Endoscopic Variceal Obturation Research Articles

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis

Background/AimsWe retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding.MethodsPatients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included.ResultsNinety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597).ConclusionsBoth EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.

COMPLICATIONS OF NECROSIS ULCER ON ENDOSCOPIC TISSUE ADHESIVE INJECTION IN VARICEAL BLEEDING

Endoscopic variceal obturation with tissue adhesive injection is a mainstay treatment to control gastric variceal bleeding. We looked into the side effects and risks that come with this treatment in a subject. Therefore, this study aimed to evaluate and present a case study of this type of complication. A retrospective complications analysis was performed of a 57-year-old male patient with gastric variceal hemorrhages who was admitted to tertiary care. The patient received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation. Four days past the surgery, the patient experienced recurrent and uncontrolled massive hematemesis and later died of uncontrollable bleeding. This report concludes that although complications from endoscopic variceal obturation with Histoacryl glue N-butyl-2-cyanoacrylate in the treatment of gastric varices are uncommon, they may still occur.

Primary prophylaxis of gastric variceal bleeding: endoscopic obturation, radiologic intervention, or observation?

No single effective method has yet been established for the primary prophylaxis of bleeding from gastric varices (GV). We retrospectively analyzed liver cirrhosis patients with GV who had undergone either endoscopic variceal obturation (EVO) or balloon-occluded retrograde transvenous obliteration (BRTO) as prophylactic treatments, comparing them with those who were observed without any procedural intervention. The endpoints were GV bleeding rate and complete eradication rate. 72 patients in EVO, 41 patients in BRTO, and 97 patients in the clinical observation groups were enrolled. No difference was observed in baseline characteristics. As the primary endpoint, 14 (19.4%) patients in the EVO group and 3 (7.3%) in the BRTO group bled from GV after prophylactic treatment, and 34 (35.1%) patients bled in the observation group during the median follow-up of 35months (p = 0.001). Patients who received EVO or BRTO developed less bleeding from GV than those who received observation only, with no difference between EVO and BRTO (EVO vs. observation, p = 0.038; BRTO vs. observation, p = 0.001; EVO vs. BRTO, p = 0.089). As secondary endpoints, GV disappeared completely in 33 patients (45.8%) in the EVO group and 31 patients (75.6%) in the BRTO group (p = 0.003). By multivariate analysis, complete eradication of GV was the sole determinant for predicting GV bleeding. EVO and BRTO are effective and safe primary prophylactic treatments for preventing bleeding from GV. In particular, BRTO is better than EVO in complete eradication of GV.

Two Cases of Fungemia after Endoscopic Variceal Obturation for Gastric Variceal Bleeding

Fever is a common complication of endoscopic variceal obturation (EVO) therapy for gastric variceal bleeding. However, fungemia related to EVO therapy has not yet been reported. Herein, we report two cases of post-EVO fungemia in cirrhotic patients who underwent therapeutic EVO for gastric variceal bleeding. Both patients developed sustained high fever after repeated EVO procedures while on prophylactic antibiotic use. In both patients, blood cultures revealed yeast, and they were finally diagnosed with Candida infection. Candida is a common member of the intestinal flora; however, it can cause invasive infection with consequent poor prognosis in cirrhotic patients. The route of Candida invasion is unclear; however, repeated EVO may predispose patients to Candida infection, particularly those who are in the end stage of liver disease and receiving prophylactic antibiotics. Our cases highlight that repeated invasive procedures can increase the risk of fungal infections, and fungemia should be considered in the differential diagnosis of post-EVO fever.

A retrospective cohort study of intensive gastric variceal ligation versus endoscopic gastric variceal obturation in the management of gastric variceal bleeding.

Gastric variceal bleeding is often more serious and can be fatal. Currently, international consensus recommendations for the treatment of gastric variceal bleeding vary according to endoscopic classification. Few studies have investigated ligation versus gastric variceal obturation (GVO) for the treatment of gastric varices. The study included 79 patients with cirrhosis-induced bleeding from esophageal and fundal varices who were treated at the Second Hospital of Hebei Medical University between January 2016 and December 2020 and who met the inclusion criteria. Among them, 42 patients were included in the intensive gastric varices ligation (IGVL) group, and 37 were included in the GVO group. We conducted a retrospective cohort study to analyze the effectiveness and safety of these 2 treatments. The rebleeding rate after initial treatment was significantly lower in the IGVL group than in the GVO group (23.8% vs. 48.6%, P<0.05). No significant between-group difference was observed in overall mortality (14.3% vs. 32.4%), 6-week mortality (0.0% vs. 2.7%), or 1-year mortality (11.9% vs. 13.5%, all P>0.05). The >1-year mortality and bleeding-related mortality rates were significantly higher in the GVO group than in the IGVL group (23.3% vs. 2.7%, P<0.05; 27.0% vs. 9.5%, P<0.05). The incidence of adverse events was 57.1% in the IGVL group and 48.6% in the GVO group, with no significant difference (P>0.05). Independent predictors for rebleeding after initial treatment were the use of GVO as endoscopic treatment, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment. Rebleeding after initial treatment was lower after IGVL than GVO. Independent predictors for rebleeding after initial treatment were endoscopic treatment method, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding.

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

951f – A Randomized Controlled Trial of Endoscopic Ultrasound Guided Selective Variceal Devascularization Versus Standard Endoscopic Variceal Obturation for Secondary Prophylaxis of Gastroesophageal Variceal Bleeding in a Tertiary Teaching Hospital

951f – A Randomized Controlled Trial of Endoscopic Ultrasound Guided Selective Variceal Devascularization Versus Standard Endoscopic Variceal Obturation for Secondary Prophylaxis of Gastroesophageal Variceal Bleeding in a Tertiary Teaching Hospital

Risk Factors and On-site Rescue Treatments for Endoscopic Variceal Ligation Failure.

The success rate of endoscopic variceal ligation (EVL) is about 85-94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment. Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion. Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-butyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group. The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.

Procedure-related complications in gastric variceal obturation with tissue glue.

AIMTo focus on procedure-related complications, evaluate their incidence, analyze the reasons and discuss the solutions.METHODSOverall, 628 endoscopic gastric variceal obturation (EGVO) procedures (case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.RESULTSIn the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.CONCLUSIONAlthough EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.

Endoscopic variceal ligation-induced ulcer bleeding: What are the risk factors and treatment strategies?

This study was aimed to determine the risk factors of endoscopic variceal ligation-(EVL) induced ulcer bleeding.The prevalence of EVL-induced ulcer bleeding is reported to be 3.6%. However, there are only limited reports of this serious complication, and the risk factors and the treatment methods are not well established.A total of 430 patients who had undergone EVL in Chonnam National University Hospital from January 2014 to October 2016 were studied. EVL was performed for prophylaxis or acute hemorrhage. The patients were classified into 2 groups: a bleeding group (n = 33) and a non-bleeding group (n = 397). The patients who had endoscopically confirmed EVL-induced ulcer bleeding were included in the bleeding group.EVL-induced ulcer bleeding occurred in 7.7% (n = 33) of the patients. In a multivariate analysis, model for end-stage liver disease (MELD) score >10 (odds ratio [OR]: 3.42, 95% confidence interval [CI]: 1.10–10.64), concomitant GV F3 (OR: 14.1, 95% CI: 2.84–71.43), and detachment of o-ring bands on follow-up endoscopy (OR: 8.06, 95% CI: 2.55–25.64) were independent predictive factors of EVL-induced ulcer bleeding. Various endoscopic modalities were attempted for hemostasis (EVL in 8 cases [24.2%], endoscopic variceal obturation [EVO] with cyanoacrylate in 6 cases [18.2%], argon plasma coagulation [APC] in 1 case (3%), Sengstaken–Blakemore (SB) tube in 3 cases [9.1%]), and proton pump inhibitor therapy only in 15 cases (45.5%).MELD score >10, concomitant GV F3, and detachment of o-ring bands on follow-up endoscopy are risk factors for EVL-induced ulcer bleeding.

A Sinister Cause of Hematemesis

Question: A 52-year-old man with myelofibrosis presented to the emergency room with hematemesis. Earlier that day, he had experienced cough, rhinorrhea, and pharyngitis. On the evening of admission, he vomited blood, prompting him to seek medical attention. He denied fevers, chills, chest pain, abdominal pain, melena, hematochezia, prior history of upper gastrointestinal bleeding, nonsteroidal anti-inflammatory drug ingestion, or alcohol abuse. He was afebrile and hemodynamically stable. Physical examination was significant for splenomegaly and brown, guaiac-positive stool. His abdomen was nontender and nondistended without overt evidence of hepatomegaly. Pertinent laboratory results were as follows: blood urea nitrogen, 34 mg/dL; International Normalized Ratio, 1.3; white blood cell count 4.6 K/μL; platelets, 194 K/μL; and hemoglobin, 12.5 g/dL, which decreased to 9.6 g/dL on repeat 6 hours later. On presentation, he was given an intravenous bolus of esomeprazole 80 mg and initiated on an intravenous esomeprazole drip at 8 mg/h. An urgent upper endoscopy revealed isolated gastric varices with recent evidence of bleeding (Figure A, yellow arrow). He was given a bolus of intravenous octreotide 50 μg followed by an intravenous octreotide drip at 50 μg/h and ceftriaxone 1 g/d. The patient was transferred to the intensive care unit for further monitoring. What was the cause of this patient’s gastric varices (GV) and what is the next appropriate step? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT of the abdomen and pelvis revealed marked splenomegaly and prominent gastric (Figure B, C, arrow), paragastric, splenic, and mesenteric varices (Figure B, C, arrowhead). The patient underwent a liver biopsy, which revealed extramedullary hematopoiesis without evidence of fibrosis or nodular regenerative hyperplasia. Measurement of hepatic venous pressure gradient was 8 mmHg, confirming absence of right-sided portal hypertension. In our patient, sinistral portal hypertension and gastric variceal bleeding occurred secondary to splenomegaly from increased splenic blood flow owing to myelofibrosis-induced extramedullary hematopoiesis. Isolated GV are less prevalent than esophageal or gastroesophageal varices. Our patient had type 1 varices (IGV1), which are confined to the fundus. A common cause of IGV1 is splenic vein thrombosis and this diagnosis should be excluded. Initial management of gastric variceal bleed includes antibiotics, vasoactive drugs, and selective transfusion.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Beyond this initial management, studies have documented the use of splenectomy, splenic embolization, endoscopic variceal obturation (EVO) using tissue adhesives such as cyanoacrylate (CA), endoscopic injection sclerotherapy (EIS), variceal band ligation (EBL), transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration.2Goh B.K. Chen J.J. Tan H.K. et al.Acute variceal bleed in a patient with idiopathic myelofibrosis successfully treated with endoscopic variceal band ligation.Dig Dis Sci. 2007; 52: 173-175Crossref PubMed Scopus (2) Google Scholar CA has demonstrated higher hemostasis and lower rebleeding rates compared with EBL and EIS. A recent study has shown that endoscopic ultrasonographic (EUS)-guided therapy for fundal varices with CA and coils may improve efficacy and decrease embolization of glue.3Binmoeller K.F. Weilert F. Shah J.N. et al.EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos).Gastrointest Endosc. 2011; 74: 1019-1025Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar CA is not currently available in the United States. However, many experts agree that, in patients with bleeding gastric fundal varices, the use of CA is preferred where available, with EBL as an alternative.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Splenectomy can be definitive treatment in patients with GV associated with sinistral portal hypertension.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar In patients with myelofibrosis and splenomegaly, splenectomy is reserved for those with drug-refractory, symptomatic splenomegaly associated with frequent transfusions, portal hypertension, or severe thrombocytopenia. In our patient, splenectomy was chosen over EVO or transjugular intrahepatic portosystemic shunt owing to lack of available CA in the United States and the lack of elevated right-sided portal pressures. Postoperatively, his white blood cell count was 6.7 K/μL and platelet count was 279 K/μL. He received low-molecular-weight heparin for splenic and portal vein thrombosis, as well as hydrea and interferon. Repeat endoscopy 1 year after surgery showed no evidence of any varices. This case highlights the need for larger scale, randomized, controlled trials to guide management of gastric variceal bleeding. In addition, not all effective endoscopic and interventional techniques to treat GV are widely available, making it difficult for providers to follow current recommendations.

Mo1350 The Evaluation of the Cyanoacrylate Injection Treatment of Gastric Varices With Endosonography

Endoscopic variceal obturation with cyanoacrylate glue (cyanoacrylate based tissue adhesive) is effective for gastric variceal bleeding, with better control of initial hemorrhage as well as lower rates of rebleeding. Number of sessions is determined depending on the endoscopists. During the procedure, if

Proton pump inhibitor administration delays rebleeding after endoscopic gastric variceal obturation.

To clarify the efficacy of proton pump inhibitors (PPIs) after endoscopic variceal obturation (EVO) with N-butyl-2-cyanoacrylate. A retrospective study was performed on 16 liver cirrhosis patients with gastric variceal bleeding that received EVO with injections of N-butyl-2-cyanoacrylate at a single center (Kyung Hee University Hospital at Gangdong) from January 2008 to December 2012. Medical records including patient characteristics and endoscopic findings were reviewed. Treatment results, liver function, serum biochemistry and cirrhosis etiology were compared between patients receiving PPIs and those that did not. Furthermore, the rebleeding interval was compared between patients that received PPI treatment after EVO and those who did not. The patient group included nine males and seven females with a mean age of 61.8 ± 11.7 years. Following the EVO procedure, eight of the 12 patients that received PPIs and three of the four non-PPI patients experienced rebleeding. There were no differences between the groups in serum biochemistry or patient characteristics. The rebleeding rate was not significantly different between the groups, however, patients receiving PPIs had a significantly longer rebleeding interval compared to non-PPI patients (22.2 ± 11.2 mo vs 8.5 ± 5.5 mo; P = 0.008). The duration of PPI use was not related to the rebleeding interval. A total of six patients, who had ulcers at the injection site, exhibited a shorter rebleeding interval (16.8 ± 5.9 mo) than patients without ulcers (19.9 ± 3.2 mo), though this difference was not statistically significant. PPI therapy can extend the rebleeding interval, and should therefore be considered after EVO treatment for gastric varices.

Management of acute variceal bleeding.

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

Percutaneous transhepatic variceal embolization with 2-Octyl.Cyanoacrylate versus endoscopic cyano- acrylate injection for treatment of gastric variceal bleeding

Objective To compare the efficacy of a modified percutaneous transhepatic variceal em- bolization （FIVE） with 2-Octyl-Cyanoacrylate （2-OCA） and endoscopic variceal obturation （EVO） in pre- venting gastric variceal bleeding. Methods Seventy-seven patients with history of gastric variceal bleeding who underwent either EVO or PTVE were retrospectively reviewed. The rebleeding rate, survival rate and complications were compared between the two groups. Results EVO was performed in 45 patients ; PTVE was performed in 32 patients. During the follow-up （ 19. 78±7. 70 months in EVO group, vs. 21.53 ±8.56 months in PTVE group） , rebleeding occurred in 17 patients （37.78%） of EVO group, and in 4 patients （ 12. 5% ） of FTVE group （P =0. 028）. The cumulative rebleeding free rate for EVO was 75% , 59%, and 49% in 1,2, and 3 years, respectively; 93%, 84%, 84% for PTVE （P=0. 011）. There is no significant different in survival rate and the incidence of complications was similar in two groups. Conclusion Com- pared with EVO, PTVE with 2-OCA demonstrates advantage as an effective and safe method for gastric vail- ces. Key words: Gastric varices ; Embolization, therapeutic ; Tissue adhesives ; Hemorrhage

Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding

To compare the efficacy of modified percutaneous transhepatic variceal embolization (PTVE) with 2-octyl-cyanoacrylate (2-OCA) and endoscopic variceal obturation (EVO) with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. In this retrospective study, the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA (EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed. Patient demographics, rebleeding rate, survival rate, and complications were compared between the two groups (PTVE and EVO). All results were expressed as mean ± SD, or as a percentage. Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or the χ² test (with Yates correction) where appropriate. A P value less than 0.05 was considered significant. Statistical computation was performed using SPSS 13.0 software. A total of 77 patients were included; 45 patients who underwent EVO and 32 patients who received PTVE. During the follow-up (19.78 ± 7.70 mo in the EVO group, vs 21.53 ± 8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group (37.78% vs 12.5%, P = 0.028). The cumulative rebleeding-free rate was 75%, 59%, and 49% in 1, 2, and 3 years respectively for EVO, and 93%, 84%, and 84% for PTVE (P = 0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment. Variables including age, gender, cause, Child-Pugh classification, size of gastric varices (GV), location of GV, and treatment methods were analyzed. It was revealed that Child-Pugh classification [risk ratio (RR) 2.10, 95%CI: 1.03-4.28, P = 0.040], choice of treatment (RR 0.25, 95%CI: 0.08-0.80, P = 0.019), and size of GV (RR 2.14, 95%CI: 1.07-4.28, P = 0.032) were the independent factors for predicting rebleeding. Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up, eight patients in the EVO group and four patients in the PTVE group died. The cumulative survival rates at 1, 2, and 3 years were 93%, 84%, and 67% respectively in the EVO group, and 97%, 88%, and 74% respectively in the PTVE group. The survival rates were not significantly different between the two groups (P = 0.432). Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival (RR 2.77, 95%CI: 1.12-6.80, P = 0.027). The incidence of complications was similar in both groups. With extensive and permanent obliteration of gastric varices and its feeding veins, PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.

The secondary prophylactic efficacy of beta-blocker after endoscopic gastric variceal obturation for first acute episode of gastric variceal bleeding

Background/AimsThe most appropriate treatment for acute gastric variceal bleeding (GVB) is currently endoscopic gastric variceal obturation (GVO) using Histoacryl®. However, the secondary prophylactic efficacy of beta-blocker (BB) after GVO for the first acute episode of GVB has not yet been established. The secondary prophylactic efficacy of BB after GVO for the first acute episode of GVB was evaluated in this study.MethodsNinety-three patients at Soonchunhyang University Hospital with acute GVB who received GVO using Histoacryl® were enrolled between June 2001 and March 2010. Among these, 42 patients underwent GVO alone (GVO group) and 51 patients underwent GVO with adjuvant BB therapy (GVO+BB group). This study was intended for patients in whom a desired heart rate was reached. The rates of rebleeding-free survival and overall survival were calculated for the two study groups using Kaplan-Meyer analysis and Cox's proportional-hazards model.ResultsThe follow-up period after the initial eradication of gastric varices was 18.14±25.22 months (mean±SD). During the follow-up period, rebleeding occurred in 10 (23.8%) and 21 (41.2%) GVO and GVO+BB patients, respectively, and 39 patients died [23 (54.8%) in the GVO group and 16 (31.4%) in the GVO+BB group]. The mean rebleeding-free survival time did not differ significantly between the GVO and GVO+BB groups (65.40 and 37.40 months, respectively; P=0.774), whereas the mean overall survival time did differ (52.54 and 72.65 months, respectively; P=0.036).Conclusions Adjuvant BB therapy after GVO using Histoacryl® for the first acute episode of GVB could decrease the mortality rate relative to GVO alone. However, adjuvant BB therapy afforded no benefit for the secondary prevention of rebleeding in GV.

Clinical features and outcomes of gastric variceal bleeding: retrospective Korean multicenter data

Background/AimsWhile gastric variceal bleeding (GVB) is not as prevalent as esophageal variceal bleeding, it is reportedly more serious, with high failure rates of the initial hemostasis (>30%), and has a worse prognosis than esophageal variceal bleeding. However, there is limited information regarding hemostasis and the prognosis for GVB. The aim of this study was to determine retrospectively the clinical outcomes of GVB in a multicenter study in Korea.MethodsThe data of 1,308 episodes of GVB (males:females=1062:246, age=55.0±11.0 years, mean±SD) were collected from 24 referral hospital centers in South Korea between March 2003 and December 2008. The rates of initial hemostasis failure, rebleeding, and mortality within 5 days and 6 weeks of the index bleed were evaluated.ResultsThe initial hemostasis failed in 6.1% of the patients, and this was associated with the Child-Pugh score [odds ratio (OR)=1.619; P<0.001] and the treatment modality: endoscopic variceal ligation, endoscopic variceal obturation, and balloon-occluded retrograde transvenous obliteration vs. endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt, and balloon tamponade (OR=0.221, P<0.001). Rebleeding developed in 11.5% of the patients, and was significantly associated with Child-Pugh score (OR=1.159, P<0.001) and treatment modality (OR=0.619, P=0.026). The GVB-associated mortality was 10.3%; mortality in these cases was associated with Child-Pugh score (OR=1.795, P<0.001) and the treatment modality for the initial hemostasis (OR=0.467, P=0.001).ConclusionsThe clinical outcome for GVB was better for the present cohort than in previous reports. Initial hemostasis failure, rebleeding, and mortality due to GVB were universally associated with the severity of liver cirrhosis.

659 BLEEDING RISK OF ENDOSCOPIC VARICEAL LIGATION (EVL) IN PATIENTS WITH PORTAL VEIN THROMBOSIS (PVT) AND ANTICOAGULATION: AN ANALYSIS OF 1235 PROCEDURES

Background: Acute variceal bleeding is one of the most serious complications in liver cirrhosis patients with high risk of mortality. Baveno Consensus Workshops IV identified an independent factor, Adjusted Blood Requirement Index (ABRI). ABRI value of ≥0.75 at any point time was defined as a failure to control variceal bleeding. However, there are few studies to validate clinical value of ABRI in patients with acute variceal bleeding. The present study aimed to determine the correlation of ABRI with 5th day bleeding control failure in patients with acute variceal bleeding. Methods: All consecutive patients presenting with variceal bleeding were prospectively recruited from April 2008 to Feburary 2011. Endoscopic intervention either band ligation or endoscopic variceal obturation was performed in cased with evidence of bleeding from varices on endoscopy. ABRI scores were calculated using the formula [ABRI = blood units transfused/[(final hematocrit-initial hematocrit)+0.01]. Definitions of treatment failures were defined according to Baveno IV criteria except ABRI. We validated the predictability of ABRI with treatment failure defined in Baveno IV.

PROSPECTIVE VALIDATION OF ADJUSTED BLOOD REQUIREMENT INDEX FOR PREDICTING TREATMENT FAILRUE OF ACUTE VARICEAL BLEEDING

Background: Acute variceal bleeding is one of the most serious complications in liver cirrhosis patients with high risk of mortality. Baveno Consensus Workshops IV identified an independent factor, Adjusted Blood Requirement Index (ABRI). ABRI value of ≥0.75 at any point time was defined as a failure to control variceal bleeding. However, there are few studies to validate clinical value of ABRI in patients with acute variceal bleeding. The present study aimed to determine the correlation of ABRI with 5th day bleeding control failure in patients with acute variceal bleeding. Methods: All consecutive patients presenting with variceal bleeding were prospectively recruited from April 2008 to Feburary 2011. Endoscopic intervention either band ligation or endoscopic variceal obturation was performed in cased with evidence of bleeding from varices on endoscopy. ABRI scores were calculated using the formula [ABRI = blood units transfused/[(final hematocrit-initial hematocrit)+0.01]. Definitions of treatment failures were defined according to Baveno IV criteria except ABRI. We validated the predictability of ABRI with treatment failure defined in Baveno IV.