Endoscopic Management Of Gastric Varices Research Articles

Advances in the endoscopic management of gastric varices.

This review provides an overview of the treatment options available for gastric varices (GV) with a focus on endoscopic methods. Various minimally invasive techniques, including endoscopic band ligation, endoscopic cyanoacrylate injection, and transjugular intrahepatic portosystemic shunt, can be applied to the treatment of GV. Endoscopic cyanoacrylate injection is now recognized as a first-line treatment for GV. Endoscopic ultrasound-guided cyanoacrylate injection combined with coils has shown good security and effectiveness. Thrombin injection therapy is a promising treatment, with a similar hemostasis rate to cyanoacrylate injection but with fewer serious complications. With the deepening understanding of the hemodynamics of the GV system, various treatment methods and their combination are gradually evaluated to provide patients with safer and more effective treatment options.

Management of Gastric Varices: GI Perspective

AbstractThere is a paucity of literature on the management of gastric varices and current guidelines rely heavily on expert opinion. Optimal treatment of gastric varices requires a multidisciplinary team including gastrointestinal endoscopist, hepatologist, and interventional radiologists. Initial management relies on endoscopic diagnosis followed by therapeutic modalities based on the experience of the endoscopist and the institution. Definitive management may be endoscopic, endovascular, or a combination of the two disciplines. In this review, we discuss endoscopic management of gastric varices with direct endoscopic glue injection, endoscopic ultrasound-guided management, limitations, and adverse events. We conclude by describing a case of gastric variceal bleeding managed with endoscopy when interventional radiographic techniques were not feasible.

Safety and Cost-Effectiveness of N-butyl-2-Cyanoacrylate without Lipiodol in Endoscopic Management of Gastric Varices

Introduction: Gastric varices are frequently seen in patients with portal hypertension. The mainstay of treatment is variceal injection with a mixture of N-butyl-2-Cyanoacrylate and lipiodol. The use of N-butyl-2-Cyanoacrylate without lipiodol is not extensively studied and it can be a cost-effective approach. The objective of our study was to evaluate whether the use of N-butyl-2-Cyanoacrylate without lipiodol is a safe and effective endoscopic treatment for gastric varices. Material and Methods: This prospective observational study was conducted between June 2016 and May 2017 at the Department of Gastroenterology, Gujranwala Medical College/ DHQ Teaching Hospital, Gujranwala. A total of 100 patients with gastric varices diagnosed on upper GI endoscopy were enrolled in the study. N-butyl-2-Cyanoacrylate without lipiodol was injected into the gastric varices of all the patients. All procedures were performed by experienced gastroenterologists. The patients underwent monthly follow-up endoscopies to determine the outcome and adverse events. Results: Out of 100 patients, 40 patients (40 %) were men and 60 (60%) were women. The mean age was 53 years. The mean volume of N-butyl-2-Cyanoacrylate used per session was 1.5ml ± 0.5 ml (range 1-2ml). Obliteration of Gastric varices was achieved in 92 patients (92%) while in 04 patients (4%) varices did not obliterate over a mean follow-up of 12 months. No treatment-related immediate or late complications were observed in all patients. Four patients (4%) died of delayed rebleeding (after two weeks of intervention). Conclusion: Injection therapy of gastric varices with N-butyl-2-Cyanoacrylate alone without lipiodol is a safe and cost-effective method for gastric varices.

864 SUCCESSFUL EUS-GUIDED TREATMENT OF GASTRIC VARICES WITH COIL EMBOLIZATION AND INJECTION OF ABSORBABLE GELATIN SPONGE

Gastric varices occur in 15-20% of patients with portal hypertension and are associated with significant gastrointestinal bleeding and high mortality. Endoscopic options are currently limited in patients with bleeding gastric varices. Here, we report our experience with endoscopic ultrasound-guided coil embolization and injection of absorbable gelatin sponge for the treatment of gastric varices. A 51 year old female with alcoholic cirrhosis, complicated by ascites, hepatic encephalopathy, and known type 1 gastric varices, presents to the hospital with hematemesis. She was deemed by interventional radiology to not be a suitable candidate for either transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO). It was therefore decided to offer EUS-guided treatment of her gastric varices. On EUS, four large collections of gastric varices were visualized, each with multiple individual compartments measuring 7-12 mm in short axis. Multiple varices were seen to directly contact the surface of the fundus. Using a 19 gauge EUS needle, a collection of gastric varices was punctured, followed by deployment of multiple 20 mm x 14 cm and 20 mm x 7 cm embolization coils. Following coil embolization, there was immediate obliteration of Doppler flow. After multiple coils were deployed, and contrast injections ruled out the presence of a gastrorenal shunt, additional injection was performed of absorbable gelatin sponge (prepared as a slurry) in order to further enhance variceal eradication. The process was then repeated until all four collections of gastric varices were eradicated. In total, eight vascular coils were deployed. The patient tolerated the procedure well and has not had recurrent bleeding on follow-up. EUS guided coil embolization and injection of absorbable gelatin sponge is a feasible and effective technique for the endoscopic management of symptomatic gastric varices in patients considered to be poor candidates for standard treatments such as TIPS and BRTO. This case highlights the advantages of coil embolization and absorbable gelatin sponge application, as well as the benefit of EUS guidance, over traditional direct cyanoacrylate injection for the endoscopic management of gastric varices.

Medical and Endoscopic Management of Gastric Varices

In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed.

Endoscopic Management of Gastric Varices with Cyanoacrylate Injection Therapy: Systematic Review and Meta-analysis

Endoscopic Management of Gastric Varices with Cyanoacrylate Injection Therapy: Systematic Review and Meta-analysis

Endoscopic Management of Gastric Varices: Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate in a North American Patient Population

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America. To assess the safety and efficacy of gastric variceal glue injection in a North American population. Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed. Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%. The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.

Endoscopic Management of Gastric Varices; Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate

Background: Bleeding from gastric varices is an important cause of morbidity and mortality in patients with portal hypertension. Injection of glue directly into gastric varices can achieve hemostasis in acutely bleeding lesions as well as prevent rebleeding of varices. Aims: The aim of the present was to describe the clinical characteristics and outcomes of patients undergoing gastric variceal gluing in a well defined Canadian patient population. Methods: This descriptive epidemiological study involves a retrospective chart review of patients undergoing glue injection of gastric varices in the Calgary Health Region (CHR) from 2000-2005. Results: Twenty-nine patients (16 male, 13 female) underwent a total of 40 separate gluing procedures. The mean age was 52 years. Cirrhosis was present in 20 patients and extrahepatic portal vein obstruction in 7. Seventeen had prior known esophageal or gastric varices. At endoscopy, 75% had esophagogastric varices and 25% had isolated gastric varices. Ten also had portal hypertensive gastropathy. Of all gluing procedures, 78% (31 of 40) presented with upper gastrointestinal bleeding prior to endoscopy, although only 12 had actively bleeding gastric varices at endoscopy. Of those, 92% (11 of 12) achieved immediate hemostasis; the other patient died from variceal hemorrhage. One patient had a non-bleeding varix that bled uncontrollably after glue injection requiring insertion of a Linton tube. Rebleeding within 48 hours of gluing was observed after 3 procedures (8%). Two of these episodes were successfully treated with repeat glue injections. At follow-up endoscopy, gastric varices were eradicated in 23 patients (79%). Complications other than bleeding included superior mesenteric vein thrombosis in 1 patient, ulceration at the site of glue injection in 3, and damage to the endoscope in 2. No glue emboli were observed. Twenty-seven (93%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.5% (1 of 40). Conclusions: In the Calgary Health Region, glue injection with cyanoacrylate is safe and effective in the treatment of bleeding and recently bleeding gastric varices.

Endoscopic management of the liver transplant patient

Endoscopic management of the liver transplant patient

Variceal bleeding and portal hypertension: new lights on old horizon.

New clinical, endoscopic, and imaging modalities for diagnosing varices and predicting bleeding are being investigated. Transnasal endoscopy and ultrathin battery-powered esophagoscopes are being used to improve patient comfort and compliance. Patients who respond to portal pressure-reducing drugs not only have a reduced risk of bleeding, but also a reduced risk of developing other complications, with improved survival. Nitrates have been shown to have no definite role in primary prophylaxis against variceal bleeding. The hemodynamic response to treatment has an independent prognostic value for the risk of variceal bleeding. Newer drugs have been investigated for reducing the hepatic venous pressure gradient, but with little success. Survival after bleeding has increased due to improved patient care and technological advances. Combined radiographic and endoscopic management of gastric varices is evolving and appears to be promising. Nonvariceal bleeding from portal hypertensive gastropathy is increasingly being recognized as a potential cause of bleeding in patients with portal hypertension, and pharmacotherapy with octreotide appears to be promising for the treatment of this condition. Variceal band ligation in children has been found to be as safe and effective as in adults.