 0.032], and the incidence of postinjection ulcers [n = 4 (8.9%) vs n = 12 (27.3); p = 0.023)]. Following EUS or DEI-CYA treatment, the patient's liver function did not show any significant deterioration or decline. CONCLUSION EUS-CYA has a higher eradication success rate and fewer complications, recurrences, and rebleeding episodes than DEI-CYA used for GOV1 treatment. In addition, EUS-CYA did not impair liver function.
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Affiliation(s)
- Zhihong Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China.
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14
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Iqbal Janjua F, Ahmad M, Javed S, Zia MQ, Abbas G, Aslam N, Farooq K, Shafqat MN. Endoscopic Therapy of Gastric Varices: Safety and Efficacy of N-Butyl-2-Cyanoacrylate Injection. Cureus 2023; 15:e49539. [PMID: 38156146 PMCID: PMC10753266 DOI: 10.7759/cureus.49539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Background Upper gastrointestinal bleeding (UGIB) is a common medical emergency that results in significant morbidity, mortality, and socioeconomic burden. Both types of cardio-fundal varices, gastro-esophageal varix 2 (GOV2) and isolated gastric varices type 1 (IGV1), can cause massive bleeding and often are difficult to treat compared to the other types of gastric varices. Endoscopic variceal band ligation (EVBL) is a less effective treatment modality for gastric varices than esophageal varices and is associated with high re-bleeding rates. N-butyl-2-cyanoacrylate (Histoacryl) injection is an effective and potential treatment option for fundal varices. This study aims to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate injection therapy in cardio-fundal varices. Objective To assess the efficacy and safety of n-butyl-2-cyanoacrylate injection therapy for fundal varices. Methods This retrospective observational cohort study was conducted at the Department of Gastroenterology, Allied Teaching Hospital, Gujranwala, over one year. All patients, irrespective of age and gender, presenting with UGIB and in whom fundal varices were diagnosed on gastroscopy followed by n-butyl 2-cyanoacrylate injection therapy were included in this study. The efficacy and safety of Histoacryl therapy were assessed by analyzing successful hemostasis, frequency of re-bleeding, obliteration, and regression of fundal varices on repeat endoscopy. Adverse events such as re-bleeding and mortality related to fundal variceal treatment were documented. Results A total of 60 patients were included in the study. Of these, 70% had IGV1, while the remaining 30% had GOV2. Hemostasis was achieved in 100% of patients following n-butyl-2-cyanoacrylate injection. Successful obliteration with regression of varices was observed in 91.3% of patients. Various adverse events were observed, with abdominal pain being the most common observed complication in 18.3% of participants. However, only 8.3% of participants developed re-bleeding due to ulcer formation at the injection site, and no death occurred directly due to fundal variceal treatment. Conclusion N-butyl-2-cyanoacrylate injection therapy is a lifesaving, effective, and safe intervention for controlling bleeding from cardio-fundal varices, leading to improved health status and a consequent decrease in episodes of recurrent bleeding. Its side effects are few and infrequent. However, larger-scale studies are needed to further evaluate the safety and effectiveness of n-butyl-2-cyanoacrylate injection therapy. These studies will be crucial in establishing comprehensive guidelines for the management of fundal varices.
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Affiliation(s)
- Fawad Iqbal Janjua
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
| | - Mahmood Ahmad
- Department of Gastroenterology and Hepatology, Amna Inayat Medical College, Lahore, PAK
| | - Salman Javed
- Department of Gastroenterology and Hepatology, Services Institute of Medical Sciences, Lahore, PAK
| | - Muhammad Qasim Zia
- Department of Gastroenterology and Hepatology, Khawaja Muhammad Safdar Medical College, Sialkot, PAK
| | - Ghulam Abbas
- Department of Gastroenterology and Hepatology, Allama Iqbal Medical College, Lahore, PAK
| | - Naveed Aslam
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
| | - Kamran Farooq
- Department of Gastroenterology and Hepatology, Sheikh Khalifa Medical City, Abu Dhabi, ARE
| | - Muhammad Nabeel Shafqat
- Department of Gastroenterology and Hepatology, Allied Teaching Hospital, Gujranwala, Gujranwala, PAK
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15
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Laleman W, Mertens J, Vanderschueren E, Praktiknjo M, Trebicka J. Advances in Endohepatology. Am J Gastroenterol 2023; 118:1756-1767. [PMID: 37610016 DOI: 10.14309/ajg.0000000000002482] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Joachim Mertens
- Department of Gastroenterology & Hepatology, Klinik Hirslanden, Zurich, Switzerland
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Michael Praktiknjo
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
- European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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16
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Zhang M, Mou H, Wang G, Li P, Kong D, Li S, Feng Q, Sun R, Yan J, Huang G, Shi Y, Tuo B, Zhang C. Clinical outcomes of clip-assisted endoscopic cyanoacrylate injection versus conventional endoscopic cyanoacrylate injection in treating gastric varices with a gastrorenal shunt. Scand J Gastroenterol 2023; 58:1173-1179. [PMID: 37128690 DOI: 10.1080/00365521.2023.2204388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND AND STUDY AIMS The optimal treatment for gastric varices (GVs) is a topic that remains definite for this study. This study compared the clinical outcomes of clip-assisted endoscopic cyanoacrylate injection (clip-ECI) to conventional endoscopic cyanoacrylate injection (con-ECI) for the treatment of GVs with a gastrorenal shunt. PATIENTS AND METHODS Data were collected retrospectively in five medical centers from 2015 to 2020. The patients were treated with con-ECI (n = 126) or clip-ECI (n = 148). Clinical characteristics and procedural outcomes were compared. Patients were followed until death, liver transplantation or 6 months after the treatment. The primary outcome was rebleeding, and the secondary outcome was survival. RESULTS There were no significant differences in age, sex, etiology, shunt diameter and Child-Pugh classification between the two groups. Fewer GVs obliteration sessions were required in the clip-ECI group than in the con-ECI group (p = 0.015). The cumulative 6-month rebleeding-free rates were 88.6% in the clip-ECI group and 73.7% in the con-ECI group (p = 0.002). The cumulative 6-month survival rates were 97.1% in the clip-ECI group and 94.8% in the con-ECI group (p = 0.378). CONCLUSIONS Compared with con-ECI, clip-ECI appears more effective for the treatment of GVs with a gastrorenal shunt, which required less sessions and achieved a higher 6-month rebleeding-free rate.
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Affiliation(s)
- Mingyan Zhang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Haijun Mou
- Department of Gastroenterology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Guangchuan Wang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ping Li
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Derun Kong
- Department of Gastroenterology, Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Senlin Li
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Qian Feng
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Ruonan Sun
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jinming Yan
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guangjun Huang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yongjun Shi
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Biguang Tuo
- Department of Gastroenterology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Chunqing Zhang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital, Shandong University, Jinan, China
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Ryou M, DeWitt JM, Das KK, Shami VM. AGA Clinical Practice Update on Interventional EUS for Vascular Investigation and Therapy: Commentary. Clin Gastroenterol Hepatol 2023; 21:1699-1705.e2. [PMID: 37162434 DOI: 10.1016/j.cgh.2023.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 05/11/2023]
Abstract
DESCRIPTION The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies. METHODS This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.
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Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health, Indianapolis, Indiana
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, Virginia
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18
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Radlinski MJ, Strand DS, Shami VM. Evolution of interventional endoscopic ultrasound. Gastroenterol Rep (Oxf) 2023; 11:goad038. [PMID: 37398926 PMCID: PMC10313421 DOI: 10.1093/gastro/goad038] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.
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Affiliation(s)
- Mark J Radlinski
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Corresponding author. Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA. Tel: +1-434-989-4381;
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19
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Vanderschueren E, Trebicka J, Laleman W. Endoscopic Advances in Hepatology. Semin Liver Dis 2023; 43:176-188. [PMID: 37192654 DOI: 10.1055/s-0043-1769009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Endoscopy is and remains an indispensable tool in diagnosing and managing liver disease and its complications. Due to the progress in advanced endoscopy, endoscopy has become an alternative route for many surgical, percutaneous, and angiographic interventions, not only as a backup tool when conventional interventions fail but increasingly as a first-line choice. The term endo-hepatology refers to the integration of advanced endoscopy in the practice of hepatology. Endoscopy is key in the diagnosis and management of esophageal and gastric varices, portal hypertensive gastropathy, and gastric antral vascular ectasia. Endoscopic ultrasound (EUS) can be used for the evaluation of the liver parenchyma, liver lesions, and surrounding tissues and vessels, including targeted biopsy and complemented with new software functions. Moreover, EUS can guide portal pressure gradient measurement, and assess and help manage complications of portal hypertension. It is crucial that each present-day hepatologist is aware of the (rapidly increasing) full spectrum of diagnostic and therapeutic tools that exist within this field. In this comprehensive review, we would like to discuss the current endo-hepatology spectrum, as well as future directions for endoscopy in hepatology.
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Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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21
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Zeng HT, Zhang ZL, Lin XM, Peng MS, Wang LS, Xu ZL. Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy. World J Gastrointest Endosc 2023; 15:153-162. [PMID: 37034972 PMCID: PMC10080557 DOI: 10.4253/wjge.v15.i3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/26/2022] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Esophageal-gastro varices bleeding (EGVB) is the most widely known cause of mortality in individuals with cirrhosis, with an occurrence rate of 5% to 15%. Among them, gastric varices bleeding (GVB) is less frequent than esophageal varices bleeding (EVB), but the former is a more critical illness and has a higher mortality rate. At present, endoscopic variceal histoacryl injection therapy (EVHT) is safe and effective, and it has been recommended by relevant guidelines as the primary method for the treatment of GVB. However, gastric varices after endoscopic treatment still have a high rate of early rebleeding, which is mainly related to complications of its treatment, such as bleeding from drained ulcers, rebleeding of varices etc. Therefore, preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes. AIM To assess the efficacy of aluminium phosphate gel (APG) combined with proton pump inhibitor (PPI) in preventing early rebleeding after EVHT in individuals with GVB. METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021. Based on the selection criteria, 101 patients were sorted into the PPI alone treatment group, and 95 patients were sorted into the PPI combined with the APG treatment group. The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups. Statistical methods were performed by two-sample t-test, Wilcoxon rank sum test and χ 2 test. RESULTS No major variations were noted between the individuals of the two groups in terms of age, gender, Model for End-Stage Liver Disease score, coagulation function, serum albumin, hemoglobin, type of gastric varices, the dose of tissue glue injection and EV that needed to be treated simultaneously. The early rebleeding rate in PPI + APG group was 3.16% (3/95), which was much lower than that in the PPI group (12.87%, 13/101) (P = 0.013). Causes of early rebleeding: the incidence of gastric ulcer bleeding in the PPI + APG group was 2.11% (2/95), which was reduced in comparison to that in the PPI group (11.88%, 12/101) (P = 0.008); the incidence of venous bleeding in PPI + APG group and PPI group was 1. 05% (1/95) and 0.99% (1/101), respectively, and there was no significant difference between them (0.999). The early mortality rate was 0 in both groups within 6 wk after the operation, and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding. The overall incidence of complications in the PPI + APG group was 12.63% (12/95), which was not significantly different from 13.86% (14/101) in the PPI group (P = 0.800). of abdominal pain in the PPI + APG group was 3.16% (3/95), which was lower than that in the PPI group (11.88%, 12/101) (P = 0.022). However, due to aluminum phosphate gel usage, the incidence of constipation in the PPI + APG group was 9.47% (9/95), which was higher than that in the PPI group (1.98%, 2/101) (P = 0.023), but the health of the patients could be improved by increasing drinking water or oral lactulose. No patients in either group developed spontaneous peritonitis after taking PPI, and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment. CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.
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Affiliation(s)
- Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zhu-Liang Zhang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Min-Si Peng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
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Alqahtani SA, Ausloos F, Park JS, Jang S. The Role of Endoscopic Ultrasound in Hepatology. Gut Liver 2023; 17:204-216. [PMID: 36457262 PMCID: PMC10018300 DOI: 10.5009/gnl220071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/19/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022] Open
Abstract
Endoscopic ultrasound (EUS) has been an indispensable and widely used diagnostic tool in several medical fields, including gastroenterology, cardiology, and urology, due to its diverse therapeutic and diagnostic applications. Many studies show that it is effective and safe in patients with liver conditions where conventional endoscopy or cross-sectional imaging are inefficient or when surgical interventions pose high risks. In this article, we present a review of the current literature for the different diagnostic and therapeutic applications of EUS in liver diseases and their complications and discuss the potential future application of artificial intelligence analysis of EUS.
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Affiliation(s)
- Saleh A Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA.,Liver Transplant Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Floriane Ausloos
- Department of Gastroenterology and Hepatology, CHU Liège, Sart-Tilman, Liège, Belgium
| | - Ji Seok Park
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Pallio S, Melita G, Shahini E, Vitello A, Sinagra E, Lattanzi B, Facciorusso A, Ramai D, Maida M. Diagnosis and Management of Esophagogastric Varices. Diagnostics (Basel) 2023; 13:1031. [PMID: 36980343 PMCID: PMC10047815 DOI: 10.3390/diagnostics13061031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.
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Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy;
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology “S. de Bellis” Research Hospital, Castellana Grotte, 70013 Bari, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Instituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital, 00100 Rome, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
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24
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Vashishtha C, Sarin SK. Management of Gastric and Ectopic Varices. CURRENT HEPATOLOGY REPORTS 2023. [DOI: 10.1007/s11901-023-00597-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/04/2025]
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Sabry F, Seif S, Eldesoky A, Hakim H, Altonbary AY. EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices. Endosc Int Open 2023; 11:E202-E210. [PMID: 36845270 PMCID: PMC9949986 DOI: 10.1055/a-1984-7070] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.
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Affiliation(s)
- Fady Sabry
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Seham Seif
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ayman Eldesoky
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Hazem Hakim
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ahmed Youssef Altonbary
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
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Huang Z, Zhang W, Lv F, Ma L, Xiao Y, Gao S, Zhang M, Wang Y, Li P, Zhao H, Yu H, Cao J, Ke G, Wang Y, Chen M. Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study. Endosc Ultrasound 2023; 12:74-83. [PMID: 36510863 PMCID: PMC10134943 DOI: 10.4103/eus-d-21-00260] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Gastric varices (GV) with spontaneous portosystemic shunt (SPSS) are associated with ectopic embolism in endoscopic cyanoacrylate. This study targeted to assess the efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration (BRTO) for GV with high-risk ectopic embolism. MATERIALS AND METHODS We retrospectively analyzed six tertiary hospitals' 104 patients with GV at high-risk ectopic embolism (the narrowest diameter of SPSS was greater than or equal to 5 mm and the maximum diameter usually >8 mm) who underwent EUS-guided coil embolization combined with endoscopic cyanoacrylate injection or BRTO from January 2014 to December 2020. The outcomes included rebleeding, survival, and complications. RESULTS The EUS group and BRTO group contained 59 and 45 patients, respectively. The technical success rate between the two groups was similar (96.6% vs. 95.6%, P = 1.000). During the follow-up, both groups' 5-day rebleeding rate and 6-week mortality rate were 0%. One-year all-cause rebleeding rate (20.0% vs. 18.9%, P = 0.900) and 1-year mortality rate (2.0% vs. 0%, P = 1.000) in the EUS group were similar to the BRTO group. One patient experienced ectopic embolism in the EUS group, while the BRTO group did not. Both groups had similar mean days (16.0 [interquartile range (IQR), 12.0-19.0] vs. 16.5 [IQR, 11.8-26.0], P = 0.165) and cost of hospitalization (¥ 45950.6 [IQR, 39330.2-55768.2] vs. ¥ 51205.8 [IQR, 31628.8-74251.5], P = 0.680). Multivariate analysis showed that the narrowest diameter of the shunt (odds ratio [OR] = 1.86; 95% confidence interval [CI]: 1.062-3.258; P = 0.03) and content of hemoglobin (OR = 0.941; 95% CI: 0.892-0.992; P = 0.025) were the prognostic factors for survival. CONCLUSIONS The efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection for GV with high-risk ectopic embolism are comparable to BRTO.
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Affiliation(s)
- Ziyin Huang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Wenhui Zhang
- Department of Digestive System, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Fujing Lv
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lili Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Xiao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Shan Gao
- Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Ming Zhang
- Department of Gastroenterology, Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yanling Wang
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Li
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haiying Zhao
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Honggang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Jiwang Cao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Ge Ke
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Yang Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Mingkai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
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Jamwal KD, Padhan RK, Sharma A, Sharma MK. Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study. Clin Endosc 2023; 56:65-74. [PMID: 36594180 PMCID: PMC9902678 DOI: 10.5946/ce.2021.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/AIMS Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. METHODS A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. RESULTS In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. CONCLUSION EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.
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Affiliation(s)
- Kapil D. Jamwal
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India,Institute of Liver and Biliary Sciences, New Delhi, India,Correspondence: Kapil D. Jamwal Department of Gastroenterology, Artemis Hospitals, Sector 51, Gurugram, Haryana 122001, India E-mail:
| | - Rajesh K. Padhan
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
| | - Atul Sharma
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
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Hotta R, Pan W, Bhave S, Nagy N, Stavely R, Ohkura T, Krishnan K, de Couto G, Myers R, Rodriguez-Borlado L, Burns AJ, Goldstein AM. Isolation, Expansion, and Endoscopic Delivery of Autologous Enteric Neuronal Stem Cells in Swine. Cell Transplant 2023; 32:9636897231215233. [PMID: 38049927 PMCID: PMC10697035 DOI: 10.1177/09636897231215233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 12/06/2023] Open
Abstract
The enteric nervous system (ENS) is an extensive network of neurons and glia within the wall of the gastrointestinal (GI) tract that regulates many essential GI functions. Consequently, disorders of the ENS due to developmental defects, inflammation, infection, or age-associated neurodegeneration lead to serious neurointestinal diseases. Despite the prevalence and severity of these diseases, effective treatments are lacking as they fail to directly address the underlying pathology. Neuronal stem cell therapy represents a promising approach to treating diseases of the ENS by replacing the absent or injured neurons, and an autologous source of stem cells would be optimal by obviating the need for immunosuppression. We utilized the swine model to address key questions concerning cell isolation, delivery, engraftment, and fate in a large animal relevant to human therapy. We successfully isolated neural stem cells from a segment of small intestine resected from 1-month-old swine. Enteric neuronal stem cells (ENSCs) were expanded as neurospheres that grew optimally in low-oxygen (5%) culture conditions. Enteric neuronal stem cells were labeled by lentiviral green fluorescent protein (GFP) transduction, then transplanted into the same swine from which they had been harvested. Endoscopic ultrasound was then utilized to deliver the ENSCs (10,000-30,000 neurospheres per animal) into the rectal wall. At 10 and 28 days following injection, autologously derived ENSCs were found to have engrafted within rectal wall, with neuroglial differentiation and no evidence of ectopic spreading. These findings strongly support the feasibility of autologous cell isolation and delivery using a clinically useful and minimally invasive technique, bringing us closer to first-in-human ENSC therapy for neurointestinal diseases.
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Affiliation(s)
- Ryo Hotta
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Weikang Pan
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sukhada Bhave
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nandor Nagy
- Department of Anatomy, Histology and Embryology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Rhian Stavely
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Takahiro Ohkura
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Geoffrey de Couto
- Gastrointestinal Drug Discovery Unit, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Richard Myers
- Gastrointestinal Drug Discovery Unit, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Luis Rodriguez-Borlado
- Gastrointestinal Drug Discovery Unit, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Alan J. Burns
- Gastrointestinal Drug Discovery Unit, Takeda Development Center Americas, Inc., Cambridge, MA, USA
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Allan M. Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
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Yang J, Zeng Y, Zhang JW. Endoscopic ultrasound-guided diagnosis and treatment of gastric varices. World J Gastrointest Endosc 2022; 14:748-758. [PMID: 36567822 PMCID: PMC9782569 DOI: 10.4253/wjge.v14.i12.748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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30
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Singh AD, Bazarbashi AN, Lindenmeyer CC. Endo-hepatology: The changing paradigm of endoscopic ultrasound in cirrhosis. Clin Liver Dis (Hoboken) 2022; 20:209-215. [PMID: 36523865 PMCID: PMC9745261 DOI: 10.1002/cld.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
| | - Ahmad Najdat Bazarbashi
- Division of GastroenterologyWashington University in St. Louis/Barnes Jewish HospitalSt. LouisMissouriUSA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology, Hepatology and NutritionDigestive Disease and Surgery institute, Cleveland ClinicClevelandOhioUSA
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Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Ендоваскулярне лікування варикозно розширених вен шлунка під контролем ендосонографії. EMERGENCY MEDICINE 2022; 18:39-47. [DOI: 10.22141/2224-0586.18.6.2022.1519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Шлункова варикозна кровотеча супроводжується високою летальністю. Ендоскопічна ін’єкція ціаноакрилату є стандартною терапією, однак рецидивна кровотеча та побічні ефекти, такі як виразки в місці ін’єкції та дистальна емболія, є підводним каменем цієї терапії. Ендоскопічне лікування варикозного розширення вен шлунка під ендосонографічним контролем має кілька можливих переваг перед сучасними методами лікування. Воно дозволяє детально оцінити анатомію судин, подібну ефективність і безпеку поточних методів лікування, а також дає змогу оцінити ефект лікування за допомогою ультразвукової допплерівської візуалізації. Ми розглядаємо методи лікування варикозного розширення вен шлунка, включаючи ендоскопічну ін’єкцію ціаноакрилату та спіралей під контролем ендосонографії, окремо або в комбінації, ін’єкцію тромбіну та желатинової губки, що розсмоктується. Відповідний відбір пацієнтів для цих процедур має першорядне значення для забезпечення отримання корисних клінічних даних і безпеки пацієнтів. Ми шукали літературу в базі даних MedLine на платформі PubMed.
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Jearth V, Sundaram S, Rana SS. Diagnostic and interventional EUS in hepatology: An updated review. Endosc Ultrasound 2022; 11:355-370. [PMID: 36255023 PMCID: PMC9688142 DOI: 10.4103/eus-d-22-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.
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Affiliation(s)
- Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence Prof. Surinder Singh Rana, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
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Téllez-Ávila FI, García-Saenz-de-Sicilia M. Endohepatology: current status and perspectives. Ann Hepatol 2022; 27:100730. [PMID: 35786448 DOI: 10.1016/j.aohep.2022.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Félix I Téllez-Ávila
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, United States
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Luo X, Hernández-Gea V. Update on the management of gastric varices. Liver Int 2022; 42:1250-1258. [PMID: 35129288 DOI: 10.1111/liv.15181] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/13/2023]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.
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Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, CIBEREHD, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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Abstract
Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.
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Rodge GA, Goenka U, Goenka MK. Management of Refractory Variceal Bleed in Cirrhosis. J Clin Exp Hepatol 2022; 12:595-602. [PMID: 35535060 PMCID: PMC9077219 DOI: 10.1016/j.jceh.2021.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/28/2021] [Indexed: 12/15/2022] Open
Abstract
Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10-20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling. In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.
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Key Words
- BAATO, balloon-assisted antegrade transvenous obliteration
- BRTO
- BRTO, balloonoccluded retrograde transvenous obliteration
- DIPS, direct intrahepatic portacaval shunt
- EUS guided coiling
- EUS, endoscopic ultrasound
- EVL, endsocopic variceal ligation
- HVPG, hepatic venous pressure gradient
- PARTO, plug-assisted retrograde transvenous obliteration
- PTFE, polytetrafluoroethylene
- PVT, portal vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- TIPSS
- portal hypertension
- refractory variceal bleed
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Affiliation(s)
- Gajanan A. Rodge
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kolkata, India
| | - Usha Goenka
- Department of Interventional Radiology & Clinical Imaging, Apollo Gleneagles Hospital, Kolkata, India
| | - Mahesh K. Goenka
- Institute of Gastrosciences & Liver, Apollo Gleneagles Hospital, Kolkata, India
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Abstract
Gastric variceal bleeding has a high mortality. Endoscopic cyanoacrylate injection is the standard therapy; however, rebleeding and unexpected adverse events, such as injection sites ulcers and distal glue embolisms, are pitfalls of this therapy. Endoscopic ultrasound (EUS)-guided endovascular therapies offer a safer and more practical alternative for the treatment of gastric varices. EUS-guided combined therapy with coiling and cyanoacrylate injection is the most promising alternative with high obliteration rates and fewer adverse events reported. The authors reviewed the latest available data for all endoscopic therapies proposed for the management of gastric varices in patients with chronic liver disease.
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Affiliation(s)
- Roberto Oleas
- Instituto Ecuatoriano de Enfermedades Digestivas, Torre Vitalis I, Mezzanine 3, Av. Abel Romeo S/N y Av. Juan Tanca Marengo, Guayaquil 090505, Ecuador
| | - Carlos Robles-Medranda
- Instituto Ecuatoriano de Enfermedades Digestivas, Torre Vitalis I, Mezzanine 3, Av. Abel Romeo S/N y Av. Juan Tanca Marengo, Guayaquil 090505, Ecuador.
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Han C, Ling X, Liu J, Lin R, Ding Z. Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments. Therap Adv Gastroenterol 2022; 15:17562848211056148. [PMID: 35126666 PMCID: PMC8808014 DOI: 10.1177/17562848211056148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)-guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy's lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.
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Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
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39
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Forbes N, Coelho-Prabhu N, Al-Haddad MA, Kwon RS, Amateau SK, Buxbaum JL, Calderwood AH, Elhanafi SE, Fujii-Lau LL, Kohli DR, Pawa S, Storm AC, Thosani NC, Qumseya BJ. Adverse events associated with EUS and EUS-guided procedures. Gastrointest Endosc 2022; 95:16-26.e2. [PMID: 34711402 DOI: 10.1016/j.gie.2021.09.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Department of Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Sherif E Elhanafi
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX, USA
| | | | - Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew C Storm
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, TX, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, FL, USA
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40
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Bazarbashi AN, Al-Obaid L, Ryou M. Future Directions in EndoHepatology. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:98-107. [DOI: 10.1016/j.tige.2021.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
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Ryou M, Cardenas A. Endoscopic Management: Classic and New Therapies. PORTAL HYPERTENSION VII 2022:461-471. [DOI: 10.1007/978-3-031-08552-9_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Bazarbashi AN, Li M, Ryou M. Letter to the Editor: Endoscopic Ultrasound-Guided Coil Therapy for Secondary Prevention After Gastric Variceal Bleeding: A Promising Alternative. Hepatology 2021; 74:2914. [PMID: 34105790 DOI: 10.1002/hep.31997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Michael Li
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
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Pavic T, Mikolasevic I, Kralj D, Blazevic N, Skrtic A, Budimir I, Lerotic I, Hrabar D. Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand? Diagnostics (Basel) 2021; 11:2021. [PMID: 34829368 PMCID: PMC8618190 DOI: 10.3390/diagnostics11112021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022] Open
Abstract
As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.
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Affiliation(s)
- Tajana Pavic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivana Mikolasevic
- Department of Gastroenterology, University Hospital Center Rijeka, 51000 Rijeka, Croatia;
| | - Dominik Kralj
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Nina Blazevic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Anita Skrtic
- Department of Pathology, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Ivan Budimir
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivan Lerotic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Davor Hrabar
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 PMCID: PMC8567466 DOI: 10.3748/wjg.v27.i40.6874] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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Vaz K, Efthymiou M, Vaughan R, Testro AG, Lew HB, Pu LZCT, Chandran S. Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy. World J Hepatol 2021; 13:868-878. [PMID: 34552693 PMCID: PMC8422918 DOI: 10.4254/wjh.v13.i8.868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/09/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.
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Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Adam G Testro
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Hin-Boon Lew
- Department of Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
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46
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Rudnick SR, Conway JD, Russo MW. Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound. World J Hepatol 2021; 13:887-895. [PMID: 34552695 PMCID: PMC8422923 DOI: 10.4254/wjh.v13.i8.887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/18/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.
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Affiliation(s)
- Sean R Rudnick
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Jason D Conway
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Mark W Russo
- Department of Hepatology, Atrium Health, Carolinas Medical Center, Charlotte, NC 28204, United States
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Endoscopic Ultrasound-Guided Coil Embolization With Absorbable Gelatin Sponge Appears Superior to Traditional Cyanoacrylate Injection for the Treatment of Gastric Varices. Clin Transl Gastroenterol 2021; 11:e00175. [PMID: 32677809 PMCID: PMC7263642 DOI: 10.14309/ctg.0000000000000175] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Gastric variceal (GV) bleeding is a feared complication of cirrhosis. Traditional endoscopic treatment with cyanoacrylate (CYA) injection can be challenging. Alternatively, endoscopic ultrasound (EUS)-guided delivery of hemostatic coils has shown high therapeutic success without the complications profile of CYA alone. Our aim was to compare the clinical outcomes of EUS-guided coil embolization with endoscopic CYA injection for the treatment of GV.
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Nakamura K, Okamoto T, Shiratori Y, Fukuda K. Endoscopic ultrasound-guided coil deployment with sclerotherapy for gastric varices. Clin J Gastroenterol 2021; 14:76-83. [PMID: 33040299 DOI: 10.1007/s12328-020-01259-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
We present a case of gastric varices (GV) in the fundus treated by endoscopic ultrasound (EUS)-guided coil deployment with sclerotherapy. A 46-year-old man with a previous history of fatty liver and obesity presented to the emergency department with abdominal pain. Contrast computed tomography (CT) showed chronic liver disease, splenomegaly, and GV. Esophagogastroduodenoscopy (EGD) showed GV in the fundus. Follow-up EGD 6 months later revealed an increase in GV diameter to over 20 mm. Balloon-occluded retrograde transvenous obliteration appeared difficult due to the small caliber of the gastrorenal shunt observed on contrast CT. We performed EUS-guided coil deployment with sclerotherapy. The coil was deployed using a 19-gauge needle under EUS and fluoroscopic guidance. Next, 5% ethanolamine oleate with contrast medium was injected into GV using a 22-gauge needle. GV was reduced without complications, and no GV growth or hemorrhage was observed during 8 months of follow-up.
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Affiliation(s)
- Kenji Nakamura
- Department of Gastroenterology, Tokyo Dental College, Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan.
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
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Wen TT, Liu ZL, Zeng M, Zhang Y, Cheng BL, Fang XM. Lateral position intubation followed by endoscopic ultrasound-guided angiotherapy in acute esophageal variceal rupture: A case report. World J Clin Cases 2021; 9:372-378. [PMID: 33521104 PMCID: PMC7812882 DOI: 10.12998/wjcc.v9.i2.372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/22/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
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 life-saving procedures in patients with massive upper gastrointestinal hemorrhage.
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Affiliation(s)
- Ting-Ting Wen
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Zheng-Lv Liu
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Min Zeng
- Department of Anesthesiology, The Second Hospital of Yinzhou, Ningbo 315100, Zhejiang Province, China
| | - Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Bao-Li Cheng
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Xiang-Ming Fang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Song MQ, Sun XG, Li Q, Shan TD, Shen JH, Liu FG, Jiang YP. CT portography guided endoscopic injection of cyanoacrylate into gastric varices. Shijie Huaren Xiaohua Zazhi 2021. [DOI: 10.11569/wcjd.v29.i1.0000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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