Endoscopic Treatment Of Esophageal Varices Research Articles

Minimal invasive prophylaxis of bleeding from esophageal varices in children with extrahepatic portal hypertension

The objective of the work was to study the efficacy of minimally invasive endoscopic treatment of esophageal varices (EV) in children with extrahepatic portal hypertension (EHPH).Methods and Materials. Eighty children aged 3 to 17 years of age with EHPH included in this study. The patients were divided into three analysis groups. The group I (n=14) included children with EHPH who had not previously undergone any surgical interventions and endoscopic ligation of EV was performed against the background of acute bleeding or after medical hemostatic treatment. The group II (n=37) included patients who had undergone the endoscopic treatment of EV after an unsatisfactory outcome of previously performed surgical interventions. The group III included 29 children who underwent only azygos-portal disconnection procedures. We performed the comparative analysis of the severity of EV before and after sessions of the endoscopic treatment of EV, as well as the analysis of the frequency of recurrent bleedings in comparison groups.Results. According to the research results, recurrent gastroesophageal hemorrhages were noted in 44.4 % of cases in the group I. In the group II, 37 patients underwent a total of 68 sessions of the stage endoscopic treatment of EV. According to the control endoscopic examinations, there was a significant reduction in the risk of bleeding from EV between ligation sessions (p=0.001) of the endoscopic treatment of EV. During the follow-up period, in the group II, recurrent bleedings from EV were noted in 6 (16.2 %) patients. Whereas in 10 (34.5 %) children of the group III, recurrent gastroesophageal hemorrhages were noted in the postoperative period. The analysis showed a significant correlation of the presence of «red flags» with recurrent episodes of bleedings in children of the group II after the endoscopic treatment of EV (r=0.32 p=0.05). Analysis of the causes of recurrent gastroesophageal bleedings in children of the group III did not reveal significant differences in such parameters as the degree of EV and «red flags».Conclusion. Thus, the endoscopic treatment of EV is a safe and effective method of secondary prevention of bleedings from EV. The question concerning the primary prevention of gastroesophageal hemorrhages require further study.

64 STATISTICAL ANALYSIS OF PROGNOSTIC FACTORS AFFECTING LONG-TERM PROGNOSIS AFTER ENDOSCOPIC TREATMENT OF ESOPHAGEAL VARICES

Abstract Gastroesophageal varices are present in approximately 50% of patients with cirrhosis, and their rupture is a life-threatening complication. However, mortality rates have declined due to the progress in the management of these patients. Especially advances in endoscopic treatment have contributed to the improved survival rates. In this study, we investigated the prognostic factors associated with long-term survival after endoscopic treatment for esophageal varices. Methods The subjects were 260 patients who underwent initial endoscopic treatment for esophageal varices in our hospital between January 1997 and June 2019. Among them, 160 successfully followed up. The patients’ characteristics were: mean age, 65.4 years (29–85); 109 men and 51 women; and median survival period, 53 months. For analysis, subjects were divided into long-term survival and non-long-term survival groups (n = 59 for each) with a 53-month survival period as a cut-off value. Results The long-term/non-long-term survival group had a preoperative Child-Pugh score of 6.2 ± 1.1/7.4 ± 2.0 (p < 0.01) and hepatocellular carcinoma (HCC) presence rate was 25.4%/55.9% (p < 0.01), significantly higher in the non-long-term group. Analysis of the factors affecting survival period using Cox proportional hazards model showed that Child-Pugh score B or C [hazard ratio(HR):2.0143, p < 0.05], total bilirubin value≧ 2 [HR:2.5573, p < 0.05], and presence of HCC [HR:2.2450, p < 0.01] were noted as significant factors. Only presence of HCC was found to be a significant factor affecting the long-term survival using multiple logistic regression analysis [odds ratio:0.3463, p < 0.05]. Conclusion Our study revealed that liver function and the presence of HCC affect long-term prognosis after endoscopic treatment for esophageal varices.

Visceral Adipose Tissue Index and Hepatocellular Carcinoma Are Independent Predictors of Outcome in Patients with Cirrhosis Having Endoscopic Treatment for Esophageal Varices

Background: The relationship between the amount of adipose tissue and advanced-stage liver cirrhosis with esophageal varices (EV) is unknown. We aimed to reveal the prognostic significance of adipose tissues in patients with liver cirrhosis. Methods: We enrolled 87 patients with EV who received initial endoscopic treatment and underwent scheduled treatments in our hospital. Computed tomography (CT) images were obtained of a 5-mm slice at the umbilical level. We evaluated the effect of mortality based on the visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue ratio (VSR). Results: Cox hazard multivariate analysis showed that the presence of hepatocellular carcinoma (HCC; hazard ratio [HR]: 4.650, 95% confidence interval [CI]: 1.750–12.353, p = 0.002), γ-GTP (HR: 1.003, 95% CI: 1.001–1.006, p = 0.026), and VATI (HR: 1.057, 95% CI: 1.030–1.085, p < 0.001) significantly affected mortality. Cox hazard multivariate analysis for liver-related death was also significantly affected by HCC (HR: 1.057, 95% CI: 1.030–1.085, p < 0.001) and VATI (HR: 1.052, 95% CI: 1.019–1.086, p = 0.002). The difference between the Child-Pugh scores 12 months after treatment and that during initial treatment were significantly positively correlated with VATI (r = 0.326, p = 0.027). Patients with high VATI had a significantly higher frequency of HCC after EV treatment by Kaplan-Meier analysis (p = 0.044). Conclusion: Our findings suggest that VATI measured by CT could significantly predict mortality in cirrhosis patients through decreasing liver function and increasing HCC frequency, and appropriately controlling VATI could improve their prognosis.

Endoscopic treatment of esophageal varices and treatment results: A study in our institution

Endoscopic treatment of esophageal varices and treatment results: A study in our institution

Su2029 – Usefullness of Branched-Chain Amino Acid-Enriched Enteral Nutrition in the Endoscopic Treatment of Esophageal Varices

Su2029 – Usefullness of Branched-Chain Amino Acid-Enriched Enteral Nutrition in the Endoscopic Treatment of Esophageal Varices

Prognosis factors of survival in patients with liver cirrhosis and portal hypertension.

To study prognostic factors for survival in patients of liver cirrhosis (LC) with portal hypertension (PG). 155 patients (women - 49.4%, men - 50.6%, median age 56.4 years [51.3; 61.6]) were follow up for 36 months. Viral LC was diagnosed in 33.8%, alcohol LC - 22.1%, autoimmune LC - 15.6%, other causes and cryptogenic causes noted in - 28.5%. More than half of the patients had a class В of Child-Pugh (51.9%). During the study period 42 patients (28.3%) died. The analysis of survival by various factors for Kaplan-Mayer was carried out. Significant predictors: Child-Pugh class, LC etiology, comorbidity in Charlson scores, adherence to endoscopic treatment of esophageal varices were included in the model of proportional Cox risks. In a single-factor analysis, the risk of death is higher in patients who violate the timing of endoscopic treatment, but this factor has lost significance in the multifactor model. Patient with Child-Pugh C, alcoholic LC, comorbidity more 5 points by Charlson score have a higher mortality risk. Identification of risk factors that affect the survival of LC patients will allow to use of an individual plan for the LC treatment and prevention of PG complications.

PS01.042: THE PRESENCE OF HCC AFFECT LONG-TERM PROGNOSIS AFTER ENDOSCOPIC TREATMENT FOR ESOPHAGEAL VARICES

Abstract Background Gastroesophageal varices are present in approximately 50% of patients with cirrhosis, and their rupture is a life-threatening complication. However, mortality rates have declined due to the progress in the management of these patients. Especially advances in endoscopic treatment have contributed to the improved survival rates. In this study, we investigated the prognostic factors associated with long-term survival after endoscopic treatment for esophageal varices. Methods The subjects were 256 patients who underwent initial endoscopic treatment for esophageal varices in our hospital between January 1997 and January 2017. Among them, 143 successfully followed up. The patients’ characteristics were: mean age, 63.8 years (29–85); 97 men and 46 women; and median survival period, 53 months. For analysis, subjects were divided into long-term survival and non-long-term survival groups (n = 59 for each) with a 53-month survival period as a cut-off value. Results The mean age in the long-term/non-long-term survival group was 62.4 ± 9.4 years/67.2 ± 10.5 years, indicating a significantly higher age in the non-long-term group (P &lt; 0.01). Preoperative Child-Pugh score was 6.3 ± 1.2/7.5 ± 2.2 (P &lt; 0.01) and hepatocellular carcinoma (HCC) presence rate was 25.7%/56.2% (P &lt; 0.01), significantly higher in the non-long-term group. Additionally, regarding the treatment method, endoscopic injection sclerotherapy (EIS): endoscopic variceal ligation (EVL) alone in the groups was 50:9/41:18, suggesting a significantly higher EVL rate in the non-long-term group (P &lt; 0.05). Recurrence of esophageal varices occurred in 33 and 22 patients in the long-term and non-long-term groups, respectively, with no significant difference between groups. Analysis of the factors affecting survival period using Cox proportional hazards model showed that Child-Pugh score B or C [hazard ratio(HR):2.0143, P &lt; 0.05], total bilirubin value≧ 2 [HR:2.5573, P &lt; 0.05], and presence of HCC [HR:2.2450, P &lt; 0.01] were noted as significant factors, but the recurrence of esophageal varices was not noted as significant. Only presence of HCC was found to be a significant factor affecting the long-term survival using multiple logistic regression analysis [odds ratio(OR) 0.3463, P &lt; 0.05]. Conclusion Our study revealed that liver function and the presence of HCC affect long-term prognosis after endoscopic treatment for esophageal varices. Disclosure All authors have declared no conflicts of interest.

PS01.046: ENDOSCOPIC THERAPY FOR ESOPHAGEAL VARICES IN THE ELDERLY CAN BE PERFORMED IN SAFETY

Abstract Background In this study, we evaluated the risk of complications and the effects of the treatment of esophageal varices in elderly patients with cirrhosis, by comparing the data of elderly and non-elderly patients. Methods We included 284 patients who received endoscopic therapy for esophageal and gastric varices at our hospital between February 2004 and December 2016 in the study.The subjects were divided into two groups.An elderly group comprising patients who were 65 years of or order.A Non-elderly group comprising patients who were under 65 yearsWe compared various parameters such as blood data before and after the endoscopic therapy, as well as the complications associated with the treatment, and then performed statistical analyses on the results. Results Of the 284 subjects, 168 patients were elderly group 65 years or older and 116 patients were non-elderly groupaged less than 65 years. Complications were observed in 30 of 168 subjects (17.8%) in the elderly groupwho were aged 65 years or greater and in 25 of 116 subjects (21.6%) under 65 yearsin the non-elderly group, which did not indicate a significant difference between the two groups. The Child-Pugh score was 6.6 ± 0.1 in the elderly group and 7.1 ± 0.2 in the non-elderly group, indicating that the score was significantly lower in the elderly group (P &lt; 0.05). Our investigation of the patients’ medical history pertaining to liver complications indicated that 32.3% of the subjects in the non-elderly group were alcoholics, as compared to 14.8% in the elderly group, indicating a significantly higher percentage of alcoholics in the non-elderly group (P &lt; 0.01). Our investigation of the efficacy of the treatment of varices indicated that the recurrence rate within 1 year was 29.2% in the elderly group and 28.0% in the non-elderly group, indicating that there was no significant difference between the two groups. Conclusion Our study comparing the endoscopic treatment of esophageal varices in the elderly and the non-elderly revealed that there were no significant differences in the increase in the risk of complications or the efficacy of treatment. Therefore, we believe aggressive treatment shouldmay be considered even for elderly patients to avoid the risk of variceal rupture and bleeding. Disclosure All authors have declared no conflicts of interest.

PS01.039: RECURRENCE PREDICTION EQUATION OF ESOPHAGEAL VARICES

Abstract Background Endoscopic treatment is widely performed for esophageal varices, but prediction of post-treatment recurrence is difficult. Methods The subjects were 298 patients with cirrhosis who underwent initial endoscopic treatment for esophageal varices from January 1997 to December 2010 and were followed-up at our hospital. The average age was 64.5 years (29–84) and the male/female ratio was 119:89. The causes of cirrhosis were hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholism, non-alcoholic steatohepatitis (NASH), and others in 66, 14, 13, 3 and 4% of the subjects, respectively. Hepatic reserve capacity before treatment was Child-Pugh score 6.9 ± 1.5 points, albumin 3.2 ± 0.6 g/dl, total bilirubin 1.4 ± 0.7 mg/dl, and PT% 71.0 ± 13.8%. Complication of hepatocellular cancer (HCC) was present in 63 subjects (30.4%). Treatment-indicated recurrence was defined as ³F2 and ³RC2. Recurrence occurred in 102 subjects, including 65 who redeveloped varicosity within 1 year. Data were compared between patients with (n = 65) and without (n = 43) early recurrence (within 1 year). Results The early recurrence group had a significantly higher Child-Pugh score (7.4 ± 1.8 vs. 6.7 ± 1.3, P &lt; 0.01), total bilirubin (1.6 ± 0.8 vs. 1.2 ± 0.6 mg/dl, P &lt; 0.01), and HCC complication rate (44.6% vs. 23.9%, P &lt; 0.01), and significantly lower albumin (3.0 ± 0.7 vs. 3.3 ± 0.6 g/dl, P &lt; 0.01) and administration rate of antihypertensive drugs (10.8% vs. 41.0%, P &lt; 0.01). In multivariate logistic regression analysis, use of antihypertensive drugs, total bilirubin, HCC, underlying disease (alcoholism), and treatment method (endoscopic injection sclerotherapy [EIS] or endoscopic variceal ligation [EVL]) emerged as factors that affected early recurrence. Based on these findings, we developed the following predictive equation: recurrence time (months) = - 12.5206 (HCC: confirmed = 1, not confirmed = 0) - 3.5029 (total bilirubin) + 6.2169 (antihypertensive drug: used = 1, not used = 0) - 7.2581 (alcoholism: yes = 1, no = 0) - 6.0764 (EVL = 1, EIS = 0) + 35.7165. Based on this formula, we examined the predicted and actual recurrence times in 68 subjects from January 2011 to December 2012 and found a significant positive correlation between these data (R = 0.583, P &lt; 0.01). Conclusion An equation was developed for prediction of recurrence of esophageal varices after treatment and was shown to have utility in actual cases. Disclosure All authors have declared no conflicts of interest.

Risk factors analysis of early rebleeding after endoscopic treatment of esophageal varices

Objective To investigate the risk factors of early rebleeding after endoscopic treatment of esophageal varices. Methods A retrospective analysis was performed on the clinical data of 384 cirrhotic patients with esophageal varices. The factors of early rebleeding group[n=36 (9.4%)] and non-bleeding group (n=348) were compared by single factor analysis and multivariate analysis of Logistic regression. Results Single factor analysis showed that there were differences between the two groups in cirrhosis with hepatocellular carcinoma, Child-Pugh classification, Child-Pugh score, ascites volume, portal vein thrombosis, portal vein width, portal hypertensive gastropathy, shapes and numbers of varicose veins, numbers of varicose vein ligation, varicose vein red syndrome, albumin, total bilirubin, prothrombin time, prothrombin activity and platelet number. Further multivariate analysis showed that mass ascites (P=0.000, OR=7.614, 95%CI: 3.590-16.147), portal vein thrombosis (P=0.003, OR=2.867, 95%CI: 1.429-5.750), portal hypertensive gastropathy (P=0.000, OR=6.212, 95%CI: 3.036-12.711), and Child-Pugh C (P=0.008, OR=3.078, 95%CI: 1.338-7.083) were independent risk factors of early rebleeding after endoscopic treatment. Conclusion The early rebleeding rate was high after endoscopic treatment of esophageal varices. Patients with massive ascites, portal vein thrombosis, portal hypertensive gastropathy and Child-Pugh C should be highly vigilant for early rebleeding. Key words: Esophageal varices; Endoscopic variceal ligation; Endoscopic injection sclerotherapy; Early rebleeding

Does Diet Affect Post-EVL Rebleeding Rates? A Review of High-Risk Hospitalized Patients

Introduction: There is lacking evidence evaluating the impact of time to feeding and type of diet after endoscopic treatment of esophageal varices. We conducted a retrospective chart review with the aim of evaluating the impact of time to feeding and the type of diet on the incidence of rebleeding for patients treated endoscopically for bleeding gastroesophageal varices. Methods: We conducted a retrospective chart review at Elmhurst Hospital Center, cirrhotic patients presenting with an acute esophageal variceal bleed treated endoscopcially with band ligation between 2000 and 2016 were enrolled. Patient demographics, information pertaining to their cirrhosis and variceal stage, time to diet initiation, diet type and rebleeding information was collected.Table: Table. Patient DemographicsResults: A total of 49 patients were enrolled in the study, 39 were male (80%). Median age was 58, 10/22/17 patients were child pugh A/B/C respectively. INR median 1.4, Platelet count Median 87,000. Initial hemostasis was achieved in 100% of acute esophageal variceal bleeds. The total number of rebleeders was 19(39%), with 1 (5%) rebleed ocurring 30 days after band ligation. Twenty-Five patients resumed diet on post op day 1, 9 (36%) patients had rebleeding (8 clear liquids, 1 regular diet) out of which only 1 (11%) occurred < 5 days post op (clear liquid). Out of 9 patients that resumed diet on day 2, 4 (44%) (2 clear liquid, 1 pureed and 1 regular diet) rebled. Conclusion: Timing of initiation of dietary intake after the initial treatment of bleeding esophageal varices may play a role in rebleeding. Further studies are warranted to determine their relationship.

Changes in skeletal muscle mass after endoscopic treatment in patients with esophageal varices.

To the best of our knowledge, no available data with regard to changes in skeletal muscle mass for liver cirrhosis (LC) patients with esophageal varices (EVs) undergoing endoscopic therapy as a primary prophylaxis could exist. As endoscopic therapies, such as endoscopic injection sclerotherapy or endoscopic band ligation for EVs, accompany invasive procedure and patients with EVs receiving endoscopic therapies mostly rest in bed during hospitalization, clarifying these issues are clinically of importance. The purposes of this study were therefore to examine changes in skeletal muscle mass for LC patients with EVs undergoing endoscopic therapy as a primary prophylaxis and to identify pretreatment predictors which are associated with the amelioration in skeletal muscle mass. This is a subgroup analysis in our previous randomized controlled trial. A total of 51 LC patients with EVs were analyzed. Skeletal muscle mass was assessed using bioimpedance analysis (BIA). Skeletal muscle index (SMI) was defined as sum of skeletal muscle mass in body trunk and upper and lower extremities divided by height squared (cm2/m2) using data for BIA. We compared the changes in SMI at baseline and SMI at Day 50 after endoscopic treatment for EVs. Our study cohort included 33 males and 18 females with median (range) age of 62 (29–81) years. There were 31 patients with Child–Pugh A and 20 with Child–Pugh B. The median SMI for the entire cohort at baseline was 8.96 cm2/m2 (range, 5.87–13.11 cm2/m2), while the median SMI for the entire cohort at Day 50 was 8.83 cm2/m2 (range, 5.59–12.29 cm2/m2) (P = .9995). In baseline characteristics, prealbumin (P = .0477), branched-chain amino acid to tyrosine ratio (BTR) (P = .0056), and retinol-binding protein (P = .0296) in the increased SMI group (n = 15) were significantly higher than those in the nonincreased SMI group (n = 36). Multivariate analysis for the above 3 significant factors showed that only BTR was a significant prognostic pretreatment factor linked to the presence of increased SMI (P = .0235). In conclusion, pretreatment BTR level can be helpful for predicting increased SMI after endoscopic therapy as a primary prophylaxis for LC patients with EVs.

Application of Endoscopic Ultrasonography in Portal Hypertension

Application of endoscopic ultrasonography (EUS) in portal hypertension includes predicting outcome of varices, EUS –guided treatment for varices and directly portal vein catheterization. About sixty percentage portal hypertension patients have esophageal varcies. One third of them may have esophageal varcies bleeding. If untreated, the mortality rate is about fifty percent. Para-esophageal varices and peri-esophageal varices were collateral vessels outside the esophageal lumen. Although never bleeding, they are predictive factors for outcome of esophageal vaices. Esophageal varices, peri-esophageal varices and para-esophageal varices can be visualized adequately by EUS. The severity of peri-esophageal vairvces and para-esophageal varices shown in EUS is associated with esophageal varices formation. The peri-esophageal varices and para-esophageal varices in EUS are proven to be able to predict the efficacy of endoscopic treatment of esophageal varices, either for primary or secondary prophylaxis. Recently, studies also show that peri-esophageal varices and para-esphageal varices in EUS also predict pharmacological response of esophageal varices. Free hand gastric varices obliteration by histocryl injection is the standard care of secondary prophylaxis. The shortcomings of free hand hisrocyl injection are high rebleeding rate and complications of embolism. The retrospective data of EUS guided angiotherapy is promising and showed to have lower rebleeding rate and complication of embolism. Several prospective studies are on going now. In animal studies, EUS guided portal vein catheterization is a feasible method. It can be used to measure portal pressure directly and to create intrahepatic portosystemic shunt.

Portal Hypertension Over the Last 25 Years: Where Did It Go?

Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed. Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001). In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.

Endoscopic Treatment for Esophageal Varices

Endoscopic Treatment for Esophageal Varices

Lauromacrogol injection in sclerotherapy for esophageal varices

Objective To analysis of the effectiveness and safety of lauromacrogol injection in the endoscopic treatment of esophageal varices bleeding.Methods The effectiveness and postoperative complications of 166 patients receiving endoscopic sclerotherapy of lauromacrogol injection in the treatment of esophageal varices at our hospital were statistically analyzed.The efficacy and safety were evaluated.Results The hemostasis rate of endoscopic sclerotherapy of lauromacrogol injection in the treatment of esophageal varices was 90.36％.Only 17.88％ patients re-bled.Chest pain was the main postoperative complication.Conclusions Endoscopic sclerotherapy of lauromacrogol injection for esophageal varices under is effective and safe and could be easily accepted by the patients.It is worth being generalized. Key words: Lauromacrogol injection; Sclerotherapy; safety

Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment

BackgroundThe usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices.MethodsPatients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50.ResultsIn study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group.ConclusionsThe BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.Electronic supplementary materialThe online version of this article (doi:10.1007/s00535-014-0950-2) contains supplementary material, which is available to authorized users.

Correlation between Indocyanine green retention test and esophageal varices among patients with hepatocellular carcinoma

We recently read with great interest the manuscript entitled ‘‘Prophylactic impact of endoscopic treatment for esophageal varices in liver resection: a prospective study’’ [1] in which Dr. Yamazaki et al. demonstrated the usefulness of endoscopic prophylactic treatment of esophageal varices (EV) and evaluated different risk factors for post-operative progression and bleeding. The authors observed that in patients with hepatocellular carcinoma (HCC), various laboratory variables were significantly different according to the presence or absence of EV; for example, indocyanine green (ICG) retention rate at 15 min (ICG-r15) was 10.9 % (2.1–37.7) in patients without EV and 15.4 % (3.7–46.0) in patients with EV (P \ 0.001). Finally, they observed that ICG-r15 [ 30 % is independently correlated with the risk of worsening varices. We recently reported our experience [2] aimed to evaluate ICG 15-min retention test as a non-invasive marker of PH and EV in patients with compensated liver cirrhosis in which we demonstrated that among patients with well-preserved liver function, ICG retention tests indirectly correlate with the presence and degree of portal hypertension and its complications (EV). According to the observations of Dr. Yamazaki et al., ICG-r15 correlated with the presence of esophageal varices; we found two different ICG-r15 cut-off points able to accurately rule out and rule in the presence of EV (\10 % and C22.9 %, respectively). Liver-mediated uptake of organic anions (drugs or xenobiotics) is mainly mediated by organic anion transporting polypeptides (OATPs) and organic anion transporters (OATs); ICG presents a potent inhibitor effect on OATP isoforms and Na-taurocholate transporting polypeptide (NTCP). OATP1B3 and NTCP are the transporters involved in the hepatic uptake of ICG [3]. The organic anion transporter peptides (OATP) 1B1 and 1B3 are variably and progressively lost during liver carcinogenesis; a previous study performed on patients who underwent OLT because of HCC demonstrated a correlation between the loss of OATP 1B1/ 1B3 and tumor morphological features [4]. These molecular findings could, in our opinion, justify the higher ICG-r15 values observed by Dr. Yamazaki et al. in their population. Indeed, the ICG retention test, among patients with liver cirrhosis, represents both liver parenchymal reserve and hepatic blood flow; in patients with HCC, this interplay is altered by the introduction of a third variable (cancer biology) and could not be argued. This comment refers to the article available at doi:10.1007/s00535013-0841-y.

Endoscopic treatment of esophageal varices in patients with liver cirrhosis.

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

Two cases of infantile esophageal varices treated successfully by an endoscopic procedure

There is no definite consensus on the most suitable endoscopic treatment for esophageal varices in children. Especially, endoscopic treatment of infants under 1 year of age is very rare. We performed endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) for two 10-month-old infants with liver cirrhosis associated with congenital biliary atresia. Case 1 was a 10-month-old female infant who was 72 cm in height and weighed 10.0 kg. Endoscopic examination under general anesthesia was performed for melena, The source of the bleeding was identified as esophageal varices 〔Li, F2, Cb, RC (＋) 〕. An endoscope with an EVL device could be passed through the narrow opening of the esophagus, and the bleeding varix was ligated by EVL. Case 2 was a 10-month-old female infant who was 65.2 cm in height and weighed 6.6 kg. Endoscopic examination was performed as a screening procedure prior to living donor liver transplantation. Esophageal varices 〔Ls, F3, Cb, RC (＋) 〕 were found. An endoscope with an EVL device could not be negotiated through the opening of the esophagus, therefore, EIS was performed. Because of the scarcity of cases receiving endoscopic treatments among children, it is difficult to evaluate the differential therapeutic outcomes between EIS and EVL in this patient population. Based on previous reports, it would appear that the risk of complications is higher in cases treated by EIS than that in cases treated by EVL. Therefore, we think that EVL might be preferable to EIS in children. In case 1, we succeeded in performing EVL effectively and safely in a 10-month-old infant. Therefore, the endoscopic procedure of first choice for esophageal varices in infants below 1 year of age is EVL, if the EVL device can be negotiated past the opening of the esophagus.