Acute Gastric Variceal Bleeding Research Articles

Treatment of gastric varices with cyanoacrylate complicated by systemic embolization

Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.

Endoscopic Glue Injection Versus Endoscopic Human Thrombin Injection for Bleeding Gastric Varices-A Randomized Controlled Trial.

Acute gastric variceal bleeding (AGVB) is a potentially fatal consequence of portal hypertension, accounting for 10% to 30% of all variceal bleeding. Although endoscopic cyanoacrylate glue injection is a common treatment for acute hemostasis, it has been linked to significant side effects. In the treatment of AGVB, there is limited evidence of the efficacy and relative safety of endoscopic human thrombin injection over glue injection. A total of 52 AGVB patients were randomized to receive either thrombin injection (25 patients) or glue injection (27 patients). The primary outcome was the incidence of any glue or thrombin injection-related post-therapy complications. Initial hemostasis, rebleeding, and mortality were all secondary end goals. Both groups had comparable baseline data. Hemostasis of active bleeding at endoscopy was 100.0% (10/10) in the thrombin group and 87.5% (7/8) in the glue group (P=0.44). Treatment failure after 5 days occurred in 2 patients (6.1%) in the glue group compared with none in the thrombin group (P=0.165). Between 6 and 42 days after index bleeding, rebleeding occurred in 4 patients in the thrombin group compared with 6 patients in the glue group (P=0.728). In the thrombin group, none of the patients had post-treatment ulcers on gastric varices compared with 14.81% (4/27) that occurred in the glue group (P=0.045), a statistically significant observation. Overall, complications occurred in 4 (20%) and 11 (40.7%) patients in the thrombin and glue groups, respectively (P=0.105). Two patients in the glue group died. To achieve successful AGVB hemostasis, endoscopic thrombin injection has been proven efficacious. However, glue injection may be linked to a higher rate of rebleeding and post-therapy gastric variceal ulceration compared with thrombin.

Antegrade Gastric Variceal Embolization Simultaneously With Tips in Treatment of Patients with Acute Gastric Variceal Bleeding Having Unfavorable Gastric Variceal Anatomy

Gastric varices bleed at a lower Porto systemic pressure, have more catastrophic consequences and associated with large Porto systemic shunts. Occluded retrograde Trans-venous obliteration (RTO) is the mainstay of therapy for gastric variceal bleeding refractory to endoscopic therapy. A favorable afferent (Kiyosue type 1) and efferent (Kiyosue type A) anatomy of gastric varices is required for successful and safe RTO. Complex modifications in the RTO procedure are required for unfavorable afferent and efferent anatomies with high failure rates. RTO is not feasible in a type D efferent anatomy. RTO may aggravate potential complications associated with portal hypertension (ascites, catastrophic esophageal variceal bleeding). Antegrade gastric variceal embolization in adjunct to TIPS placement offers a safe, easier and effective alternative to modified RTO for gastric varices with unfavorable afferent and efferent anatomy. Concomitant placement of a TIPS stent leads to portal decompression and diminishes the risks associated with aggravation of portal hypertension. In this review, we discuss the anatomic and hemodynamic classification of gastric varices and describe the advantages of antegrade embolization (+TIPS) over RTO for management of gastric variceal bleeding in patients with complex variceal anatomies.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Gastric Variceal Bleeding in Patients with Hepatocellular Carcinoma

A total of 42 cirrhotic patients (mean age, 51.7 years ± 10.8; 38 men) with hepatocellular carcinoma who underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for controlling acute gastric variceal bleeding (GVB) were included in this multicenter retrospective study. Of these, 37 (88.1%) patients underwent emergent TIPS creation as the first-line treatment to control acute GVB. Five (11.9%) patients underwent emergent TIPS creation as a rescue/salvage treatment to control acute GVB after emergent endoscopic therapy and pharmacotherapy. Emergent TIPS creation was technically successful in 40 (95.2%) patients. Two (4.8%) patients had severe and moderate procedural adverse events. The median follow-up duration was 16.9 months (range, 0.1–100.8 months). Failure to control acute bleeding and failure to prevent rebleeding occurred in 8 (19.0%) patients during follow-up. Eighteen (42.9%) patients died during follow-up. Three (7.1%) patients had shunt dysfunction during follow-up. Overt hepatic encephalopathy occurred in 6 (14.3%) patients during follow-up.

S2203 Off-Label Use of Hemospray in Bleeding Non-Cirrhotic Portal Hypertensive Gastric Varices: A Bridge to Definitive Therapy

INTRODUCTION: With a mortality rate as high as 26%, acute gastric variceal bleeding remains an important medical emergency. Given the paucity of data, management of non-cirrhotic portal hypertension associated varices has been challenging. Current management relies on technically challenging and time consuming techniques to achieve early endoscopic hemostasis via injectable adhesives, fibrin and thrombin injections, mechanical banding, and application of sclerosants. Recent studies favor endoscopic use of topical hemostatic spray (TC-325) - a therapeutic with FDA approval in nonvariceal gastrointestinal bleeding and increasingly being used off-label in the management of gastric varices. Despite excellent short-term efficacy, hemostatic powders are limited by high rebleed rates and thus primarily serve as a bridge toward definitive therapy. CASE DESCRIPTION/METHODS: A 55-year-old gentleman with metastatic pancreatic cancer complicated by splenic vein thrombosis with isolated gastric varices, presented with epigastric pain, melena and evidence of hemodynamic compromise. Laboratory investigation revealed a hemoglobin of 6.6 g/dL. The patient was admitted to the MICU and treated with empiric antibiotics, IV fluids, pantoprazole and octreotide drips. After blood transfusion EGD was performed revealing multiple large isolated gastric varices (IGV-1) with red spots as well as active bleeding from a gastric fundus varix. The bleeding gastric varix was not amenable for band ligation or injection of sclerosants. Hemospray was generously applied to the bleeding culprit and surrounding varices, with successful hemostasis. The patient was not a candidate for splenectomy thus underwent splenic artery embolization by interventional radiology. He was continued on pantoprazole and octreotide drips for 72 hours, without evidence of rebleeding, and was discharged in stable condition. DISCUSSION: Options for treatment of bleeding isolated gastric varices are limited in the United States. Our case highlights the successful, off-label use of hemospray as a bridging intervention in non-cirrhotic gastric varices until definitive treatment with artery embolization could be performed. This contrasts with bleeding cirrhotic portal hypertensive varices that are managed with TIPS (Transjugular intrahepatic portosystemic shunt) or BRTO (Balloon-occluded retrograde transvenous obliteration). More studies are needed to validate the use of topical hemostatic powder (TC-325) in the management of non-cirrhotic gastric variceal bleeding.Figure 1.: Varix in the gastric fundus with active bleeding.Figure 2.: Gastric varices prior to administration of hemospray.Figure 3.: Gastric varices without active bleeding following administration of hemospray.

S0635 A Comparative Study of the Efficacy of Endoscopic Injection of Cyanoacrylate Glue vs Other Interventional Modalities for Treatment of Acute Gastric Variceal Bleeding: A Systematic Review and Meta-Analysis

INTRODUCTION: Cyanoacrylate glue is currently the main endoscopic therapeutic option for treatment of bleeding gastric varices. Recent studies have demonstrated that a multitude of different techniques appear to have similar efficacy and safety. This study aimed to conduct a systematic review and meta-analysis to evaluate the efficacy of cyanoacrylate glue injection versus other endoscopic and interventional modalities, including band ligation, sclerotherapy, or transjugular intrahepatic portosystemic shunt (TIPS) in the management of gastric variceal bleeding. METHODS: Multiple databases were searched through November 2018 for studies involving adults with portal hypertension and/or cirrhosis with bleeding gastric varices. Data was gathered to compare cyanoacrylate glue versus band ligation, sclerotherapy, or TIPS in achieving control of active bleeding from gastric varices within the first 24 hours. Secondary outcomes analyzed included rebleeding rate and adverse event rate. RESULTS: A comprehensive search identified 1068 potential articles with 14 comparative studies fulfilling inclusion criteria for data extraction. These studies included 1270 total patients: 634 patients underwent cyanoacrylate glue injection, 325 patients underwent endoscopic band ligation, 219 patients underwent TIPS, and 92 patients underwent sclerotherapy. Pooled analysis was performed, and odds ratios were obtained. Control of active bleeding within the first 24 hours was statistically significant favoring cyanoacrylate in all three comparisons of cyanoacrylate glue vs. band ligation, sclerotherapy, and TIPS, respectively (Figure 1). Rate of adverse events showed no significant differences among the three comparison groups (Figure 2). Rate of rebleeding also showed no significant difference among the groups (Figure 3). CONCLUSION: This meta-analysis highlights that cyanoacrylate glue injections were superior to band ligation, sclerotherapy, or TIPS in controlling active gastric variceal bleeding within the first 24 hours. Cyanoacrylate glue injections also showed no significant differences in adverse events or rebleeding rates when compared against the other interventions. These results suggest that cyanoacrylate glue injection should remain a primary therapeutic option for the treatment of gastric variceal bleeds. However, comparative studies remain limited, and further analyses evaluating the many therapeutic options available for the treatment of gastric varices against each other are warranted.Figure 1.: Bleeding Control of Gastric Varices within 24 hours in Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.Figure 2.: Rate of Adverse Events after Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.Figure 3.: Rate of Rebleeding after Therapy with Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.

Gastric variceal bleeding.

There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence. In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions. Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.

2026 Successful Hemostasis in Acute Gastric Variceal Hemorrhage With Hemospray (Hemostatic Powder)

INTRODUCTION: Currently there are few effective therapies for acute gastric variceal hemorrhage: endoscopic variceal ligation (EVL), cyanoacrylate injection, and endoscopic sclerotherapy (ESL). For variceal hemorrhage that is not amenable to these therapies, Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon-occluded retrograde transvenous obliteration (BRTO) are recommended. For patients with contraindications to these procedures there is no effective treatment. Here we present a case of acute gastric variceal hemorrhage, in which hemostasis was successfully achieved with the use of Hemospray (hemostatic powder). CASE DESCRIPTION/METHODS: A 63-year-old hispanic man with PMH of HCV and alcoholic cirrhosis presented with coffee-ground emesis and melena. Admission vitals: T-37.7, HR-117, RR-20, BP-139/72, O2 sat-100% on RA. Physical exam was significant for only mild jaundice. Hemoglobin was 6.3. We started Protonix IV BID, Octreotide drip and Ceftriaxone QD. CT abdomen showed multiple metastatic appearing liver lesions, cirrhosis, varices, and cavernous transformation of the portal vein. Overnight his hemoglobin decreased to 4.5. During EGD, multiple gastric varices were noted including a large, actively hemorrhaging, GOV-2 varix. Unfortunately, we were unable to perform EVL due to the sheer volume of bleeding present. IR was consulted for emergent TIPS. However the patient was not a candidate for TIPS or BRTO due to the cavernous transformation of his portal vein. The decision was made to utilize Hemospray. EGD was repeated and the large GOV-2 gastric varix was seen actively hemorrhaging. A large, obstructing clot was removed and the site of bleeding was visualized. Hemospray was applied and hemostasis was quickly and effectively achieved. After application, the patient did not have recurrent bleeding. DISCUSSION: Hemostasis in the setting of acute gastric variceal hemorrhage can be very challenging to achieve. Hemospray should be considered when traditional therapies fail. It becomes cohesive and adhesive when it comes into contact with moisture, forming a stable mechanical barrier. Although there are few studies investigating its use in acute variceal hemorrhage, it was very effective in this case. Hemospray can also be useful for providing temporary hemostasis in an emergent situation; giving physicians more time to organize more definite treatments. Hemospray is a powerful endoscopic tool and should be considered when standard bleeding therapies are inadequate.

Endoscopic treatment of acute gastric variceal bleeding in patients with cirrhosis using isoamyl-2-cyanoacrylate

Context Gastric variceal (GV) bleeding is a serious complication in patients with cirrhosis, as it is usually severe with high rate of mortality and rebleeding. Aim The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with isoamyl-2-cyanoacrylate (Amcrylate) in patients with cirrhosis with GV (gastroesophageal varices type 2 and isolated gastric varices type 1) bleeding. Patients and methods We prospectively studied 34 patients with cirrhosis with bleeding GV who were treated with intravariceal injection of isoamyl-2-cyanoacrylate (Amcrylate). Statistical method Data were expressed as the mean ± SD or as number (%) for numerical variables. Results After a mean dose of 1.86 ± 0.49 ml (range: 1–3 ml) of isoamyl-2-cyanoacrylate was injected in each patient, hemostasis was achieved initially in 100% of patients and complete obliteration of GV in 100% of patients. Treatment-related complications occurred in 26.5% of patients (9/34), but all complications were transient and mild. Complications included ulceration at site of injection (8.8%), fever (2.9%), abdominal pain (5.8%), chest pain (5.8%), and transient dysphagia (2.9%). Only one (2.9%) patient died closed to the cyanoacrylate treatment during hospitalization owing to hepatic encephalopathy and hepatorenal syndrome type I. During mean follow-up of 11.9 + 5.2 months (range: 2 weeks–21 months), rebleeding occurred in 8.8% of our patients. Conclusion This study has demonstrated the efficacy and safety of endoscopic treatment of bleeding GV using isoamyl-2-cyanoacrylate injection with initial hemostasis and complete obliteration of GV with no serious complications and low risk of rebleeding and bleeding-related death.

Mortality secondary to acute gastric variceal bleeding: a further prediction of outcome by acute kidney injury

Bleeding from the rupture of esophageal varices is one of the most serious complications of portal hypertension. In fact, up to 20% of patients die acutely or within 6 weeks after the bleeding episode (1). Advanced Child-Pugh class, an elevated hepatic venous pressure gradient (HVPG, ≥20 mmHg), high model for end-stage liver disease (MELD) score values are the main predictors of this poor outcome (2-4). Therefore, many studies evaluated how to prevent variceal bleeding (or rebleeding) in cirrhosis.

Acute kidney injury predicts mortality in cirrhotic patients with gastric variceal bleeding.

The International Club of Ascites (ICA) recently proposed a new definition of acute kidney injury (AKI) in cirrhotic patients. The study evaluated the ICA-AKI criteria and their association with the prognosis of cirrhotic patients with gastric variceal bleeding (GVB). A retrospective cohort study using prospective database of cirrhotic patients hospitalized with the first presentation of acute GVB at Taipei Veterans General Hospital from April 2007 to December 2010 was performed to evaluate the development of AKI. The study used Cox proportional hazards model to examine the association of ICA-AKI criteria and mortality. Of 113 patients, 46 (41%) fulfilled the ICA-AKI criteria and most (70%) initially had stage 1 AKI. Child-Pugh score, systemic blood pressure at admission, and number of blood units transfused before endoscopy were independent predictors of AKI. Among patients with AKI, 30% progressed to higher stages with more advanced liver disease, lower serum sodium, more units of blood transfusion, higher frequency of infection, and higher serum creatinine levels at diagnosis of AKI. The 6-week mortality rate was significantly higher in patients with AKI than in patients without AKI (37% vs 3%, P<0.001), and AKI stages were independent predictors of 3-month survival (93% in patients without AKI, 73% in stage 1, and 30% in stages 2 and 3, P=0.005). The occurrence of AKI as defined by the ICA criteria is common in cirrhotic patients with acute GVB. The presence of AKI was associated with much higher 6-week mortality, and the stages of AKI further predicted 3-month survival.

Therapeutic options for bleeding oesophageal varices: cyanoacrylate and balloon-occluded retrograde obliteration (BRTO)

A 56-year-old male with cirrhosis presented with acute bleeding from cardiofundal gastroesophageal varices (GOV) and was treated with endoscopic cyanoacrylate glue. Glue therapy achieved stabilisation of the patient in the...

Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience.

Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy. We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique. Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1week of initial CA injection. No embolic events were reported after any initial CA injection within 4weeks. The rate of bleed-free survival at 1year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance. ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

Safety and Efficacy of 2-Octyl-Cyanoacrylate in the Management of Patients with Gastric and Duodenal Varices Who are Not Candidates for Transjugular Intrahepatic Portosystemic Shunts

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension and cirrhosis. Options are limited for patients who are not candidates for transjugular intrahepatic portosystemic shunts (TIPS). Cyanoacrylate injections have been reported to be efficacious in previous case series. The aim of this retrospective study was to report our single-center experience with the safety and efficacy of 2-octyl-cyanoacrylate in patients who were not TIPS candidates. Electronic medical records were reviewed for 16 patients who underwent a total of 18 esophagogastroduodenoscopies for acute gastric or duodenal variceal bleeding and secondary prophylaxis of gastric varices; 14 patients had cirrhosis with an average Model for End-Stage Liver Disease score of 16, and 2 patients had noncirrhotic portal hypertension. Primary endpoints of the study included early and delayed rebleeding rate, complications, and death or liver transplantation. The rebleeding rate (early or delayed) was 7%, and no complications were found. One death was reported (unrelated to the procedure). In conclusion, 2-octyl-cyanoacrylate is a safe and effective alternative for non-TIPS candidates who present with acute gastric variceal bleeding given its low rebleeding and complication rate.

Effect of endoscopic injection of cyanoacrylate in treatment of acute esophageal and gastric variceal bleeding in children

Effect of endoscopic injection of cyanoacrylate in treatment of acute esophageal and gastric variceal bleeding in children

Outcomes and Predictors of Rebleeding After 2-Octyl Cyanoacrylate Injection in Acute Gastric Variceal Hemorrhage.

Endoscopic injection of 2-octyl cyanoacrylate (2-OCA) is used on an off-label basis for gastric variceal hemorrhage (GVH) in the United States. We assessed the efficacy, safety, and predictors of rebleeding after gastric variceal obturation (GVO) with 2-OCA in patients with acute GVH. A retrospective analysis was performed of patients with GVH who underwent 2-OCA injection for GVO over a 15-year period. Rates of acute hemostasis, predictors of rebleeding, and cyanoacrylate-related adverse events were assessed. A total of 95 patients (63 males, median age 59±14 y) were analyzed. Gastric varices were categorized as GOV-1 (3%), GOV-2 (61%), and isolated gastric varices type 1 (36%) per Sarin classification. Initial hemostasis was achieved in all patients. Successful GVO, defined as sustained hemostasis within a month after injection, was achieved in 87 (92%) patients. Failed GVO with in-hospital rebleeding was observed in 8 (8%) patients. On univariate analysis, only the model for end-stage liver disease score was associated with an increased risk of rebleeding (odds ratio 1.2; 95% confidence interval, 1.1-1.4; P<0.01). Glue-related adverse events consisted of pulmonary emboli in 2 patients (2.1%), resulting in death in 1 patient. All cause in-hospital mortality was 13% due to uncontrolled gastric variceal rebleeding (n=3), renal failure (n=6), metastatic hepatocellular carcinoma (n=1), hemorrhagic stroke (n=1), and pulmonary embolism (n=1). Injection of 2-OCA was effective at achieving hemostasis in a high proportion of patients (92%) admitted for acute GVH. The risk of glue-related pulmonary embolism approximated 2% in our patient cohort, including 1 fatality.

Evolving Indications for Tips

Transjugular intrahepatic portosystemic shunt creation is a well-established therapy for refractory variceal bleeding and refractory ascites in patients who do not tolerate repeated large volume paracentesis. Experience and technical improvements including covered stents have led to improved TIPS outcomes that have encouraged an expanded application. Evidence for other less frequent indications continues to accumulate, including the indications of primary prophylaxis in patients with high-risk acute variceal bleeding, gastric and ectopic variceal bleeding, primary treatment of medically refractory ascites, recurrent refractory ascites following liver transplantation, hepatic hydrothorax, hepatorenal syndrome, Budd-Chiari syndrome, and portal vein thrombosis. Treatment of patients with high-risk acute variceal bleeding with early TIPS and using transjugular intrahepatic portosystemic shunts as a primary therapy rather than large volume paracentesis for refractory ascites would likely be the 2 circumstances that permit expansion in the frequency of TIPS procedures. The remaining populations discussed above are relatively rare.

Clinical Outcomes of Endoscopic Cyanoacrylate Injection Sclerotherapy With Post-Injection Audible Doppler Ultrasonography

Introduction: Acute gastric variceal hemorrhage (GVH) causes significant mortality and morbidity, and patients who suffer re-bleeding have a five-fold increase in mortality rates. The sites in the stomach at which they develop make endoscopic band ligation (EBL) difficult, and their thicker mucosa and larger diameter make EBL more likely to fail to occlude the vessel. When compared to esophageal varices, gastric varices have higher rates of morbidity and mortality from hemorrhage. Several studies have shown the safety and efficacy of n-butyl 2-cyanoacrylate (CA) injection into varices. The technique employed at our institution involves CA injection followed by ultrasound doppler to confirm the cessation of variceal blood flow. We designed our study to determine if throughscope audible doppler assessment (ADA) for hemostasis after injection improves clinical outcomes for acute GVH. Methods: We retrospectively identified 75 patients who had documented gastric varices, underwent CA injection with ADA, and had at least two weeks of follow up. We included patients treated for either acute GVH or hemorrhage prophylaxis followed by ADA. We analyzed the survival and re-bleeding rates with patient characteristics, which included variceal etiology, cirrhosis etiology, initial MELD scores, and laboratory assessments at time of readmission and/or re-bleeding, and compared our data with known studies of both GVH and hemorrhage prophylaxis treated by CA injection without subsequent ADA. Results: 53 (70.7%) of the total 75 patients underwent CA injection with ADA for acute GVH. 13.7% (±5.3%) of these patients had re-bleeding within 88 days after bleeding was controlled in the first CA injection and 26.9% (±7.6%) had re-bleeding within one year. The remaining 22 (29.3%) patients had undergone CA injection with ADA for hemorrhage prophylaxis. 12.3% (±8.3%) of these patients had re-bleeding within one year after prophylaxis, the difference from acute GVH was statistically significant (p=.041) and is illustrated in Figure 1.Figure 1Conclusion: When compared to recent studies, CA injection with ADA for patients with acute GVH may be superior to CA injection alone for long term re-bleeding risk, but not seem to be significantly superior to standard CA injection for early follow up. The addition of ADA for patients undergoing CA injection for hemorrhage prophylaxis does not appear to significantly affect re-bleeding rates when compared to standard CA injection.

Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement.

The evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14-17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.

2-Octyl-Cyanoacrylate Injection for Acute Gastric Variceal Hemorrhage: 15-Year Experience of Outcomes and Predictors of Acute Rebleeding

2-Octyl-Cyanoacrylate Injection for Acute Gastric Variceal Hemorrhage: 15-Year Experience of Outcomes and Predictors of Acute Rebleeding