Endoscopic Variceal Ligation Research Articles

Endoscopic variceal ligation and percutaneous transhepatic obliteration difficulty in esophageal variceal bleeding: a case report

A 48-year-old male patient with a history of alcoholic cirrhosis was admitted to our hospital due to hematemesis with a 7-day history of melena. Emergency esophagogastroduodenoscopy revealed esophageal variceal bleeding. We attempted hemostasis with endoscopic variceal ligation (EVL). The esophageal mucosa was not aspirated into the EVL device although the patient had no history of endoscopic injection sclerotherapy or EVL. Percutaneous transhepatic obliteration (PTO) was performed and esophageal variceal bleeding was successfully hemostasis. PTO is a viable option for refractory esophageal bleeding.

Esophagogastric varix caused by extrahepatic portal vein obstruction with essential thrombocythemia: A case report.

Extrahepatic portal vein obstruction (EHPVO) is a very rare disease-causing portal hypertension. Myeloproliferative neoplasm (MPN) including essential thrombocythemia (ET) is reported as a risk factor for EHPVO due to underlying persistent thrombophilia.A Japanese woman in her 40s was referred to our hospital with a one-month history of gastric variceal bleeding due to EHPVO. Laboratory investigation demonstrated thrombocytosis despite portal hypertension. She had a mutation of clonal marker JAK2V617F with EHPVO, which prompted us to consult a hematologist. Bone marrow biopsy revealed megakaryocyte lineage proliferation, leading to a diagnosis of ET.Esophagogastroduodenoscopy indicated esophagogastric varices (LsF2CbRC2, Lg-cF1RC1). Abdominal Computed Tomography and angiography revealed splenomegaly and portal vein thrombosis with cavernous transformation. These radiologic findings suggested EHPVO.The patient had a history of ruptured esophagogastric varices and required prophylaxis against further variceal bleeding prior to anti-thrombotic therapy for EHPVO with ET. We performed laparoscopic Hassab's operation followed by endoscopic variceal ligation (EVL) and hematological cytoreduction therapy.Laparoscopic Hassab's operation and three bi-monthly EVL improved the esophagogastric varix (LmF0RC0, Lg-f F0RC0) at 6 months after surgery. Platelet count decreased to 60.1 x104 /uL by cytoreduction therapy. She was very healthy at 7 months after surgery.Patients with EHPVO are traditionally referred to the gastroenterologist for abdominal pain, intestinal bleeding, or refractory ascites; however, hypercoagulative disease may be occult in such patients and require the attention of a hematologist. When encountering the patients with splanchnic thrombosis caused by EHPVO, the gastroenterologists should screen for hematological disease, including MPN.

Early vs Delayed Feeding after Endoscopic Esophageal Variceal Ligation: A Systematic Review and Meta-Analysis

Early vs Delayed Feeding after Endoscopic Esophageal Variceal Ligation: A Systematic Review and Meta-Analysis

Computed tomography virtual oesophagography for the grading of oesophageal varices in cirrhotic liver disease patients with upper gastrointestinal endoscopic examination as the gold standard: a diagnostic validation study.

Virtual endoscopy is a postprocessing method using three-dimensional computed tomography (CT), which produces views of the inner surfaces of the human body like those produced by fibreoptic endoscopy. To evaluate and categorise patients who require medical or endoscopic band ligation to prevent oesophageal variceal bleed, a less invasive, less expensive, better tolerated, and more sensitive modality is required, as well as to reduce the use of invasive procedures in the follow-up of patients who do not require endoscopic variceal band ligation. A cross-sectional study was conducted in the Department of Radiodiagnosis in association with the Department of Gastroenterology. The study was conducted over a period of 18 months from July 2020 to January 2022. The sample size was calculated as 62 patients. Patients were recruited on the basis of inclusion and exclusion criteria after giving informed consent. CT virtual endoscopy was performed through a dedicated protocol. Classification of variceal grading was done independently by a radiologist and endoscopist who were blinded to each other's findings. The diagnostic performance of oesophageal varices detection by CT virtual oesophagography was good, with sensitivity: 86%, specificity: 90%, PPV: 98%, NPV: 56%, and diagnostic accuracy: 87%. There was substantial agreement between the 2 methods, and this agreement was statistically significant (Cohen's k = 0.616, p ≤ 0.001). Based on our findings, we conclude that the current study has the potential to change the way chronic liver disease is managed, as well as generate similar medical research endeavours. A multicentric study with a large number of patients is needed to improve the experience with this modality.

Tolerability of Endoscopic Variceal Ligation in Cirrhotic Patients without Sedation

Tolerability of Endoscopic Variceal Ligation in Cirrhotic Patients without Sedation

Retracted: Additional Benefits Conferred by Endoscopic Sclerotherapy to Liver Cirrhosis Patients Receiving Endoscopic Variceal Ligation.

[This retracts the article DOI: 10.1155/2021/1294410.].

Albumin-Bilirubin Grade as a Novel Predictor of the Development and Short-Term Survival of Post-Banding Ulcer Bleeding Following Endoscopic Variceal Ligation in Cirrhotic Patients.

Background and Objectives: Endoscopic variceal ligation (EVL) is the primary and secondary treatment for acute esophageal variceal bleeding. Post-banding ulcer bleeding (PBUB) may lead to bleeding episodes following EVL, increasing mortality. The aim of this study was to evaluate the risk factors for PBUB and predict the 6-week mortality risk after PBUB. Materials and Methods: We retrospectively analyzed the data collected from cirrhotic patients with EVL from 2015 to 2017. The incidence of PBUB and the 6-week mortality rate were evaluated. Risk factors for PBUB and predictive factors for mortality after PBUB were analyzed. Results: A total of 713 patients were enrolled in this study. Among the studied subjects, the incidence of PBUB was 5.8% (N = 41). The 6-week mortality rate was 63.4% (26/41). In multivariate analysis, MELD score ≥20 (OR: 3.77, 95% CI: 1.94-7.33, p < 0.001), ALBI score of 3 (OR: 2.67, 95% CI: 1.34-5.3, p = 0.005) and the presence of gastric varices (OR: 2.1, 95% CI: 1.06-4.16, p = 0.03) were associated with the development of PBUB. Patients with ALBI grade 3 (OR: 4.8, 95% CI: 1.18-19.6, p = 0.029) and Child-Pugh scores B and C (OR: 16.67, 95% CI: 1.75-158.1, p = 0.014) were associated with 6-week mortality after PBUB. Conclusions: PBUB is a complication with low incidence but increased mortality following EVL. The ALBI grade is a useful score to predict not only the development of PBUB but also the 6-week mortality after PBUB.

Endoscopic injection sclerotherapy with polidocanol for cardiac varices in children and adolescents

BackgroundLike esophageal varices, cardiac varices are often treated with endoscopic variceal ligation (EVL). However, we previously reported that EVL for cardiac varices may be associated with a high risk of rebleeding from the ulcer if the O-ring spontaneously drops off early. The efficacy and safety of para-variceal endoscopic injection sclerotherapy (EIS) with polidocanol for the treatment of cardiac varices in children and adolescents were evaluated. MethodsEleven patients under 18 years of age with portal hypertension who underwent para-variceal EIS with polidocanol for cardiac varices with red signs, which were considered to be at high risk of bleeding, were retrospectively reviewed. ResultsOne session of para-variceal polidocanol-EIS was performed for each of the 11 patients. One patient experienced temporary hypoxia due to aspiration of saliva when the tracheal intubation tube was removed after the procedure but recovered by endotracheal suctioning; there were no other adverse events. In six of the eight cases in which efficacy could be evaluated, eradication of cardiac varices was achieved. ConclusionPara-variceal polidocanol-EIS may be considered instead of EVL for small cardiac varices with red signs in pediatric patients with cardiac varices.

A Retrospective Analysis of the Efficacy of Endoscopic Variceal Ligation versus Endoscopic Tissue Adhesive Injection in the Treatment of Esophagogastric Variceal Bleeding

Background: The aim of the study was to investigate the effectiveness and safety of endoscopic variceal ligation (EVL) and endoscopic tissue adhesive injection (TAI) in the treatment of esophagogastric variceal bleeding (EVB). Methods: A total of 245 patients with EVB who attended the First Affiliated Hospital of Bengbu Medical College from December 2017 to June 2021 were retrospectively collected. The participants were divided into the esophageal EVL (E-EVL) + gastric EVL (G-EVL) group (n = 103) and E-EVL + gastric TAI (G-TAI) group (n = 142), according to the procedure, comparing and assessing the clinical characteristics, laboratory results, operation time, rebleeding rate, efficacy, and complications. Results: The E-EVL + G-EVL group had significantly less varicose vein diameter and operative time than the E-EVL + G-TAI group (p < 0.05). No statistical difference in the length of hospital stay between the two groups was noted (p > 0.05). The total rebleeding rate in the E-EVL + G-EVL group was 9.7%, whereas that of the E-EVL + G-TAI group was 11.9%; no statistical difference between the two groups was noted (p > 0.05). The overall effective rate of the E-EVL + G-EVL group was 90.21%, whereas that of the E-EVL + G-TAI group was 92.81%; no statistical difference between the two groups was observed (p > 0.05). The postoperative ulcer in the E-EVL + G-EVL group was smaller and more superficial than that in the E-EVL + G-TAI group, and the wound surface was smoother. Conclusion: Both EVL and TAI have good therapeutic effects on EVB. Furthermore, owing to its effectiveness in preventing rebleeding, no reduction in efficacy and no increase in complications, shortened operative time, smaller and superficial ulcer, and smoother wounds, gastric EVL is worthy of further clinical promotion.

Recombinant human thrombopoietin treatment in patients with chronic liver disease-related thrombocytopenia undergoing invasive procedures: A retrospective study.

Chronic liver disease (CLD) related thrombocytopenia increases the risk of bleeding and poor prognosis. Many liver disease patients require invasive procedures or surgeries, such as liver biopsy or endoscopic variceal ligation, and most of them have lower platelet counts, which could aggravate the risk of bleeding due to liver dysfunction and coagulation disorders. Unfortunately, there is no defined treatment modality for CLD-induced thrombocytopenia. Recombinant human thrombopoietin (rhTPO) is commonly used to treat primary immune thrombocytopenic purpura and thrombocytopenia caused by solid tumor chemotherapy; however, there are few reports on the use of rhTPO in the treatment of CLD-related thrombocytopenia. To evaluate the efficacy of rhTPO in the treatment of patients with CLD-associated thrombocytopenia undergoing invasive procedures. All analyses were based on the retrospective collection of clinical data of patients with CLD who were treated in the Department of Infectious Diseases at The First Affiliated Hospital of Soochow University between June 2020 and December 2021. Fifty-nine male and 41 female patients with liver disease were enrolled in this study to assess the changes in platelet counts and parameters before and after the use of rhTPO for thrombocytopenia. Adverse events related to treatment, such as bleeding, thrombosis, and disseminated intravascular coagulation, were also investigated. Among the enrolled patients, 78 (78%) showed a platelet count increase after rhTPO use, while 22 (22%) showed no significant change in platelet count. The mean platelet count after rhTPO treatment in all patients was 101.53 ± 81.81 × 109/L, which was significantly improved compared to that at baseline (42.88 ± 16.72 × 109/L), and this difference was statistically significant (P < 0.001). In addition, patients were further divided into three subgroups according to their baseline platelet counts (< 30 × 109/L, 30-50 × 109/L, > 50 × 109/L). Subgroup analyses showed that the median platelet counts after treatment were significantly higher (P < 0.001, all). Ninety (90%) patients did not require platelet transfusion partially due to an increase in platelet count after treatment with rhTPO. No serious adverse events related to rhTPO treatment were observed. Overall, rhTPO demonstrated good clinical efficacy for treating CLD-associated thrombocytopenia. rhTPO can improve platelet count, reduce the risk of bleeding, and decrease the platelet transfusion rate, which may promote the safety of invasive procedures and improve overall survival of patients with CLD.

Continuing Somatostatin Does Not Prevent Rebleeding After Variceal Ligation For Acute Variceal Bleeding

Background: variceal bleeding (VB) is a medical emergency. Endoscopic variceal ligation (EVL) performed quickly is beneficial. Evenafter EVL, somatostatin is still utilized in the VB band for 2–5 days. The advantage of continuing somatostatin after EVL is uncertainsince EVL is the main method for achieving hemostasis.Aim and objectives: to determine if continuing somatostatin after EVL is effective in reducing mortality and rebleeding.Subjects and methods: In this study, 75 patients with variceal bleeding were divided into two treatment groups (TG); TG2 &amp; TG5,which received somatostatin (250 micrograme bolus + a continuous infusion of 500 micrograme/h) for two days and five days,respectively, and one control group (TG0), which received 0.9 percent normal saline and was monitored for six weeks.Result: There were a total of 8 rebleeds; they happened more often in the TG0 (4%) and TG2 (2.6%) and TG5 (4%) groups, albeit notstatistically significantly (P=0.751). The treatment group substantially experienced more adverse drug reactions (ADRs) than the controlgroup (P=0.003). Diarrhoea was the most frequent ADR, followed by hyperglycemia and bradycardia, with 14 patients mentioning twoor more ADR. In comparison to the control group, ADR was considerably greater in the treatment groups. As the days of somatostatinmedication increased, the length of the hospital stay rose considerably (P=0.041).Conclusion: We conclude that in acute VB, there is no justification for continuing somatostatin after EVL since it had no beneficialeffect on preventing rebleeding and, instead, increased the risk of ADR and length of hospital stay.

S357 Presidential Poster Award Mushroom Sign: Complete Esophageal Obstruction Following Endoscopic Variceal Band Ligation

Introduction: Gastrointestinal hemorrhage secondary to esophageal varices is frequently encountered by gastroenterologists. Endoscopic variceal band ligation is a procedure that has potential for complications. However complete esophageal obstruction due to band ligation is very uncommon. Case Description/Methods: An 80-year-old female patient transferred to our hospital with complaints of inability to tolerate oral secretions and chest discomfort. 24 hours prior to transfer, she underwent endoscopic variceal band ligation and three bands placed for primary prophylaxis. CT chest showed esophagus was dilated with fluid retention. and there was 1cm mass-like lesion in distal esophagus. Upper endoscopy was performed and revealed a mushroom-like appearance of mucosa in mid-esophagus, with a full circumferential banding of the esophagus lumen causing complete esophageal obstruction. Underlying band was seen. Following initial endoscopic exam, we discussed risk and benefits of band removal. Hepatology and interventional radiology were consulted and patient was consented for a possible need for transjugular intrahepatic portosystemic shunt placement as a rescue therapy in case of an acute variceal bleeding following endoscopic intervention. Repeat endoscopy was performed using the distal attachment cap, and band was grabbed with loop cutter, and gentle pulling pressure applied resulting removal of the band uneventfully (d). Subsequent endoscopic examination showed esophageal mucosa had circumferential mushroom-like edematous mucosa with ulcerated base in 10 mm length at 30 cm from incisors (e). Due to ongoing obstruction, we performed balloon dilation (8-10mm) to prevent further stricture formation and open the esophagus lumen (f). There was no post-procedure bleeding and scope was easily traversed the stenosis. Patient recovered well post-procedure and discharged home next day. A week later, patient had ongoing dysphagia and repeat endoscopy was scheduled for dilation. Discussion: Complete esophageal obstruction from variceal band ligation is very rare. Cases with partial obstruction or patients who can handle secretions can be managed with supportive care. In this case, we removed the band with loop cutter as this was a complete obstruction and patient was at risk for aspiration and airway compromise. This case should illustrate the importance of spiral banding technique and aiming towards one column of varices at a time. Practicing gastroenterologists and trainees should be aware of this rare complication. Watch the video at https://tinyurl.com/ACGAbstractS357

Carvedilol reduces the risk of decompensation and mortality in patients with compensated cirrhosis in a competing-risk meta-analysis.

Whether non-selective β-blockers can prevent decompensation of cirrhosis warrants clarification. Carvedilol might be particularly effective since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, a major mechanism of portal hypertension in early cirrhosis. We assessed whether carvedilol may prevent decompensation and improve survival in patients with compensated cirrhosis and clinically significant portal hypertension (CSPH). By systematic review we identified randomized-controlled trials (RCTs) comparing carvedilol vs. control therapy (no-active treatment or endoscopic variceal ligation [EVL]) in patients with cirrhosis and CSPH without previous bleeding. We performed a competing-risk time-to-event meta-analysis using individual patient data (IPD) obtained from principal investigators of RCTs. Only compensated patients were included. Primary outcomes were prevention of decompensation (liver transplantation and death were competing events) and death (liver transplantation was a competing event). Models were adjusted using propensity scores for baseline covariates with the inverse probability of treatment weighting (IPTW) approach. Among 125 full-text studies evaluated, 4 RCTs were eligible. The 4 provided IPD and were included, comprising 352 patients with compensated cirrhosis, 181 treated with carvedilol and 171 controls (79 received EVL and 92 placebo). Baseline characteristics were similar between groups. Standardized differences were <10% by IPTW. The risk of developing decompensation of cirrhosis was lower with carvedilol than in controls (subdistribution hazard ratio [SHR] 0.506; 95% CI 0.289-0.887; p= 0.017; I2= 0.0%, Q-statistic-p= 0.880), mainly due to a reduced risk of ascites (SHR 0.491; 95% CI 0.247-0.974; p= 0.042; I2= 0.0%, Q-statistic-p= 0.384). The risk of death was also lower with carvedilol (SHR 0.417; 95% CI 0.194-0.896; p= 0.025; I2= 0.0%, Q-statistic-p= 0.989). Long-term carvedilol therapy reduced decompensation of cirrhosis and significantly improved survival in compensated patients with CSPH. This suggests that screening patients with compensated cirrhosis for CSPH to enable the prompt initiation of carvedilol could improve outcomes. CRD42019144786. The transition from compensated cirrhosis to decompensated cirrhosis is associated with markedly reduced life expectancy. Therefore, preventing decompensation in patients with compensated cirrhosis would be associated with greatly improved patient outcomes. There has been controversy regarding the use of non-selective β-blockers (portal pressure-lowering medications) in patients with cirrhosis and elevated portal blood pressure (portal hypertension). Herein, using a competing-risk meta-analysis to optimize sample size and properly investigate cirrhosis as a multistate disease and outcomes as time-dependent events, we show that carvedilol (a non-selective β-blocker) is associated with a reduced risk of decompensating events and improved survival in patients with cirrhosis and portal hypertension.

S2585 Does Size Matter? A Case Series on Management of Duodenal Varices

Introduction: Duodenal varices (DVs) are a rare cause of life-threatening bleeding in cirrhotic patients. No standardized guidelines for their management exist. We present two cases of DV hemorrhage who were successfully managed by endoscopic variceal band ligation (EVL) and coil embolization respectively. Case Description/Methods: Case 1: A 63-year-old male with cirrhosis was admitted for upper GI bleeding and Hemoglobin (hgb) of 7.1. Endoscopy showed small to medium-sized DVs with stigmata of recent bleeding with a platelet plug in the second portion of duodenum. EVL was done with adequate decompression and no immediate bleeding. One week later, he developed recurrent hematochezia. Full GI work up including upper endoscopy, small bowel capsule and colonoscopy showed previously noted non-bleeding ulcers in the duodenum with no new active bleeding sites. Case 2: A 68-year-old male with cryptogenic cirrhosis complicated by large hepatocellular carcinoma causing portal vein obstruction was admitted for GI bleeding and hgb of 4.3. Endoscopy showed multiple large DVs with active bleeding. Successful hemostasis was achieved using three hemostatic clips but without adequate decompression. However, given the size of the varix, the patient then underwent successful percutaneous transsplenic porto-venous variceal coil embolization by interventional radiology (IR). Discussion: Variceal bleeding occurs in 25-30% of cirrhotic patients with ectopic varices accounting for 1-5% of these bleeds. DVs are uncommon but can cause massive hemorrhage with a high mortality up to 40%, due to challenges with treatment. Management options include EVL, sclerotherapy, clipping or IR guided Trans Jugular Intrahepatic Portosystemic Shunt (TIPS), Balloon-Occluded or Coil Assisted Retrograde Transvenous obliteration. One concern with EVL is the size of the DV and risk of re-bleeding. Among case reports using EVL, re-bleeding was seen only in 3/19 cases with hemostasis achieved with repeat banding in 2 out of the three cases. However, for successful band ligation, accessibility, and size of the varices to fit into the banding cap are important factors to consider. Small – medium duodenal varices (case 1) were adequately managed by EVL, however endoscopic decompression could not be completely achieved in large varices (case 2) and eventually required IR guided coil embolization. Therefore, the size and location of the duodenal varices are important factors to be considered in choosing the appropriate management modality for DVs (Figure 1).Figure 1.: A, Percutaneous transsplenic splenic venogram demonstrating large duodenal varix(white arrows) with linear endoscopically placed clip corresponding with site of hemorrhage in the vertical segment of the duodenum (black arrow). The splenic vein (white arrowhead) drains via the large varix as the main portal vein is occluded secondary to hepatic tumor; B, Percutaneous transsplenic splenic venogram demonstrating successful coil embolization of the varix (black arrowheads); C, Endoscopic view of large varices in second portion of duodenum, post hemostatic clip placement.

S2579 Colonic Varices: What Are the Therapeutic Options?

Introduction: Colonic varices are a rare case of lower gastrointestinal bleeding (LGIB) with an incidence of 0.07%. The most common sites of colonic varices are the rectum and cecum. Colonic varices are diagnosed on colonoscopy, mesenteric angiography, or computed tomography (CT) scans. Currently, there are no standardized treatments for treatment of colonic varices due to the heterogeneity in localization and vascular anatomy. We present a case of LGIB due to an ascending colon varix. Case Description/Methods: A 38 year-old-man with a history of decompensated alcoholic cirrhosis complicated by esophageal and gastric variceal bleed requiring balloon-occluded retrograde transvenous obliteration one month ago was transferred from an outside hospital (OSH) for liver transplant evaluation and hematochezia. He underwent a colonoscopy at the OSH which showed an ascending colon varix with white nipple sign. His vital signs were normal. His physical exam was benign except for scleral icterus with spider angiomas on his chest. His labs were pertinent for a hemoglobin of 8.0, hematocrit 24, platelet 50,000, alanine aminotransferase 50, total bilirubin 3.0, and international normalized ratio 2.0. The patient was treated with octreotide infusion and antibiotics for spontaneous bacterial peritonitis prophylaxis. A CT three phase abdominal imaging was revealed significant perisplenic and ascending colon varices with smaller varices supplying the descending colon. The case was reviewed with interventional radiology and hepatology and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement with coil and plug embolization of the splenic varix and gonadal varix feeding into the ascending colon varix. The patient did not have any further episodes of hematochezia and his hemoglobin stabilized. A few days later, the patient underwent an orthotic liver transplant. His post-operative clinical course was uncomplicated. Discussion: This is a rare case of a colonic varix resulting in a clinically significant LGIB. There is no standardization of therapy for ectopic varices due to the heterogeneity in vascular anatomy. Therapeutic options include endoscopic variceal band ligation, cyanoacrylate injections, surgery, TIPS and coil embolization. This case highlights the importance of a multi-disciplinary approach with gastroenterologists, hepatologist, interventional radiologists, and surgeons for the treatment of colonic varices.

S2303 Endoscopic Balloon Dilation of Recurrent Peptic Stricture in a Patient With Portal Hypertension

Introduction: Variceal hemorrhage is a devastating complication and a major cause of mortality in patients with portal hypertension. Unfortunately, one third of patients with varices develop bleeding in their lifetime. This case depicts a rarely reported intervention that physicians may be hesitant to pursue. Case Description/Methods: A 61-year-old male with history significant for atrial fibrillation (afib), alcoholic cirrhosis complicated by gastric and esophageal varices, and GERD presented with dysphagia. He previously underwent endoscopic variceal band ligation (EVL) in 2009 for primary prevention of esophageal varices and placed on daily nadolol. His GERD was controlled with twice daily PPI and as-needed H2 antagonist. Despite this, he developed strictures secondary to severe erosive esophagitis. He was then started on apixaban for afib and transitioned from nadolol to carvedilol. His MELD-Na is 8 and had a reported distant history of hepatic encephalopathy. He presented to the esophageal motility clinic with progressive dysphagia to both solids and liquids. An EGD was scheduled which revealed a partially obstructive ulcerative stricture spanning 29 - 34 cm from incisors. The stricture was injected with 4 ml of triamcinolone acetonide distributed in 1 cm increments across 4 quadrants. Then the stricture was dilated with a 10-12 mm cre balloon under fluoroscopic guidance. Dilation caused shallow mucosal tears with scant blood but otherwise no significant bleeding or complication. The scope was traversed into the stomach with retroflexion revealing moderate gastric varices in the cardia. After the procedure was completed, the patient had complete resolvent of symptoms and tolerated oral nutrition (Figure). Discussion: This case describes a cirrhotic patient with portal hypertension requiring frequent endoscopic balloon dilations for severe dysphagia secondary to recurrent peptic strictures. Extensive literature review did not reveal any documented cases describing this scenario. The presence of gastric varices in this patient is indicative of active portal hypertension. This in combination with the patient’s anticoagulation places a theoretical high risk of bleeding during the procedure. Although this case demonstrates that it is safe to perform serial dilations in patients with portal hypertension if they have undergone EVL and do not have active esophageal varices.Figure 1.: A) EGD showed ulcerative peptic stricture located in the mid-esophagus. (B) There was scant bleeding after dilation, otherwise no significant bleeding or complication. (C) Retroflexion was performed in the stomach and revealed moderate gastric varies in the cardia.

Efficient Initial Eradication of Large Esophageal Varices by Balloon-compression Endoscopic Injection Sclerotherapy

The management of large esophageal varices (EVs) remains challenging because of the difficulty of endoscopic variceal ligation and fatal post-endoscopic variceal ligation bleeding ulcers. The current study evaluated the efficacy and safety of balloon-compression endoscopic injection sclerotherapy (bc-EIS) in the treatment of large EVs. This retrospective study included 105 patients with cirrhosis exhibiting large EVs (64 in the bc-EIS group and 41 in the EIS group). Primary outcomes included the initial rate of variceal eradication and intraoperative bleeding signs. Secondary outcomes included incidences of rebleeding, mortality, complications, and optimal time of balloon-compression (bc). The initial rate of variceal eradication in the bc-EIS group was significantly higher than that in the EIS group (46.9 vs. 24.4%; P =0.021). The incidence of intraoperative bleeding, which was represented as oozing and spurting, in the bc-EIS group was markedly lower than that in the EIS group (43.8 vs. 61.0% and 9.4 vs. 39.0%, respectively; P =0.043). Patients in the bc-EIS group showed a significantly lower incidence of rebleeding (0.0 vs. 17.1%; P =0.001). However, no significant difference in mortality rate was observed between different groups. Chest pain or discomfort tended to be more common in the EIS group than in the bc-EIS group (58.5 vs. 17.2%; P =0.001). The cut-off value of 11.5-minutes appeared to have a maximum combined sensitivity and specificity of 80.0% and 58.8%, respectively. The area under the curve was 0.708 (95% confidence interval =0.576-0.839; P =0.004). bc-EIS could achieve a higher variceal eradication rate and milder intraoperative bleeding signs in large EVs. Furthermore, 11.5-minutes appeared to be the optimal compression time in bc-EIS.

S1476 Efficacy and Clinical Outcomes of Endoscopic Variceal Ligation With N-butyl-2-cyanoacrylate in Pediatric Patients in a Tertiary Care Center—A Retrospective Study

Introduction: Acute variceal bleeding (AVB) from gastroesophageal varices is a life-threatening complication in patients with portal hypertension. Bleeding from gastric varices is less common and treatment options are not standardized. Endoscopic variceal obliteration (EVO) with N-butyl-2-cyanoacrylate glue or balloon-occluded retrograde transvenous obliteration (BRTO) are the 2 most common treatment modalities and information on these are limited to adult series. There is paucity of information about gastric varices and its treatment in children. Methods: We conducted a retrospective cohort study among pediatric patients (1-18 years) who presented to our center with AVB from gastric varices. Between 2011-2021, we identified 538 among 4539 cases (12%) of portal hypertension with bleeding from gastric varices. Of these only 14 cases (2.6%) had a diagnosis of gastric variceal bleeding in children. Details of 13 patients were extracted with non-availability of records of 1 patient. Cyanoacrylate glue in 0.5-1 ml were injected in to the gastric varices. Patients were evaluated for efficacy, safety and complications associated with the treatment. Endoscopy was repeated after 3 weeks for assessment of variceal size and need for repeat glue injection. Results: The mean age of the patients was 13.3±5.2, with males (54%) and females (46%). The mean age at first presentation to hospital with gastrointestinal bleeding was 8.7±3.6, with hematemesis (62%) being the most common presentation. On endoscopy, 8 patients had type 1 gastro-esophageal varices and 3 patients had type 2 gastroesophageal varices. All 13 patients had stigmata of recent gastric variceal bleeding. The most common cause of portal hypertension was extra hepatic portal venous obstruction (EHPVO) (54%). The mean age at glue therapy treatment was 11.3±5.3. While immediate hemostasis was achieved in all 13 patients (100%) with gastric variceal bleeding, re-bleeding was seen among 3 patients, which occurred after 1 month of glue therapy. 1-3 sessions were required for obliteration of gastric varices. There was one case of death among the 13 children: a patient with decompensated Wilson’s disease. We did not encounter complications like anaphylactic shock, treatment-associated infection, gastric perforation, and distant emboli. Conclusion: The experience from our series suggests that endoscopic vascular obliteration using cyanoacrylate glue injection is safe and effective in children with gastric variceal bleeding.

Comparison of betablockers and endoscopic variceal band ligation (EVBL) for secondary prevention of variceal bleed in cirrhotics.

Objective: To compare the efficacy of pharmacological and endoscopic procedures (band ligation) in preventing variceal bleed. Study Design: Randomized Control Trial. Setting: MU-I of Allied Hospital Faisalabad. Period: January to June 2020. Material &amp; Methods: 80 patients were enrolled after fulfilling exclusion and inclusion criteria, divided into two groups. Group A, patients treated Carvedilol 6.25-12.5mg pulse rate of 60-70 beats per minute. Group B patients underwent repeated endoscopic procedures (band ligation), repeated every 2 weeks until obliteration of varices was achieved. Surveillance endoscopy was done one month later. Follow up was done by telephonic contact at 3 months. Results: In our study, mean age was 52.88+9.29 and 53.57+8.85 years in Group-A and B, 42.5%(n=17) in Group-A and 50%(n=20) in Group-B were male, 57.5%(n=23) in Group-A and 50%(n=20) female in group B, Recurrence of variceal bleeding and efficacy of drug comparison showed that 7.5%(n=3) in Group-A and 27.5%(n=11) in Group-B had a recurrence of variceal bleed while 92.5%(n=37) in Group-A and 72.5%(n=29) in Group-B had no recurrence of variceal bleed, p-value (0.01) was significant. Conclusion: Beta-blocker (Carvedilol) is more efficacious for preventing recurrence of variceal bleed than Endoscopic Band Ligation.

Primary sclerosing cholangitis - an insidious enemy of the liver - case report

Background and introduction&#x0D; Primary sclerosing cholangitis (PSC) is a chronic liver disease with features of cholestasis as a result of inflammation and damage to the bile ducts, which can eventually lead to liver fibrosis and parenchymal failure at an advanced stage.&#x0D; Case Report&#x0D; A 22-year-old man was admitted urgently to the Department of Gastroenterology for complaints of abdominal pain, weakness and tarry stools. A panel of detailed examinations was performed to establish the diagnosis. An abdominal ultrasound scan showed significant enlargement of the liver and spleen. Gastroscopy revealed variceal columns of II degree in the lower esophagus, which were cauterized. Laboratory tests confirmed anemia, reduced platelet and white blood cell counts, increased activity of ALT, ASP, GTP, ALP and slight elevation of total bilirubin in the blood. Based on the clinical disease manifestation and the results of diagnostic tests, cirrhosis of unknown origin was suspected. Subsequent magnetic resonance cholangiopancreatography (MRCP) revealed the presence of multiple strictures in the intra- and extrahepatic bile ducts and gave rise to the diagnosis of PSC. Pharmacological treatment was administered. Currently, the patient remains under the close care of the Transplant Clinic, where he undergoes regular checks of liver function, and endoscopic variceal ligation (EVL) as required.&#x0D; Discussion with conclusions&#x0D; The case presented here shows that the course of PSC can be insidious and asymptomatic. Despite the absence of clinical symptoms, the disease can lead to the development of advanced cirrhosis even in patients of young age and be diagnosed as late as at the decompensated stage, when the only treatment option remains organ transplantation.