Esophageal Variceal Band Research Articles

Outcome of Post Esophageal Variceal Band Ligation with Sucralfate and Proton Pump Inhibitor vs. Proton Pump Inhibitor Alone in Cirrhotic Patients

Introduction: Endoscopic band ligation is the mainstay of treatment in bleeding varices in cirrhosis. Subsequent bleeding from the band ulcers is a possible complication. Proton pump inhibitors and Sucralfate are commonly used post band ligation and often in combination. The aim of the study was to identify the advantage of combining Sucralfate to proton pump inhibitor in reducing the number and size of band ulcers.Materials and Methods: This was an open-label comparative study conducted in a tertiary level hospital of Nepal. Patients with cirrhosis after band ligation were included. Eligible patients were randomized into a proton pump inhibitor alone (Group A) or proton pump inhibitor and sucralfate group (Group B) and they underwent upper gastrointestinal endoscopy after two weeks. Baseline parameters, number and mean size of band ulcers were compared.Results: A total of 58 patients, 29 in each group, were evaluated. The baseline characteristics were comparable. EBL was done for bleeding varices in 51.7% and as primary prophylaxis in the rest of them. All the patients had band ulcers after two weeks. The mean size of the largest ulcer was 1.62±0.72 and 1.10±0.60 (p=0.78) respectively in groups A and B. Low albumin was significantly associated with OR of 8.7 (95% CI:1.68-44.99) for the formation of multiple (more than two) ulcers (p=0.01).Conclusions: The ulcer formation was universal after band application. The addition of sucralfate did not offer more benefits in terms of the number and mean size of the ulcer. Low albumin was the independent predictor for multiple ulcer formation.

Over-the-scope clip as salvage therapy in refractory bleeding from esophageal variceal band ligation-induced ulcer.

Over-the-scope clip as salvage therapy in refractory bleeding from esophageal variceal band ligation-induced ulcer.

Esophageal Variceal Band Ligation Interval and Number Required for the Obliteration of Varices: A Multi-center Study from Karachi, Pakistan.

IntroductionEsophageal variceal band ligation (EVBL) is the best form of treatment for variceal bleeding. The frequency of EVBL for the eradication of esophageal varices has no consensus. We evaluated the number and interval of EVBL sessions required for the obliteration of esophageal varices.MethodsEsophagogastric varices were treated endoscopically with band ligation on initial presentation and then every after three weeks till the obliteration of the varices. Endoscopic band ligation consists of placing rubber elastic bands on large varices. Frequencies were calculated for qualitative variables and mean ± standard deviations for continuous variables.ResultsA total of 107 cases with esophagogastric varices were enrolled. Out of them, seven patients with small esophageal varices and large fundal varices were excluded. The remaining 100 with large esophageal varices had EVBL performed. The second session of EVBL was done in 46 patients with large esophageal varices. The third session of EVBL for the obliteration of esophageal varices required in 20 patients with large esophageal varices and the fourth session was required in only two patients. The total sessions required for the complete obliteration for esophageal varices were 2±1. Only one patient developed post-EVBL bleeding one week after band ligation.ConclusionEsophageal variceal ligation was a safe and well-tolerated procedure performed at three-week intervals in patients with large esophageal varices. On average, two to three sessions of EVBL are required for the complete obliteration of esophageal varices.

Rare cause of dysphagia after esophageal variceal banding: A case report

Rare cause of dysphagia after esophageal variceal banding: A case report

Mallory-Weiss Tear Following Banding of Esophageal Varices: A Rare Complication

Banding esophageal varices is a common procedure in cirrhotic patients. In rare circumstances, complications may occur. In this case, we present a cirrhotic patient with bleeding esophageal varices that underwent banding and a rare subsequent Mallory-Weiss tear with secondary bleeding. A 41yo female with history of cirrhosis 2/to hepatitis C and alcohol abuse presented to emergency department with hematemesis associated with lightheadedness and shortness of breath. Her vitals demonstrated HR of 114 bpm and systolic blood pressure of 95 mmHg. Physical exam revealed findings consistent with decompensated cirrhosis (jaundice, scleral icterus, abdominal distension) and RUQ abdominal pain. Labs revealed hgb 9.7 g/dL, INR 2.8, tbil 24.2 mg/dL, and ALT 54 units/L. She was admitted to MICU and was given Octreotide, Pantoprazole, and antibiotic. She underwent endotracheal intubation (airway protection and need for deep sedation) and subsequent endoscopy within 5 hours of presentation and was found to have 2 columns of large varices with red wale signs, residual blood in stomach, and moderate portal gastropathy. Bands were placed x 3. In less than 1 hour, patient's sedation was ineffective and she experienced severe retching and vomiting with 1 band being expelled. Patient then experienced more hematemesis. Endoscopy was emergently repeated once sedation was achieved and found 2 intact esophageal bands and a Mallory-Weiss tear at GEJ with visible vessel that was oozing. An endoclip was applied to site with observed hemostasis. Her hgb was stable thereafter with no recurrent bleeding. This case represents a rare complication of esophageal variceal banding where excessive retching and vomiting post-procedure resulted in a Mallory-Weiss tear at site of prior banding.

High Burden of GI Disease and Unmet Need in Rwanda: Findings From Rwanda Endoscopy Week

Introduction: Rwanda is an East African country of 12 million people that currently has 8 internists regularly performing diagnostic endoscopy. The country has four public referral hospitals with endoscopic capabilities. The Rwandan Society of Endoscopy (RSE) has a goal of expanding its coverage and increasing skills in therapeutic endoscopy. Prior case series of EGDs in Butare and Kigali have revealed major endoscopic diagnoses (i.e. ulceration, stricture and malignancy) in up to 40% of exams. Rwandan endoscopy week was a collaborative effort between a US gastroenterology team and members of the Rwandan Society of Endoscopy (RSE) who have a longstanding working relationship through a series of international physician exchanges. Methods: Six US GI physicians, two nurses, two technicians and a biomedical engineer worked in collaboration with members of the RSE (15 physicians and 18 nurses) for one week. Combined US/Rwandan teams were deployed to the four referral hospitals with endoscopic capabilities. GI consultation was done on the hundreds of patients referred for endoscopy to ensure appropriateness of the procedure. Patient demographic data, procedural indication and results were collected at the four sites with the Google Forms online tool. Results: Completed procedures included 200 EGDs, 39 colonoscopies and 5 ERCPs. 33% of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), esophageal stenosis (2.5%) and benign-appearing gastric outlet obstruction (2.5%). Interventional procedures included esophageal variceal banding (7), placement of esophageal stents (2), balloon dilation of the esophagus (7), duodenum (1) and pylorus (1). Of those presenting for colonoscopy, the most common indications included hematochezia (41%), abdominal pain (31%) and constipation (28%). Significant findings on colonoscopy included hemorrhoid disease (23%) and suspected colorectal cancer (7.7%). Findings on ERCP included two patients with choledocholithiasis, one with a choledochoduodenal fistula and one with suspected cholangiocarcinoma. Conclusion: Our findings support the presence of a high burden of GI disease in Rwanda. Expanding Rwanda’s current capabilities to address this need is feasible, but will require many more physicians to be trained in diagnostic and therapeutic endoscopy. As the current Rwandan endoscopists are proficient in diagnostic endoscopy, advancement to therapeutic skills is a natural next step.

Evaluation of Esophageal Varices Band Ligation Effects on Rectal Varices and Hemorrhoids Development and Grading in Post-HCV Cirrhosis

Background: Rectal varices and hemorrhoids are a gastrointestinal complication of portal hypertension. There is a large discrepancy in previous studies regarding prevalence of rectal varices and hemorrhoids and their correlation with other factors. Aim of the work: goal of our study was evaluation of the effect of band ligation of oesophageal varices (OVs) on the evolution and/or progression of rectal varices and haemorrhoids. Patients and Methods: This study conducted on 50 postHCV cirrhotic patients screened for esophageal varices. They were divided into two main groups; Group I: It included 25 post-HCV cirrhotic patients, screened for OVs, band ligation was indicated in them, and they were banded for OVs. Group II: It included 25 post-HCV cirrhotic patients, screened for OVs, and band ligation was not indicated in them. All of them were submitted to oesophagogastrodudenoscopy (OGD) for assessment of OVs and short colonoscopy for assessment of rectal varices & haemorrhoids at the baseline and after 6 months. Results: Obliteration of esophageal varices by endoscopic variceal band ligation did not affect the incidence of hemorrhoids (38% before and after) and anorectal varices (12% before and after). Conclusion: It is concluded that esophageal variceal band ligation does not affect the incidence of hemorrhoids, or anorectal va1rices inpatients with liver cirrhosis.

973 OPEN SESAME: A NOVEL LUMEN APPOSING METAL STENT DEPLOYMENT SYSTEM FOR THE MANAGEMENT OF SHORT LUMINAL STRICTURES

The use of short, fully-covered lumen apposing metal stents (LAMS) has emerged as a novel therapeutic intervention in the management of short luminal strictures. Similar to self-expanding metal stents (SEMS), LAMS are self-expanding and removable. Unlike SEMS, LAMS have lumen-apposing proximal and distal flanges, which may limit the risk of migration. LAMS are designed to be deployed via a therapeutic echoendoscope. When LAMS deployment is attempted with a therapeutic gastroscope, the much longer length of the deployment catheter relative to the gastroscope and inability to luer lock the catheter in place result in unstable endoscopic visualization and need for a second operator. These difficulties predispose to inaccurate stent placement. We demonstrate a video series including four patients with disparate pathologies resulting in luminal strictures in whom we successfully implemented a novel, alternative LAMS deployment system. At bedside, the 10 mm x 15 mm LAMS, which was previously deployed from the catheter, is pulled with standard grasping forceps into the 3.7 mm accessory channel of the therapeutic gastroscope. The scope tip is then advanced to the stricture, and the LAMS is pushed out under fluoroscopy until the distal flange opens. As the scope is slowly withdrawn, the proximal flange is deployed under endoscopic visualization. The deployed stent is then dilated with a through the scope balloon to obtain maximal stent expansion. This technique is now demonstrated in the following patients: 1. A 70 year old woman with ulcerative colitis, status post total proctocolectomy with ileal pouch-anal anastomosis, complicated by refractory pouchitis and pouch-vaginal fistula, on infliximab, presented over a decade later for management of a refractory anastomotic stricture at the inflow tract to the pouch. 2. A 48 year old woman with disseminated tuberculosis and actinomyces complicated by esophageal fistula, status post partially covered esophageal stent placement, since removed, presented with odynophagia 2 months later secondary to an upper esophageal stricture refractory to balloon dilation. 3. A 63 year old woman with HBV cirrhosis status post esophageal variceal band ligation, complicated by mid-esophageal stricture formation less than 2 weeks later, who was initially treated with balloon dilation and fully covered SEMS placement, returned due to stricture recurrence following distal SEMS migration. 4. A 59 year old male with recurrent diverticulitis status post open sigmoidectomy complicated by anastomotic breakdown requiring a diverting loop ileostomy, developed a complete obstruction at the colorectal anastomosis refractory to balloon dilation. With use of our novel technique, we were able to easily and accurately place LAMS across these short luminal strictures, thus obtaining symptom alleviation for our patients and avoiding surgery.

A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage

To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH). Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (≤12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices. We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ≤5 d), length of stay, and 30-day readmission. Guideline adherence was variable: endoscopy ≤12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P≤0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks. Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.

A Unique Case of Congenital Hepatic Fibrosis

Introduction Congenital hepatic fibrosis (CHF) is a rare disorder that affects the portobillary systems resulting in ductal plate malformation. This results in abnormal branching of intrahepatic portal veins resulting in eventual portal tract fibrosis and the development of portal hypertension. CHF is commonly associated with hepatorenal fibrocystic diseases. We present a unique case of a young adult patient diagnosed with CHF by liver biopsy without renal disease. Case Presentation: A 36 year old male presented with one month of melena. He denied any blood transfusions or FH of liver disease. Physical exam was unremarkable without signs of cirrhosis. LFTs and coagulation studies were normal. He underwent an EGD which showed gastric varices (GOV1) with healed superficial erosions. No evidence PUD, AVMs, or other sources of bleeding were seen. Esophageal variceal band ligation was performed. Abdominal US and CT scan showed a nodular liver with coarsened echotexture consistent with cirrhosis. There was no evidence of liver lesions or biliary ductal dilatation. Kidneys were normal, without cysts or parenchymal abnormalities. Lab workup for cirrhosis was performed. Tests for Hepatitis A, B, C, HIV, HSV, EBV, AMA, ASMA, ALKM, immunoglobulins, celiac, alpha1 antitrypsin, ceruloplasmin and iron studies and were negative. As a result, liver biopsy was performed revealing variably sized dense fibrous septa occasionally enclosing nodules and periportal fibrosis with benign bile duct proliferation in the absence of inflammation. Findings were consistent with CHF (Figure A & B).Figure: pathological findings consistant with congenital hepatic fibrosis.Discussion: CHF is a rare congenital disorder with a few cases reported in the literature. It is characterized by ductal plate malformation and abnormal branching of the intrahepatic portal veins resulting in periportal fibrosis progressing to cirrhosis. The disease commonly presents in neonates, however, delayed presentation is seen in children and adults. Although the exact reason is unclear, CHF is commonly associated with Autosomal Recessive Polycystic Kidney Disease (ARPKD). We present a case which illustrates a unique presentation of a rare disorder. Despite being a congenital disorder, the patient was diagnosed in adulthood which is not well understood. In addition, there was no evidence of cystic renal disease or impairment of renal function. Although rare, CHF needs to be considered in the workup of patients with cryptogenic cirrhosis even in the absence of polycystic renal disease.

Incidence and Outcomes of Thrombosis in Cirrhotic Patients Listed for Liver Transplantation

Introduction: The liver plays a key role in the regulation of hemostasis. Patients with cirrhosis are at increased risk for developing clots, but are also at increased risk for bleeding. Therefore, it is unclear if a cirrhotic patient would benefit from anticoagulation in the setting of a venous thrombosis, or if the risk for adverse outcomes is prohibitive. In this study, we aimed to a) ascertain the incidence of clotting and bleeding events in cirrhotic patients pre-transplantation, b) determine factors associated with successful anticoagulation for venous thrombosis (VT), c) and assess outcomes for patients who were anticoagulated. Methods: This is a retrospective case-control study of all patients who received liver transplantation at Cleveland Clinic from 1/1/2012 to 12/31/2015. Patients were excluded if they were under age 18 at the time of transplantation, or received a transplant primarily for hepatocellular carcinoma. Demographic data, lab data, MELD-NA score, Child-Pugh Score (CPS), and esophageal banding data were obtained from chart review of the electronic medical record. All laboratory data was obtained 1-60 days before the VT event. Anticoagulation failure was defined as cessation of anticoagulation before the pre-determined end date chosen by the clinician. Results: A total of 836 subjects were transplanted between 1/1/2010 and 12/31/2015. 8% (95 % CI 6.2, 9.9) of patients had clotting events and 9.8%( 95% CI 7.8,11.8) had bleeding events prior to liver transplantation (Fig. 1). Post-transplantation survival curves were the same for the first 24 months in both groups though this did not meet statistical significance (p=0.60; Figure 2). Of 67 patients with clotting events, 20 patients were treated with anticoagulation (AC) and 8 of those patients failed treatment (Table 1). There was no statistically significant difference between the two groups (Table 1). However, there was a positive association between pre-VT esophageal variceal banding and the success of treatment (p=0.60; Table 1). Of those with AC failures, 4 had gastrointestinal bleeding, 1 had hemorrhagic paracentesis, 1 had catheter site bleeding, and 2 had worsening thrombocytopenia.Figure: Incidence of clotting and bleeding event with the confidence intervals depicted.Figure: Post-Liver transplantation (LT) survival of patients with GI bleeding (GIB) or Clotting events pre-transplantation.Table: Table. Analysis of the outcomes of patients with venous thrmobosis prior to L treated with anticoagulationConclusion: Both bleeding and thrombotic events occur at the same rate in cirrhotic patients pre-transplantation. When AC therapy is anticipated, obliteration of gastro-esophageal varices may be associated with successful completion of AC therapy without major bleeding episodes.

Mo1520 - Effects of Esophageal Variceal Band Ligation on Esophageal Motility. A Study Using High Resolution Manometry (HRM)

Mo1520 - Effects of Esophageal Variceal Band Ligation on Esophageal Motility. A Study Using High Resolution Manometry (HRM)

A Prospective Randomized Study on the Risk of Bacteremia in Banding versus Sclerotherapy of Esophageal Varices.

Esophageal variceal banding may be less likely to cause bacteremia than sclerotherapy. The existing data about the frequency of bacteremia after esophageal variceal banding are conflicting, and few studies include both banding and sclerotherapy. We conducted a prospective randomized controlled trial to compare the frequency of bacteremia after esophageal variceal banding and sclerotherapy. Over a 2-year period, patients with liver disease admitted for upper gastrointestinal bleeding or for outpatient elective variceal therapy were enrolled. New patients were randomized preprocedure to either banding or sclerotherapy, and subsequent sessions utilized the initial procedure. The groups consisted of banding, sclerotherapy, and endoscopy without variceal therapy. Subjects underwent endoscopy by one out of three gastroenterologists. Blood cultures were obtained 5 min before and 30 min after endoscopy to check for bacteremia. Postendoscopic blood cultures were positive following 4 out of 139 (2.9%) sessions: 1 sclerotherapy and 3 control sessions. All postendoscopic positive blood cultures were found following emergency sessions (4/92, 4.3%). One pre-endoscopic blood culture was positive in a patient with emergency banding. The rates of positive postendoscopic blood cultures among groups with emergency banding (0/22, 0%), emergency sclerotherapy (1/41, 2.3%), and emergency control (3/29, 10.3%) were not significantly different. Postendoscopic positive blood cultures were not found after elective sessions with either banding or sclerotherapy. Postendoscopic bacteremia was infrequent following emergency endoscopy in patients with esophageal variceal bleeding. Bacteremia was not found after esophageal variceal banding, although this was not significantly less frequent than after sclerotherapy. Postendoscopic bacteremia was not associated with elective variceal therapy.

Sucralfate and Lidocain: Antacid 50:50 solution in Post Esophageal Variceal Band Ligation Pain

Objective:To compare the effectiveness of pain relief of Sucralfate and lidocain antacid 50:50 solution in post esophageal variceal band ligation pain.Methods:All patients who had under gone Esophageal Variceal Band Ligation (EVBL) were included in the study. Patients un-willing to be included in the study or those who didn’t have post EVBL pain were excluded. Patients with post EVBL pains were divided into two groups: one group was given sucralfate and other was given lidocaine: antacid 50:50 solution. Both were inquired about the duration of the pain relief after the medication. The results were analyzed on SPSS 23. Independent samples T-test was performed to find out whether the difference in duration of pain relief was significantly different in the two groupsResults:Out of 110 patients who have EVBL, 66(60.00%) had pain and 44(40.00%) were pain free. In the pain group 46 (69.7%) were given sucralfate and 20 (30.3%) were given lidocain: antacid 50:50 solution. Mean duration of pain relief in two groups was 2.78 (SD ± 2.096) and 2.5 days (SD ±. 0.76) respectively. Independent samples T-test results revealed that there was no statistically significant difference in the duration of pain relief between these two groups with p value 0.426.Conclusion:Both Sucralfate and Lidocain: antacid 50:50 solutions are effective in relieving the post EVBL pain. However, no statistically significant difference in duration of pain relief was detected in separate groups of patients treated with either treatment.

Safety of Endoscopy in Cancer Patients on Antiangiogenic Agents

Introduction: Antiangiogenic agents (AA) such as Bevacizumab and Aflibercept are inhibitors of vascular endothelial growth factors and offer survival benefit in combination with cytotoxic chemotherapy. Their use has expanded significantly in the last few years leading to an increased awareness of potential toxicities including gastrointestinal perforation(GIP) and bleeding. It is currently recommended that AA be held for 28 days before and after surgery. There is no data or recommendation regarding the safety of endoscopy (endo) while on AA. This study investigated the incidence of adverse events (AE) in patients undergoing endo within 31 days of administration of AA. Methods: Data regarding AA administration, procedures and maneuvers were retrieved from coding records at 5 cancer centers between Apr-2008 and Aug-2014. Retrospective chart review was performed on all patients undergoing endo within 31 days of administration of AA. The primary outcome measures were procedure-related AE and death within 31 days of endo. Data collected included age, cancer type, timing of AA and maneuvers performed. Results: 449 patients (Cancers were 229 colorectal, 69 pulmonary, 57 breast, 37 gynecologic, 57 unspecified; mean age 54 yrs) underwent a total of 561 endo. Mean time from AA to endo was 12.1 days. There were 345 upper endoscopies, 129 colonoscopies, 39 sigmoidoscopies, 44 Endoscopic ultrasounds (EUS) and 4 endoscopic retrograde cholangiopancreatographies. Maneuvers included 168 biopsies, 58 gastrostomy tube placement (PEG), 17 celiac neurolysis or fine needle aspiration (FNA), 6 hemostasis, 5 foreign body removals among other maneuvers. There were 4 procedure-related AE: Mucosal esophageal tear 2 days after upper EUS, esophageal bleeding a day after banding of esophageal varices, pancreatitis a day after upper EUS/FNA, bleeding from the gastrostomy site 2 days after PEG placement. None of the AE was higher than grade 2 (Common terminology Criteria for AE). 36 patients died within 31 days of the procedure with none of the deaths considered procedure related. Conclusion: Endo related AE in patients on AA appear to be low when performed in specialized cancer centers with no procedure related perforation. Careful attention to risk and benefits of endoscopy should be made and if the patient is perceived to benefit from endoscopy while on AA, the risk should not be prohibitive. Prospective studies are needed to confirm these findings.

Esophageal Variceal Band Ligation as a Means of Eradicating Barrett’s Esophagus

Introduction: Barrett’s esophagus (BE) is a precancerous condition involving intestinal metaplasia of the tubular esophagus. Eradication of BE can decrease the risk of progression to esophageal adenocarcinoma. Currently available endoscopic therapies for BE include band-ligation endoscopic mucosal resection (EMR), which has been used to excise focal areas of concern as well as entire BE segments. It is believed that, following removal of the metaplastic mucosa, neosquamous epithelium is generated in the absence of further acid exposure. We describe a case of band ligation without resection leading to partial BE eradication. A 61-year-old Caucasian male with known BE and a strong family history of esophageal cancer (2 brothers) presented for evaluation. Past history was notable for liver transplantation to treat alcoholic cirrhosis, complicated by portal vein thrombosis (PVT) and subsequent portal hypertension with development of varices. Upper endoscopy revealed ultra-long segment BE (C8M10 by Prague classification) without any dysplasia present on transepithelial brush biopsies performed in place of forceps sampling due to the presence of large esophageal varices and moderate thrombocytopenia. A gastric varix and portal hypertensive gastropathy also were seen. Given his BE segment length and family history, the decision was made to first eradicate his esophageal varices and then ablate his BE once the risk of variceal complications was minimized. A first round of endoscopic variceal band ligation was performed without difficulty. Within six days of the second banding procedure, the patient presented with acute upper gastrointestinal bleeding manifested by hematemesis and melena. Upper endoscopy demonstrated circular ulcerations at the banding sites without active bleeding. No intervention was performed at that time. Over the course of five weeks, recurrent life-threatening bleeding was treated with additional band placement, ethanolamine injections, and insertion of two Blakemore tubes. PVT precluded standard radiologic interventions, and ultimately an emergent surgical shunt was placed, followed by radiologic decompression of his portal vein and obliteration of his gastric varices. After these interventions, his bleeding ceased. Repeat endoscopy one month later showed resolution of the ulcerations with circular neosquamous islands at the banding sites. It is unclear if the band ligation itself or subsequent ulceration ultimately led to formation of the neosquamous epithelium. Further investigation is required to evaluate whether band ligation, which does not involve energy-mediated tissue trauma, could be an alternate method for BE eradication when more standard techniques are not possible.

Small Bowel Variceal Bleeding Secondary to Gyno-Enteric Shunt

Introduction: A 70-year-old woman with a history of cirrhosis secondary to hemochromatosis and prior alcohol abuse (with long-term abstinence) was admitted for large-volume hematochezia. She had a history of esophageal variceal bleeding in the past, which was effectively treated with esophageal variceal band ligation. Her last EGD and banding was performed 4 years prior to presentation with obliteration of esophageal varices. Two years prior to admission, she had a negative surveillance colonoscopy for a personal history of colon polyps. A bleeding scan was performed shortly after admission. Accumulation of radiotracer was noted in the right lower quadrant, suggesting active hemorrhage from the distal small bowel or right colon. Mesenteric angiography was performed with the intention of hemostasis following the positive bleeding scan. A clear bleeding site was not identified. At this point, the patient had received 20 units of red blood cells, several units of FFP, and vitamin K. The platelet count remained above 60 K/μL. She did not receive platelet transfusion. Her fibrinogen level was normal. As the site of bleeding remained unclear, a colonoscopy was performed to the distal 30 cm of ileum. This demonstrated blood clots and fresh blood to the proximal extent of the exam. EGD was performed using a pediatric colonoscope. The proximal 80 cm of small bowel was examined. EGD-enteroscopy did not demonstrate a clear bleeding source. No esophageal or gastric varices were seen. To further define the bleeding site, abdominal and pelvic CT angiography was performed. A portosystemic shunt between the parametrial veins and the superior mesenteric vein was identified (Figure 1). A partial portal venous thrombosis was also seen. The patient was taken to the operating room for exploratory laparatomy. The involved segment of small bowel was resected and suture ligation of the shunt was performed. Following surgery, there was no further hematochezia.Figure 1: Small bowel varices with communication to the superior mesenteric vein and parametrial veins.

Retrocardiac mass in a patient with cirrhosis: A case report

Introduction: the most common cause of a supradiaphragmatic posterior mediastinal mass is a hiatus hernia. However, an unexplained round or lobulated retrocardiac shadow without air or air-fluid level in patients with marked portal hypertension should raise the suspicion of dilated venous collaterals. case report: this is a case of a 58-year-old Asian male with a history of chronic liver disease secondary to alcohol abuse and hepatitis b and banding of esophageal varices due to bleeding presenting to the hospital after a low-velocity motor vehicle accident. Plain X-ray of chest showed a double density structure through the left cardiac shadow. Further investigation revealed paraesophageal varices simulating a retrocardiac mass on a contrast enhanced helical computed tomography scan of the abdomen. conclusion: Differential diagnoses of mediastinal, retroperitoneal, and mesenteric masses in patients with cirrhosis most commonly include varices rather than a neoplasm or adenopathy. Portosystemic collateral veins most likely need many years to reach such a size that they can be visible on a chest X-ray. Giant esophageal varices may present as a posterior mediastinal mass on a chest X-ray in as many as 5% of cirrhotic patients. Diagnosis

Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: A multicentre randomized controlled trial

Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective β blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

Safety of Performing Esophageal Variceal Banding in Patients with Thrombocytopenia

Purpose: Thrombocytopenia, a frequent complication of portal hypertension, could potentially increase the risk of bleeding after variceal banding. Aim was to evaluate the safety of performing esophageal variceal band ligation in patients with thrombocytopenia. Methods: We performed retrospective chart analysis of patients who underwent esophageal variceal ligation (EVL) between January 2010 and July 2012. Data collected also included, demographics, severity of liver disease (MELD score, Child's score, baseline hemoglobin, hematocrit and platelet counts). Signifi cant post EVL bleeding was defined as either a drop in hematocrit of 10% from the baseline needing hospitalization (covert bleeding) or admission within 3 months with an episode of overt bleeding. Severe thrombocytopenia was defined as a platelet count of less than 60,000/mcL. Fifty patients with a mean age of 56 years (range 33-81) with follow-up data at least up to 3 months were included in the analysis. The demographics were as follows: Caucasains 34 (68%); African Americans 12 (24%); and Hispanic 4 (8%); 33 males, 17 females. A p<0.05 was considered as statistically significant. Results: Gastrointestinal bleeding within 90 days after EVL was noted in 5 of the 36 (13.8%) in those with platelet count >60,000 (Childs Pugh C-3, B-1, A-1) compared to none of the 14 patients with platelet counts <60,000/mcL. In multivariate regression analysis, platelet count did not predict post banding bleeding events. Conclusion: Esophageal variceal banding can be safely done in patients with platelet counts <60,000/mcL without increased risk of bleeding. Despite theoretical concerns, the risk of bleeding within 90 days from band ligation in patients with severe thrombocytopenia was not apparent.Table