4524 Hemodynamics of esophageal varices observed by three-dimensional endoscopic ultrasonography and selection of endoscopic treatment.

Abstract

Background: Endoscopic variceal sclerotherapy (EVS) and endoscopic variceal ligation (EVL) are known to be equally effective for the treatment of esophageal varices. However, the indications for each type of therapy have not been decided. Endoscopic ultrasonography (EUS) is a well-accepted procedure for the diagnosis of gastrointestinal lesions, and three-dimensional (3D) imaging has recently been developed. Aims: The aim of this study was to observe the hemodynamics of esophageal varices using 3DEUS and to examine the selection of endoscopic treatment. Subjects and Methods: 3D-EUS was done with a 3D ultrasonic image processing system (EU-M30, EU-IP-2, Olympus Optical Co. Ltd.) using a small probe (12 MHz, 3.4 mm in diameter) by the mechanical spiral scanning method (length of 40 mm and pitch of 0.5 mm) with water irrigation. The area from the cardia to the distal esophagus was scanned before treatment, and 3D images were prepared that clearly displayed the architecture of the esophageal varices. The pattern of variceal blood flow detected on 3D images was classified into 4 types according to its architecture. Type 1 was cardial inflow without collateral vessels, Type 2 was cardial inflow with collateral vessels, Type 3 was an azygos-perforating pattern, and Type 4 was a complicated pattern. Thirty-four patients (100%) with esophageal varices underwent 3D-EUS observation. Subsequently, 23 patients were treated by EVS using 5%ethanolamine oleate and 11 patients by EVL, after which the results were assessed. Results: Based on 3D-EUS data, 16 patients (47.1%) were classified as Type 1, 4 patients (11.8%) as type 2, 4 patients (11.8%) as type 3, and 10 patients (29.4%) as Type 4. Three sessions of either EVS or EVL initially eradicated Type 1 esophageal varices, but recurrence was observed in 2 of 11 patients (18.2%) treated by EVS and in 3 of 5 patients (60.0%) treated by EVL. Type 3 varices were eradicated by 2.0 sessions of EVL, with none of the 3 patients showing recurrence. Conclusions: It was easy to assess the architecture of esophageal varices on 3D images. Based on the 3D-EUS findings, varices could be classified into 4 types and this classification was useful for the selection of endoscopic treatment. To treat the cardial inflow type without collateral vessels, obliteration of the feeding vessels is necessary, so EVS is selected. When collateral vessels are present and variceal blood flow can shift to the collateral pathways, EVL is more efficient should be selected.