Esophageal Varices Research Articles

Impact of breakfast skipping on esophageal health: A mendelian randomization study

Background & AimsPrevious studies have indicated that, in addition to the types of food consumed, eating habits are also associated with the risk of esophageal diseases. Some studies have suggested a possible link between breakfast skipping and esophageal tumors as well as gastroesophageal reflux disease. However, it remains unclear whether breakfast skipping has a causal relationship with esophageal diseases. To address this issue, this study aimed to investigate the potential causal relationship between breakfast skipping and esophageal diseases using a two-sample mendelian randomization (MR) approach. MethodsWe obtained data from genome-wide association studies (GWAS) involving 193,860 individuals from the UK Biobank on breakfast skipping. The summary statistics for the esophageal diseases were derived from the IEU open GWAS project. In this two-sample MR analysis, inverse variance weighted was used, supplemented with weighted median, simple mode and weighted mode methods. ResultsThe results revealed significant causal relationships between breakfast skipping and esophageal cancer (odds ratio (OR): 5.992, 95% confidence interval (CI): 1.606-22.350, p=0.008), Barrett’s esophagus (OR: 4.041, 95% CI: 1.837-8.889, p<0.001), gastroesophageal reflux disease (OR: 2.463, 95% CI: 1.995-3.041, p<0.001), and esophageal varices (OR: 4.454, 95% CI: 1.785-11.112, p=0.001). All of the supplementary methods supported the findings. ConclusionOur research provides evidence for the association between breakfast skipping and esophageal diseases. Breakfast skipping could be a potential risk factor for esophageal cancer, Barrett's esophagus, gastroesophageal reflux disease and esophageal varices. For high-risk groups prone to these esophageal diseases, emphasizing the importance of regular breakfast and maintaining consistent dietary habits is crucial for esophageal health.

Challenges and Opportunities in the Adoption of p-TIPS for Acute Variceal Bleeding: Insights from a US Tertiary Center.

Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort. A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center. Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01). Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.

Demographic Profile and Upper Gastrointestinal Endoscopic Findings among Children with Gastrointestinal Symptoms

Background: Upper endoscopy is an essential, safe and sensitive tool for diagnosing pediatric gastrointestinal issues. In Bangladesh, the practice of pediatric endoscopy remain rudimentary due to lackoftrained pediatricendoscopist. There is limited study on pediatric upper GI endoscopy in our country. The aim of the study was to find out the indications, common endoscopic findings and immediate post procedure complication of UGI endoscopy in children. Materials and methods: This is a retrospective study, the medical records of all patients whose age is under 18 years and who underwent upper GI endoscopy in last 2 years were included. Results: Among the total of 150 children (Age &lt;18 years), the most common indications were recurrent abdominal pain in 95 (63.3%) patients followed by Vomiting 26(17.33%), hematemesis 22(17.67%), dysphagia 4(2.7%), jaundice 3(2%). In almost half of the patients 75 (50%), the endoscopic findings were normal. The most common abnormal endoscopic findings were esophagitis seen in 42(28%) of patients followed by 18(12%) cases of superficial gastritis, duodenal ulcer 5 (3.3%), esophageal varix 4(2.6%), gastric polyp 3 (n=2%), antral gastritis 1(0.7%), biliary ascariasis 1(0.7%), esophageal ulceration 1(0.7%). Conclusion: The commonest indication for Pediatric UGI endoscopy was recurrent abdominal pain and the commonest endoscopic feature was esophagitis. No significant post procedure complication was noted in this study. Chatt Maa Shi Hosp Med Coll J; Vol.22 (2); July 2023; Page 75-78

Porto-sinusoidal vascular disorder with known etiologies had more severe portal hypertension and poorer outcomes

BackgroundPorto-sinusoidal vascular disorder (PSVD) is a clinicopathological entity and often associated with various etiologies. We aimed to compare the clinical and pathological features and outcomes of PSVD in patients with and without known etiologies in a Chinese cohort. MethodsThis retrospective study enrolled liver-biopsy confirmed patients with PSVD. Patients’ demographics, comorbidities, laboratory and imaging information were collected and the outcomes were followed up. ResultsTotally 128 patients with PSVD were included, with 75 (58.6 %) having known etiologies including prothrombotic conditions, immunological disorders, hematological disorders, drug exposure. PSVD patients with known etiologies exhibited significantly higher rates of gastroesophageal varices (87.0 % vs 54.0 %, p < 0.001), portosystemic collaterals (94.0 % vs. 58.0 %, p < 0.001), lower level of serum albumin (36.5 vs 40.0, p < 0.001), and a higher prevalence of portal vein thrombosis (PVT, 34.0 % vs 13.0 %, p = 0.010). During follow-up, PSVD patients with known etiologies had a significantly higher incidence of liver-related events (ascites, variceal hemorrhage or HE) (p = 0.027). ConclusionsPSVD with known etiologies had more severe portal hypertension, poorer liver function reserve, higher PVT prevalence, and worse clinical outcomes.

Splenic artery embolization for variceal bleeding in portal hypertension: a systematic review and metanalysis.

Splenic artery embolization (SAE) has emerged as a promising alternative for managing variceal bleeding secondary to portal hypertension (PH). This study aims to elucidate the significance of SAE in managing esophageal variceal bleeding in patients with PH, providing an overview of its efficacy, safety, and role in PH management. A systematic review and meta-analysis were conducted in accordance with PRISMA standards. EMBASE, PubMed, Scopus, and Web of Science databases were searched from inception until April 14, 2024. Original observational and clinical studies on SAE in managing variceal bleeding due to PH were included. Meta-analyses were performed using a random-effects model, and publication bias was assessed using regression and rank correlation tests for funnel plot asymmetry. Eighteen studies met the inclusion criteria, encompassing 531 patients. The meta-analysis revealed a significant reduction in variceal bleeding post-SAE (RD = -0.86; 95% CI: -0.97, -0.75; p < 0.001). Complete resolution of varices was observed in 26% of patients (95% CI: 11%, 45%; p = 0.006), and 78% showed improvement in variceal grade (95% CI: 43%, 88%; p < 0.001). SAE significantly increased platelet counts (SMD = 1.15; 95% CI: 0.63, 1.68; p < 0.001). Common complications included post-embolization syndrome, and the overall complication rate was low. This systematic review and meta-analysis study supports the efficacy and safety of SAE in managing variceal bleeding due to PH, demonstrating significant reductions in bleeding, improvements in variceal grade, and increases in platelet counts.

Serum Ferritin Levels and Liver-Related Events in Individuals With Steatotic Liver Disease: A Longitudinal Cohort Study.

Serum ferritin has been suggested as a potential biomarker associated with disease progression in metabolic dysfunction-associated steatotic liver disease (MASLD). We investigated the association between serum ferritin levels and liver-related events (LREs) in individuals with steatotic liver disease (SLD). This cohort study included 17,560 adults with SLD (MASLD [n = 15,744], MASLD with increased alcohol intake (MetALD) [n = 1103] and cryptogenic SLD [n = 713]) without LRE at baseline. A steatotic liver was diagnosed using ultrasound, and LRE was defined as the development of decompensation (ascites, variceal bleeding and hepatic encephalopathy) or hepatocellular carcinoma. Participants were categorised into high (≥ 300 μg/L for males, ≥ 200 μg/L for females) or normal to low (< 300 μg/L for males, < 200 μg/L for females) ferritin levels. During 211,425 person-years of follow-up (median: 12.3 years), 74 incident LRE cases were identified, with 63 cases in MASLD, 10 in MetALD and 1 in cryptogenic SLD. The multivariable-adjusted hazard ratio (aHR) for LRE comparing individuals with high and normal-to-low ferritin level was 3.13 (95% confidence interval [CI] 1.89-5.18). Increased risk of LRE in individuals with high serum ferritin level compared to those with normal to low serum ferritin level was consistent across SLD subtypes (aHR 2.69, 95% CI 1.55-4.67 for MASLD; aHR 5.73, 95% CI 1.31-25.0 for MetALD), and SLD severity assessed by Fibrosis-4 (FIB-4) index (aHR 2.38, 95% CI 1.34-4.21 for FIB-4 ≥ 1.3; aHR 3.13, 95% CI 1.18-8.29 for FIB-4 < 1.3). Serum ferritin levels correlated with the risk of LRE in patients with SLD.

The effect of propranolol on gastrointestinal motility and permeability in patients with cirrhosis and significant portal hypertension

BackgroundPatients with cirrhosis and portal hypertension may have alterations in intestinal barrier resulting in increased susceptibility for infections. We investigated the effect of propranolol in gastrointestinal motility, permeability and bacterial overgrowth in cirrhosis.MethodsPatients with cirrhosis and esophageal varices were studied before and after a build-up dose of propranolol according to standard guidelines. Serum TNF-a, IL-6, IL-1b, LPS and bacterial DNA were measured before and during propranolol therapy. Oro-caecal transit time (OCTT) and bacterial overgrowth (BO) have been evaluated with H2 breath testing. Intestinal paracellular (IP), cellular passive non-carrier (ICNC), cellular passive carrier-mediated (ICCM), and gastric permeability (GP) were evaluated by measurement of lactulose, mannitol, D-xylose and sucrose respectively in urine, with high performance liquid chromatography (HPLC).Results35 patients with cirrhosis and portal hypertension with median age was 59.6 years (range 42–86) were included in the study. Twenty one had viral hepatitis and 25 were classified as having advanced cirrhosis (Child-Pugh B: 14 or C: 11). Median dose of administrated propranolol was 40 mg/day. After 7 days propranolol treatment BO was resolved in 15 out of 16 patients (93.7%, p = 0.0001) and OCTT was reduced significantly from 180 min to 139 min (SD 58.5, difference − 4 1 min, p = 0.0001). Serum IL-6 levels were reduced in 21/35 (60%) patients from 41.1 to 19 pg/ml (p = 0.01), TNF-a in 10/35 (28.5%) patients from 10.7 to 5.6 pg/ml (p = 0.007) and LPS in 20/35 (57%) from 7.1 to 5.2 mg/L (p = 0.1). No bacterial DNA was detected in serum of all patients either baseline or under propranolol treatment. IP was significantly reduced (0.2 to 0.16, p = 0.04) whereas ICNC (p = 0.9), ICCM (p = 0.4) and GP (p = 0.7) were not affected significantly. Intestinal Permeability (PI) index (Lactulose to Mannitol ratio) was significantly reduced (0.027 to 0.02, p = 0.03).ConclusionIn patients with cirrhosis and portal hypertension, propranolol use is associated with reduction in BO, increase in intestinal motility and amelioration in intestinal permeability. Moreover IL-6 and LPS levels are being decreased in the majority of patients under propranolol.

Current status of treatment for acute variceal bleeding in liver cirrhosis

Acute variceal bleeding (AVB) continues to be a fatal complications of cirrhotic portal hypertension. Although the hospitalization rate of patients with acute variceal bleeding has significantly decreased with the advancement of medical technology, and the mortality rate has dropped from 50% three decades before to 15%～20% now, the in-hospital mortality rate is still high and is closely related to the severity of cirrhosis, ranging from 0 in Child A grade to 32% in Child C grade. Therefore, it is a good choice to risk stratify these patients and individualize the treatment method according to the expected risk, as the risk of death in patients with acute variceal bleeding is highly heterogeneous. This article mainly reviews the current status of risk stratification and treatment of acute variceal bleeding in cirrhosis.

Liver and spleen stiffness measurement using the new FibroScan module for prediction of esophageal varices and monitoring response to beta blockers in portal hypertension

BackgroundThis study aimed to assess the clinical use of the new FibroScan module for measurement of liver and spleen stiffness (LS and SS), comparing their usefulness in prediction of esophageal varices (EV) in patients with portal hypertension (PH) and their clinical value for monitoring response to non-selective beta blockers (NSBB) treatment in these cases. The study included 120 patients with compensated cirrhosis and PH, in addition to 30 healthy comparable controls. Based on gastrointestinal endoscopy, patients were classified into three groups: 48 without EV, 42 with small EV, and 30 with large varices needing treatment. Then, abdominal ultrasound and assessment of LS and SS using new FibroScan 630 Expert module were done for both patients and controls. Group 3 patients were then initiated on NSBB (propranolol), and follow-up of these parameters was done after 3 months.ResultsLS and SS were significantly increased in cirrhotic patients compared to controls and were positively correlated with ultrasonography parameters (spleen length and portal vein diameter). Moreover, they were significantly higher in patients with varices than in those without varices (compared to other noninvasive parameters), correlating with varices severity, and significantly decreased with NSBB treatment, especially SS.ConclusionScreening of cirrhotic patients for development of EV by elastography (LS and especially SS) using the new FibroScan machine seems to be an optimal method in clinical practice and superior to other noninvasive tests in the diagnosis, assessment of severity, and follow-up of response to treatment in these patients.

Considerations in the development of the International Multicenter Pediatric Portal Hypertension Registry

AbstractPortal hypertension, a common sequela of chronic liver disease, is complicated by variceal hemorrhage, one of its most serious complications. Evidence‐based approaches to managing variceal hemorrhage are limited by the scarcity of data related to this rare entity. Multicenter international registries are increasingly utilized to garner critical information about rare diseases. The International Multicenter Pediatric Portal Hypertension Registry (IMPPHR) was developed to acquire pediatric data about the mortality of first variceal hemorrhage and approaches to primary and second prophylaxis of variceal hemorrhage with a goal of improving outcomes in children with portal hypertension. IMPPHR evolved from pediatric portal hypertension symposia at the Baveno V and VI meetings in 2010 and 2015, with a formal executive committee initiating the development of IMPPHR in 2019. The registry opened in 2020, with data closure in 2024, including information from 44 centers and &gt;700 subjects. The complexities and approaches to developing IMPPHR are described.

Portal hypertension in doublecortin domain‐containing protein 2 (DCDC2) related neonatal sclerosing cholangitis

AbstractMutations in doublecortin domain‐containing protein 2 (DCDC2) lead to neonatal sclerosing cholangitis (NSC), and portal hypertension (PHTN). The objective of the study was to systematically evaluate PHTN, variceal bleeding, and outcomes of patients with DCDC2‐related NSC. The study included children with homozygous or compound heterozygous variants in DCDC2. All 14 children with DCDC2‐related NSC had PHTN. Eight (57.1%) developed variceal bleed at a median age of 3 years (range: 1.9–5 years). Eleven (78.6%) children with high‐risk varices underwent endotherapy. Varices were completely eradicated in three, downstaged to low‐risk in five, and there was no response with endotherapy in three. All three children with failure to eradicate/downstage varices had rebleed, and required listing for liver transplantation (LT). The study shows that children with variants in DCDC2 have a high incidence of variceal bleed at a very young age. Variceal eradication may often be difficult and rebleed rates are high; often necessitating LT.

Frequency of Different Etiologies in Patients of Upper GI Bleed

Objectives: To find out the frequency of different etiologies of upper GI bleed, based on endoscopic findings. Methodology: It was a retrospective study done over a period of 6 months in gastroenterology department of Federal Government polyclinic (FGPC), hospital from 1st January 2023 to 30th June 2023. Results:A total of 229 patients presented with Upper gastrointestinal bleed.Chronic liver disease manifesting as variceal bleed or portal hypertensive gastropathy was found in significant number of patients as compared to peptic ulcer disease.The predominant age group for most of causes of bleed was 5th decade of life with a significant female predominance. Conclusion:Viral hepatitis along with other causes of portal hypertension seem to be the major predisposing factor as a cause of upper GI bleed. There is an increased need for future awareness campaigns about viral hepatitis in order to reduce the risk of upper GI bleed. It is further suggested to study the impact of such awareness programson incidence of upper GI bleed through future studies.

Assessment of the Child-Pugh Score, Model for End-Stage Liver Disease Score, Fibrosis-4 Index, and AST to Platelet Ratio Index as Non-endoscopic Predictors of the Presence of Esophageal Varices and Variceal Bleeding in Chronic Liver Disease Patients

Assessment of the Child-Pugh Score, Model for End-Stage Liver Disease Score, Fibrosis-4 Index, and AST to Platelet Ratio Index as Non-endoscopic Predictors of the Presence of Esophageal Varices and Variceal Bleeding in Chronic Liver Disease Patients

Analysis of Prognostic Factors for Mortality in Patients With Gastrointestinal Bleeding: Application of Machine Learning Tools

Introduction: Treatment of upper gastrointestinal bleeding (UGIB) is a complex challenge due to the wide range of causes and factors affecting hospitalization outcomes.Objective: To study the impact of various factors on 30-day hospital outcomes using machine learning (ML) tools.Materials and methods: We compiled a retrospective data set that includes clinical, laboratory, and imaging data of 101 patients. The database was divided into 2 groups by UGIB etiology: ulcer and variceal bleedings. Both etiological groups were processed using ML tools in 2 steps: imputation by the MICE (multiple imputation by chained equations) model and factor importance analysis using the Random Forest model.Results: Analysis revealed that the most prognostically valuable parameters in both groups were well-known mortality predictors and emerging predictive factors, such as creatinine, blood pressure, activated partial thromboplastin time, level of consciousness, urea, lactate, comorbidity status, procalcitonin, ferritin, and total protein.Conclusions: The application of advanced tools confirmed the significance of popular and validated mortality predictors and contributed to the development of predictors, both explored and unexplored ones.

Laparoscopic Splenectomy with Pericardial Devascularization for Hypersplenism and Esophageal Variceal Hemorrhage Due to Portal Hypertension.

Hypersplenism and esophageal variceal hemorrhage caused by portal hypertension are common and serious complications of decompensated cirrhosis. In recent years, with the widespread application of various therapeutic methods such as drugs, endoscopy, splenic artery embolization, transjugular intrahepatic portal shunt, and liver transplantation, the role of surgery in the treatment of portal hypertension has gradually diminished, and the indications for surgical treatment have become more strictly defined. However, according to the clinical practice in China, surgical treatment of portal hypertension still holds an important role that other treatments cannot fully replace. In fact, surgical treatment of portal hypertension is widely performed in hospitals at all levels in China, saving numerous lives. Splenectomy combined with pericardial devascularization (SPD) is the most common surgical method for treating hypersplenism and esophageal variceal hemorrhage caused by portal hypertension. Long-term clinical practice has proven that SPD is a safe and effective treatment for hypersplenism and esophageal variceal rupture and hemorrhage due to portal hypertension. With the rapid development of laparoscopic techniques, the minimally invasive advantages of laparoscopic splenectomy combined with pericardial devascularization (LSPD) have become increasingly evident. However, the successful performance of LSPD mainly depends on the skill and proficiency of the surgeon. In this context, this article presents detailed techniques for LSPD.

Current approaches for management of gastric varices in the United States: a survey of providers’ attitudes and practices

Introduction Bleeding from gastric varices (GV) is more drastic and associated with higher mortality than that from esophageal varices. There are multiple therapeutic approaches for GV bleeding. Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as the first-line management for GV bleeding worldwide, its implementation in the US is limited. We conducted a survey among health care providers to examine attitudes and practice related to GV management. Methods Collected data were cleaned using SPSS V24. Summary statistics and graphical analyses for continuous and categorical variables were used to describe the data. Continuous variables with a normal distribution are presented as mean ± standard deviation. Results A total of 339 providers completed the survey, for a response rate of 16.95%. Nearly a quarter of respondents reported performing ECGI in patients with GV bleeding. Male healthcare providers (odds ratio [OR]: 2.1, 95% confidence interval [CI] = 1.22-3.75, P = 0.006), transplant hepatologists (OR: 2.6, 95% CI = 1.25-4.87, P = 0.019), and those working in hospitals with liver transplantation centers (OR: 2.5, 95% CI = 1.35-4.62, P = 0.002) were more likely to perform ECGI in GV bleeding cases. However, only gender was significant in the multivariate model. Conclusions Our results indicate the underutilization of ECGI in GV patients among US endoscopists. Key hurdles are lack of training and approval from the US Food and Drug Administration.

The Role of Small-Bowel Endoscopy in the Diagnosis and Management of Small-Bowel Neuroendocrine Tumours.

Neuroendocrine tumours (NETs) are relatively rare neoplasms but represent one of the most frequent types of primary small-bowel tumours. Their incidence is rising, and this is most likely because of their more frequent early-stage detection, physician awareness, and increasing availability and use of imaging and small-bowel endoscopic techniques, such as video capsule endoscopy and device-assisted enteroscopy, which enable the detection, localisation, and histological sampling of previously inaccessible and underdiagnosed small-bowel lesions. This review summarises the role of small-bowel endoscopy in the diagnosis and management of small-bowel NETs to assist clinicians in their practice. Small-bowel endoscopy may play a complementary role in the diagnosis of these tumours alongside other diagnostic tests, such as biomarkers, conventional radiology, and functional imaging. In addition, small-bowel enteroscopy may play a role in the preoperative setting for the identification and marking of these tumours for surgical resection and the management of rare complications, such as small-bowel variceal bleeding, in cases of portal hypertension due to the encasement of mesenteric vessels in fibrotic small-bowel NETs.

Psychometric Hepatic Encephalopathy Tests and Electroencephalogram Results Among Cirrhotic Patients.

Background and Objectives: Patients with cirrhosis who seem normal during physical examinations may still have abnormalities in their electroencephalogram (EEG) or show pathological results in neuropsychological tests. This study aimed to investigate the progression of minimal hepatic encephalopathy, its effects on quality of life, its prognostic value, and its significance for daily functioning. Materials and Methods: This study involved 50 patients with confirmed cirrhosis (28 Child A, 12 Child B, 10 Child C) who were assessed for psychological symptoms and underwent several tests: the Minimal Mental State Examination (MMSE), the Letter Cancellation Test, the Digit Symbol Coding Test, and EEG. Results: showed that 40% of patients exhibited neuropsychiatric symptoms, with somatization being the most common at 96%. The MMSE revealed cognitive impairment in 48% of patients. In the Letter Cancellation Test (LCT) (total error), 80% of patients had organic disorders, and 24% showed affections with (LCT) (completion time). The Digit Symbol Coding Test results showed affection in 28% of patients. Significant EEG changes were observed in patients with Child C cirrhosis. Patients with portal hypertension (including varices and variceal bleeding), liver cell failure symptoms (such as ascites, lower limb edema, and bleeding tendency), as well as those who smoke, or obese, or have hyperlipidemia, all displayed notable EEG and psychological test abnormalities, making them more likely to develop hepatic encephalopathy. Conclusions: psychological testing and EEG changes are effective in detecting minimal hepatic encephalopathy, with a higher incidence in Child C patients compared to those in Child A and B.

Correlation between the diameter of esophageal varices measured using a virtual ruler under endoscopy and portal pressure gradient.

Esophageal variceal diameter (EVD) is a crucial factor in determining the risk of esophageal variceal bleeding, which is associated with an increased portal pressure gradient (PPG). However, research into the relationship between EVD and PPG has been limited, primarily because the assessment of EVD depends on visual estimation during endoscopy. Recently, we developed an artificial intelligence (AI)-based method to accurately detect EVD. In this study, we aim to investigate the correlation between EVD and PPG, with the goal of evaluating EVD as a potential non-invasive indicator of PPG. This study included both retrospective and prospective data from 128 patients diagnosed with portal hypertension and gastroesophageal varices, gathered from two medical institutions. Clinical data including PPG, biochemical markers, and routine blood tests were collected. In the retrospective phase, EVD was evaluated using an AI-based virtual ruler. In the prospective phase, PPG was measured using radiological intervention methods, and EVD was measured during endoscopy with the aid of AI. A positive correlation between PPG and EVD was identified (r = 0.521, P < 0.001), which was further supported by multivariate linear regression analysis (b = 6.521, t = 6.872, P < 0.001). When patients were stratified into two groups based on PPG levels (27 patients with PPG < 20 mmHg and 101 patients with PPG ≥ 20 mmHg), a significant difference in EVD was observed between the groups (OR = 29.275, 95% CI 5.590-153.304, P < 0.001), with larger EVD in the higher PPG group. These findings suggest that EVD may serve as a predictor of adverse events associated with elevated PPG levels. In addition, receiver operating characteristic (ROC) curve analysis showed that EVD had an accuracy of 0.814 in diagnosing PPG function (standard error 0.048, 95% CI 0.720-0.908; P < 0.001), indicating that PPG levels are likely to exceed 20 mmHg when the variceal diameter is greater than 1.1 cm. EVD demonstrated a positive correlation with PPG and could potentially be used as a predictive marker for assessing PPG levels. These findings provide novel insights for the non-invasive evaluation of PPG in clinical practice.

Self-Expanding Metal Stents in the Acute Management of Oesophageal Variceal Bleeding: A Systematic Review.

Acute variceal bleeding (AVB) continues to challenge physicians and healthcare systems. Despite significant advances in our multimodal approach to managing this problem, namely medical, endoscopic, and radiological techniques, the mortality rates for this patient cohort remain as high as 20% on the index admission. This mortality rate has remained unchanged over the past 25 years. A crucial tool in the management of AVB is the balloon tamponade technique. However, this is associated with numerous severe and potentially life-threatening adverse events. Due to the limitations of oesophageal balloon tamponade devices, there has been an increased interest in using self-expanding metal stents (SEMS) to manage refractory variceal bleeding. There is a base of experience in using SEMS derived from their use in managing malignant obstructions. This study aimed to synthesise all available evidence, for the first time, on using SEMS to manage refractory oesophageal AVB. This study was a systematic review of published papers, which is reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We identified 16 suitable studies for review. These comprised one randomised controlled trial comparing SEMS to balloon tamponade, one prospective cohort study, nine retrospective cohort studies, four case reports, and one case series. In total, 246 patients were included. An average survival rate of 49% was seen among the 11 studies that reported a six-week survival rate; this included a cohort of 225 patients. The SEMS were left in situ for an average of 7.5 days, with a maximum average of 18 days in one study. The average rate for controlling the acute bleeding episode in patients receiving a SEMS was 96%. The re-bleeding rate on the removal of SEMS was 5%, far superior to the widely reported 50% re-bleeding rate for the balloon tamponade technique. The adverse event profile for the SEMS appears superior to the balloon tamponade technique overall. The rate of stent-related adverse events in patients receiving a SEMS was 25%. The most common adverse events were technical issues related to stent functioning, namely stent migration. The most severe stent-related adverse event was compression of the left main bronchus in two cases, which required the removal of the stent. Our study has several limitations, which we have alluded to throughout the paper. The studies on this issue are of poor quality, with only one randomised controlled trial performed. As a result, we must interpret the results of our research with caution. Our study supports the use of SEMS in managing AVB as a promising area of research. We have highlighted that further well-designed randomised controlled trials are needed to assess the efficacy of this technique, ideally compared directly to the balloon tamponade technique. However, based on this systematic review, the current body of evidence would suggest that the SEMS is superior to the balloon tamponade technique in terms of adverse event profile, re-bleeding rate, and length of time the device can safely be left in situ. Current evidence suggests that SEMS are as effective at controlling acute bleeding episodes as the balloon tamponade technique.