Gastric Fundal Varices Research Articles

Innovations in endoscopic ultrasound for portal hypertension and its role in managing complications in clinical practice: Lessons learned from a tertiary referral public hospital

AbstractPortal hypertension (PH) poses significant challenges. This paper presents an innovative study on the utilization of endoscopic ultrasound (EUS) for both the diagnosis and management of PH. Conducted at Dr. Cipto Mangunkusumo National General Hospital in Jakarta, this retrospective case series included patients diagnosed with PH through clinical examination, imaging evaluation, and esophagogastroduodenoscopy. Exclusion criteria comprised a history of reduced blood consumption within the last 5 days, hepatocellular carcinoma, massive ascites, or elevated international normalized ratio (>1.4). EUS‐guided portal pressure gradient (PPG) measurements were performed using an innovative standard manometer. The study involved 15 patients, with 14 having liver cirrhosis and 1 diagnosed with Budd–Chiari syndrome. Among them, nine patients experienced bleeding due to gastroesophageal varices. Small and large esophageal varices were identified in four and eight patients, respectively. Gastroesophageal varices type 1 were observed in two patients, and type 2 in four patients. Isolated gastric fundal varices type 1 were present in one patient. Based on EUS‐PPG measurements, 14 patients exhibited clinically significant portal hypertension. Seven patients underwent endoscopic band ligation and three underwent EUS‐guided cyanoacrylate injection during the same session as the EUS‐PPG measurement procedure. Notably, no adverse events, such as abdominal pain, perforation, or bleeding were observed during or after the procedure. EUS emerges as a promising and accurate tool for both diagnosis and management.

Measurement of portal vein indices and splenic index by ultrasound and their association with gastroesophageal varices in cirrhosis of liver

Background and Objectives: Esophageal and gastric fundic varices are common in liver cirrhosis patients. Ultrasound with the Doppler study assesses liver cirrhosis severity, measuring portal vein and splenic indices’ association with gastroesophageal varices. Methodology: This study was conducted on 64 subjects with sonographic features of chronic liver disease who were referred for routine follow-up scans. Portal vein diameter, average velocity, splenic index, congestion index (CI), and portal vein area and velocity were measured. Result: Subjects with gastroesophageal varices had significantly larger portal vein diameters (14.7±1.64 mm) compared to those without varices (12.05±1.26 mm) (P<0.05). Conversely, subjects without varices exhibited a higher portal vein velocity of (17.9±0.6 cm/s) than with varices (13.91±2.01 cm/s) (P=0.0005). The splenic index was higher in subjects with varices (1120±494 cm3) than those without varices (419 cm3) (P<0.05). The CI was also higher in subjects with varices. Portal vein velocity showed the highest sensitivity (94%) with a cutoff of 19 cm/s, while the CI had the highest diagnostic accuracy (93.75%) with a cutoff of 0.10 cm xsec. The splenic index demonstrated a sensitivity of 92.85% and diagnostic accuracy of 92.18% with a cutoff of 480 cm3. The splenic index followed by the CI is found to be a better predictor of esophageal varices (area under the curve of 96.8 and 96%, respectively). Conclusion: Ultrasonographic assessment of the portal vein and spleen is a reliable, noninvasive method for predicting gastroesophageal varices in liver cirrhosis. The splenic index and CI have high diagnostic accuracy.

Balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic cyanoacrylate injection for treating gastric varices draining through gastrorenal shunts

Background and study aimsBalloon-occluded retrograde transvenous obliteration-assisted endoscopic cyanoacrylate injection (E-BRTO) temporarily treats gastric fundic varices draining through gastrorenal shunts (GRS) occluding the GRS with a balloon, then endoscopically injecting cyanoacrylate. We retrospectively examined the safety, feasibility, and efficacy of E-BRTO. Patients and MethodsWe enrolled 85 patients with hepatic cirrhosis plus gastric fundic varices with GRS; 34 underwent E-BRTO. The 51 patients who refused all secondary prophylactic treatments served as controls. ResultsFinally, 33 of the 34 patients underwent successful E-BRTO without major adverse events. Gastric varices were eradicated from all 33 patients in the E-BRTO group; the average follow-up time was 161.0 (74.0) weeks (mean [SD]). Four end-point events (12%) were recorded during the follow-up period. In the control group, 33 patients (65%) suffered repeat variceal bleeding, resulting in seven deaths. The cumulative rebleeding rates of the E-BRTO group on the 6th, 24th, 48th, 96th, 144th, 192nd, 240th, and 288th week were 0%, 3%, 9%, 9%, 13%, 13%, 13%, and 13%, while the cumulative rebleeding rates of the control group in the same period were 10%, 20%, 35%, 46%, 55%, 65%, 76%, and 76%. ConclusionsE-BRTO was safe, feasible, and well tolerated by patients with hepatic cirrhosis plus gastric fundic varices with GRS. Over the long-term follow-up period, the E-BRTO group demonstrated a lower rate of repeat bleeding than the control group.

Pre-emptive TIPS for the treatment of bleeding from gastric fundal varices: Results of a randomised controlled trial

Background & AimsBleeding from gastric fundal varices (isolated gastric varices type 1/gastroesophageal varices type 2) represents a major problem because of a high incidence of rebleeding and death with standard-of-care therapy (endoscopic obliteration with tissue adhesives plus pharmacological therapy). Transjugular intrahepatic portosystemic shunts (TIPSs) are recommended as a rescue therapy. Pre-emptive ‘early’ TIPS (pTIPS) significantly improves control of bleeding and survival in patients at high-risk of dying or rebleeding from esophageal varices. MethodsThis randomised controlled trial investigate whether the use of pTIPS improves rebleeding-free survival in patients with gastric fundal varices (isolated gastric varices type 1 and/or gastroesophageal varices type 2) compared with standard therapy. ResultsThe study did not achieve the predefined sample size because of low recruitment. Nevertheless, pTIPS (n = 11) was more effective compared with combined endoscopic and pharmacological therapy (n = 10) in improving rebleeding-free survival (per protocol analysis: 100 vs. 28%; p = 0.017). This was mainly because of a better outcome in patients with Child-Pugh B or C scores. There were no differences in serious adverse events or in the incidence of hepatic encephalopathy among the different cohorts. ConclusionThe use of pTIPS should be considered in patients with Child-Pugh B or C scores bleeding from gastric fundal varices. Impact and implicationsThe first-line treatment of gastric fundal varices (GOV2 and/or IGV1) is the combination of pharmacological therapy and endoscopic obliteration with glue. TIPS is considered the main rescue therapy. Recent data suggest that, in patients at high-risk of dying or rebleeding (Child-Pugh C or B scores + active bleeding at endoscopy) from esophageal varices, the use of pTIPS, performed during the first 72 h from admission, results in an increased rate of control of bleeding and survival compared with combined endoscopic and pharmacological therapy. Herein, we present a randomised controlled trial comparing pTIPS with combined endoscopic (injection of glue) and pharmacological therapy (first, somatostatin or terlipressin; carvedilol after discharge) in the treatment of patients bleeding from GOV2 and/or IGV1. Although we were not able to include the calculated sample size because of the scarcity of these patients, our results show that the use of pTIPS is associated with a significantly higher actuarial rebleeding-free survival when analysed as per protocol. This is because of the greater efficacy of this treatment in patients with Child-Pugh B or C scores.

CLINICAL EFFECT OF ENDOSCOPIC TITANIUM CLIPS COMBINED WITH TISSUE ADHESIVE IN THE TREATMENT OF GOV2 GASTRIC FUNDAL VARICES

Objective: To analyze the effect of endoscopic titanium clips combined with tissue adhesive in treating GOV2 (Type 2 Gastroesophageal Varices) patients. Methods: One-hundred-and-seventeen GOV2 patients from June 2018 to June 2020 were divided into the observation group ([Formula: see text]) and control group ([Formula: see text]). The observation group was treated with endoscopic titanium clip combined with the tissue adhesive, while controls were treated with tissue adhesive alone. The clinical effects were compared at 1, 6, and 24 months. Results: Overall response rates of the observation group at 1, 6, and 24 months were 98.31%, 96.61%, and 91.53%, respectively, vs. 81.03%, 76.27%, and 55.17% in controls ([Formula: see text]). The number, diameters, red color sign proportion of varicose veins, and incidence of bleeding in the observation group were lower than the control group, and the GQOL-74 (Generic Quality of Life Inventory 74) score was higher at 1, 6, and 24 months ([Formula: see text]). There was no significant difference in complications, mortality at 6 and 24 months, and recurrence rate at 6 months ([Formula: see text]); however, the recurrence rate at 24 months after treatment was lower in the observation group (6.78% vs. 20.69%) ([Formula: see text]). Conclusions: Endoscopic titanium clips combined with tissue adhesive can be applied to treat GOV2 patients.

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PREFACE

Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals.

BACKGROUNDThere is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited.AIMTo determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1. METHODS Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed.RESULTSSignificant differences in routine blood examination, Child–Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients. CONCLUSIONSignificant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

A Histogram Model to Predict the Risk of Bleeding from Oesophageal and Gastric Variceal Rupture in Cirrhosis.

To establish and verify a nomogram for individualized prediction of patients with oesophageal and gastric variceal rupture and haemorrhage in cirrhosis. Descriptive study. Department of Digestive Internal Medicine, Funan County People's Hospital, Anhui, China, from June 2017 to June 2020. Univariate and multivariate logistic regression analyses were used to identify the risk factors for oesophageal and gastric variceal bleeding in cirrhosis. An individualized risk prediction model was established, which was validated by the parallel bootstrap method and an external validation set. It was found that emotional stimuli (OR=4.591, 95% CI: 1.419-14.852), improper diet (OR=3.702, 95% CI: 1.606-8.526), overwork (OR=3.529, 95% CI: 1.331-9.366), lower temperature (OR=3.013, 95% CI:1.242-7.308), and increased abdominal pressure (OR=2.416, 95% CI: 0.900-6.487) were independent risk factors for oesophageal and gastric variceal bleeding in cirrhosis. A risk prediction model was established based on the five risk factors, and the R equation test showed that the C-index of the modelling group and the verification group was 0.815 (95% CI: 0.794-0.836) and 0.812 (95% CI: 0.793-0.831), respectively. The results of the correction curve showed little difference, which indicated that the risk prediction model has good accuracy and differentiation. Cirrhosis, Oesophagus varices and gastric fundus varices, Bleeding, Risk factors, Risk model, Validation.

Long-term outcomes of patients with cirrhosis presenting with bleeding gastric varices.

AimTo establish a therapeutic strategy for cirrhosis patients with gastric variceal bleeding.MethodsThe outcomes of 137 patients with bleeding gastric varices were evaluated.ResultsThe bleeding source was gastroesophageal varices (GOV) in 86 patients, and gastric fundal varices (FV) in 51 patients. The Child-Turcotte-Pugh classes were A, B, and C in 26, 79, and 32 patients, respectively; 34 patients (24.8%) had hepatocellular carcinoma (HCC), of which 11 also had complicating portal venous tumor thrombosis (PVTT). Patients with GOV were treated by endoscopic variceal ligation or endoscopic injection sclerotherapy (EIS) with ethanolamine oleate, while those with FV were treated by EIS with cyanoacrylate; 29 patients with FV also underwent additional balloon-occluded retrograde transvenous obliteration (BRTO). Hemostasis was successfully achieved in 136 patients (99.3%), and the cumulative 1-year, 3-year, and 5-year rebleeding rates were 18.1%, 30.8%, and 30.8%, respectively, in the patients with GOV, and 2.2%, 12.5% and 12.5%, respectively, in the patients with FV. The overall 1-year, 3-year, and 5-year survival rates were 79.7%, 71.5% and 64.4%, respectively, in the patients with GOV, and 91.0%, 76.9% and 59.5%, respectively, in the patients with FV. Multivariable analysis identified PVTT and alcoholic cirrhosis as a significant risk factor associated with rebleeding, model for end-stage liver disease (MELD) score and PVTT as significant factors associated with survival.ConclusionsEndoscopic therapies with or without BRTO appeared to be useful therapeutic strategies to prevent rebleeding in patients with gastric variceal bleeding, and favorable outcomes were obtained, except in patients with underlying HCC associated with PVTT and/or severe liver damage.

Balloon‐occluded retrograde transvenous obliteration for gastric varices improves hepatic functional reserve in long‐term follow‐up

Background and AimBalloon‐occluded retrograde transvenous obliteration (BRTO) has been widely adopted for the management of gastric fundal varices (GVs). There are a few reports that BRTO leads to the improvement of mid‐term and long‐term hepatic functional reserve (HFR). We retrospectively investigated the long‐term effect on HFR and prognosis among patients who had undergone BRTO for GVs.MethodsThis single‐center, retrospective study included 57successful patients out of 60 patients who underwent BRTO for GVs from December 2005 to September 2018. We examined the indicators of HFR (e.g., encephalopathy and ascites statuses, serum total bilirubin and albumin levels, % prothrombin time, and Child–Pugh and albumin–bilirubin [ALBI] scores) during 3 years of follow‐up after BRTO. We analyzed survival using the Kaplan–Meier method and identified the independent prognostic factors via multivariate analyses.ResultsGVs disappeared in all patients who were successfully treated by BRTO. At 3 years after BRTO, serum albumin levels were significantly elevated (from 3.3 to 4.0 g/dL, P = 0.008), while Child–Pugh and ALBI scores were significantly decreased (from 7.0 to 5.7, P = 0.043, and from −1.94 to −2.60, P = 0.006, respectively). The median survival time among all patients was 2207 days; the survival rates after BRTO were 87.0% at 1 year, 81.8% at 3 years, 67.3% at 5 years, and 44.1% at 10 years. Multivariate analyses revealed that ascites, hepatic encephalopathy, and malignant neoplasms were independently associated with poor prognosis.ConclusionBRTO for GVs has a favorable effect on long‐term HFR.

S2314 Management of Pregnancy in a Patient With Extrahepatic Portal Hypertension Complicated by Gastric Fundal Varices, Splenomegaly and Thrombocytopenia

S2314 Management of Pregnancy in a Patient With Extrahepatic Portal Hypertension Complicated by Gastric Fundal Varices, Splenomegaly and Thrombocytopenia

Outcome of patients treated with N-Butyl-2-cyanoacrylate in gastric variceal bleeding.

Objective: Aim of study was to determine outcomes of patients treated with N-butyl-2-cyanoacrylate. Study Design: Retrospective study. Setting: Department of Gastroenterology at Liaquat University of Medical and Health Sciences, Jamshoro. Period: December 2019 to March 2020. Material & Methods: A Retrospective study was conducted between by viewing medical records and endoscopy reports. Total 31 patients were enrolled with gastric variceal bleed that underwent endoscopic injection of N-butyl-2-cyanoacrylate we examined the mortality rate, hemostasis, Hospital stay, need of blood transfusion, and effectiveness of procedure. Results: A Total of 31 patients, out of which 18 (58.1 %) were male; the mean age was 55.23±8.778 years. Of these patients 23 (74.2 %), had concomitant esophageal varices, Child-Pugh class-A, B, C were seen in 4, 20 & 7 patients (12.9, 64.5 % & 22.6) respectively. Average duration of hospital stay was 5 to 8 days in 22 cases (71.0 %). Less than 3 pints of PRBC were transfused in 17 cases (54.8 %). Hemostasis was achieved in 27 patients (87%). Overall mortality rate was 3 out of 31(9.7%). one patient was referred for TIPSS. No complications from cyanoacrylate injection were observed. Conclusion: Standardized injection technique and regimen ensures the success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices in experienced hands.

An Unusual Cause of Isolated Gastric Varices

Question: A 57-year-old man presented with intermittent epigastric pain, accompanied by belching and regurgitation occasionally. His medical records revealed that upper gastrointestinal endoscopy found varices in gastric fundus 3 years ago. However, he did not experience any onset of gastrointestinal bleeding or anemia ever since. Repeated color Doppler ultrasound examination and contrast-enhanced computed tomography (CECT) scan failed to determine the etiology. The patient also denied any chronic liver diseases or known pancreatic disorders.

СЕЛЕКТИВНАЯ ДЕВАСКУЛЯРИЗАЦИЯ ДНА ЖЕЛУДКА У ПАЦИЕНТОВ С ХРОНИЧЕСКИМ ПАНКРЕАТИТОМ И ПОДПЕЧЁНОЧНОЙ ПОРТАЛЬНОЙ ГИПЕРТЕНЗИЕЙ. Предварительное сообщение о серии случаев

Background. Making treatment / prevention decisions in bleeding from gastroesophageal varices in patients with subhepatic portal hypertension remains challenging and thus requires further research. Objective. To perform a preliminary analysis of the outcomes of selective devascularization of the gastric fundus in patients with chronic pancreatitis and subhepatic portal hypertension. Material and methods. Selective devascularization of the gastric fundus was performed in five patients (3 men and 2 women) aged 23 to 54 with chronic recurrent pancreatitis and subhepatic portal hypertension. In 2 patients, Roux-en-Y cystojejunostomy for pancreatic pseudocyst was performed as the main treatment, and in 3 patients - Frey's surgery. Selective devascularization of the gastric fundus was adjuvant to a draining surgery or a resection-draining one. Results. All patients underwent surgery successfully. The duration of the operation (Me [min; max]) was 205 [190; 255] min. The time spent in the Department of anesthesiology, resuscitation and intensive care comprised 1 [1; 2] days. Postoperative follow-up of these patients over the period of 17 - 58 months detected no recurrence of bleeding from gastric varices. Endoscopy performed a year after revealed a decrease in the size of esophageal varices in all patients. Conclusions. The proposed technique of selective devascularization of the gastric fundus is substantiated by numerous studies of the variant anatomy of venous outflow from the spleen in extrahepatic portal hypertension. This technique is regarded as adjuvant to a draining surgery or a resection-draining one in patients with chronic pancreatitis and subhepatic portal hypertension performed to prevent bleeding from gastric fundus varices. There should be noted the reproducibility of this surgical intervention, its effectiveness and safety. Further research on the efficiency of the technique using randomized controlled trials is required.

Correlation of Portal and Splenic Vein Diameter with Presence and Size of Esophageal and Gastric Varices in Liver Cirrhosis Patients on MDCT

Introduction: Variceal formation depends upon the pattern of dilatation of the portal and various splanchnic veins in patients with cirrhotic liver and portal hypertension. Multidetector Computed Tomography (MDCT) may be helpful in the evaluation of such gastroesophageal varices and predicting their risk of haemorrhage.Methods: After obtaining ethical clearance and consent, 50 patients meeting the inclusion criteria were included and MDCT obtained. The diameters of the portal vein (PV), splenic vein (SV) and left gastric vein (LGV) were measured and originating vein of LGV determined. Pattern, location and diameter of varix was evaluated. Association between the diameters of the originating vein and the grade and pattern of the esophagael and gastric fundic varices was determined.Results: Of the 50 patients, 41 had gastroesophageal (GE) varices equal to or larger than 1mm with 34% having high-risk varices. The SV was predominantly the originating vein of the LGV. Cutoff SV diameter of 7.75mm and LGV diameter of 5.75mm had a sensitivity of 77.8% with a specificity of 73.2% and 75.6% respectively for the presence of varices.Conclusions: In our study, EV and GEV was more common and mostly supplied by LGV while isolated gastric fundic varices were supplied by non LGV veins only. The diameters of SV and LGV were associated with the presence and grade of esophageal and gastric fundic varices. MDCT is an important non-invasive modality in patients with portal hypertension and should be used for diagnosis, risk stratification and monitoring of varices.

Efficacy and safety of combined endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous occlusion (BRTOcc) of gastrorenal shunts in patients with bleeding gastric fundal varices

BackgroundEndoscopic cyanoacrylate (glue) injection of fundal varices may result in life-threatening embolic adverse events through spontaneous gastrorenal shunts (GRSs). Balloon-occluded retrograde transvenous occlusion (BRTOcc) of GRSs during cyanoacrylate injection may prevent serious systemic glue embolization through the shunt. This study aimed to evaluate the efficacy and safety of a combined endoscopic–interventional radiologic (BRTOcc) approach for the treatment of bleeding fundal varices.MethodsWe retrospectively analysed the data of patients who underwent the combined procedure for acutely bleeding fundal varices between January 2010 and April 2018. Data were extracted for patient demographics, clinical and endoscopic findings, technical details, and adverse events of the endoscopic–BRTOcc approach and patient outcomes.ResultsWe identified 30 patients (13 [43.3%] women; median age 58 [range, 25–92] years) with gastroesophageal varices type 2 (53.3%, 16/30) and isolated gastric varices type 1 (46.7%, 14/30) per Sarin classification, and median clinical and endoscopic follow-up of 151 (range, 4–2,513) days and 98 (range, 3–2,373) days, respectively. The median volume of octyl-cyanoacrylate: Lipiodol injected was 7 (range, 4–22) mL. Procedure-related adverse events occurred in three (10.0%) patients, including transient fever, non-life-threatening pulmonary glue embolism, and an injection-site ulcer bleed. Complete gastric variceal obturation was achieved in 18 of 21 patients (85.7%) at endoscopic follow-up. Delayed variceal rebleeding was confirmed in one patient (3.3%) and suspected in two patients (6.7%). Although no procedure-related deaths occurred, the overall mortality rate was 46.7%, primarily from liver-disease progression and co-morbidities.ConclusionThe combined endoscopic–BRTOcc procedure is a relatively safe and effective technique for bleeding fundal varices, with a high rate of variceal obturation and a low rate of serious adverse events.

Liver lobe based intravoxel incoherent motion diffusion weighted imaging in hepatitis B related cirrhosis: Association with child-pugh class and esophageal and gastric fundic varices.

Liver cirrhosis is a common chronic progressive liver disease in clinical practice, and intravoxel incoherent motion (IVIM) is a promising magnetic resonance method to assess liver cirrhosis, so our purpose was to investigate association of liver-lobe-based IVIM-derived parameters with hepatitis-B-related cirrhosis and its severity, and esophageal and gastric fundic varices. Seventy-four patients with hepatitis-B-related cirrhotic and 25 healthy volunteers were enrolled and underwent upper abdominal IVIM diffusion-weighted imaging with b-values of 0, 20, 50, 80, 100, 200, 400, 600, and 800 s/mm2. IVIM-derived parameters (D, pure molecular diffusion; D∗, pseudo diffusion; and f, perfusion fraction) of left lateral lobe (LLL), left medial lobe (LML), right lobe (RL), and caudate lobe (CL) were assessed statistically to show their associations with cirrhosis and its severity, and esophageal and gastric fundic varices. In this research, we found that D, D∗, and f values of LLL, LML, RL, and CL were lower in cirrhotic liver than in normal liver (all P-values <.05). D, D∗, and f values of LLL, LML, RL, and CL were inversely correlated with Child–Pugh class of cirrhosis (r = −0.236 to −0.606, all P-values <.05). D of each liver lobe, D∗ of LLL and CL, and f of LLL, LML, and CL in patients with esophageal and gastric fundic varices were lower than without the varices (all P-values <.05). D values of RL and CL could best identify cirrhosis, and identify esophageal and gastric fundic varices with areas under receiver-operating characteristic curve of 0.857 and 0.746, respectively. We concluded that liver-lobe-based IVIM-derived parameters can be associated with cirrhosis, and esophageal and gastric fundic varices.

Role of serotonin in development of esophageal and gastric fundal varices

Objective The aim was to determine the role of plasma free serotonin concentrations on the development of esophageal and gastric fundal varices. Background Esophageal and gastric varices are a serious consequence of portal hypertension in patients with the chronic liver disease. Several studies have evaluated possible noninvasive predictors for the presence of varices including plasma serotonin level. Materials and methods This study was conducted on 100 patients: 60 hepatic patients with esophageal and/or gastric varices, 20 hepatic patients without varices, and 20 nonhepatic patients who were admitted to Tropical Medicine Department in Menoufia University Hospitals. Patients and control were subjected to laboratory investigations, abdominal ultrasound, upper endoscopy, and quantitative measurement of plasma free serotonin using enzyme-linked immunosorbent assay technique. Results The plasma free serotonin levels were much higher in patients with liver cirrhosis with varices than in nonhepatic patients (mean: 92.240 ± 18.534 vs. 20.015 ± 3.042 ng/ml; P Conclusion Free serotonin is significant in the development of esophageal and fundal varices, indicating the clinical value of serotonergic receptor blockers in these patients.

2159 Endoscopic Management of Isolated Gastric Varices: Hematemesis in Pancreatitis-Induced Splenic Vein Thrombosis

INTRODUCTION: Brisk upper GI bleeding with acute blood loss anemia requires emergent endoscopic evaluation. Often, lesions are due to peptic ulcer disease or variceal hemorrhage. Here, we present a case of isolated bleeding gastric varices in a patient with splenic vein thrombosis likely due to recurrent episodes of acute pancreatitis. CASE DESCRIPTION/METHODS: A 48-year-old man with alcohol abuse, thrombocytopenia, and chronic LUQ abdominal pain presented with four days of hematemesis and melena. He intermittently takes PPI, but reported no NSAID use or history of H. pylori. Previously, two similar episodes associated with severe epigastric pain radiating to his back occurred with heavy drinking. On exam, he is hemodynamically stable with an unremarkable abdominal exam. His admission hemoglobin is 4.9 g/dl and BUN is 26 mg/dl. He is resuscitated with blood products and EGD reveals type 1 isolated gastric varices (IGV) in the fundus with stigmata of recent bleed (Figure 1). Subsequent EUS confirms presence of fundal varices. Hemostasis is achieved with coiling and cyanoacrylate (CYA) glue (Figures 2 and 3). CT A/P shows splenomegaly with chronic splenic vein thrombosis with collateral gastric varices. On discharge, he is counseled on alcohol cessation, as his bleeding gastric varices were attributable to pancreatitis-induced splenic vein thrombosis (PISVT). DISCUSSION: PISVT is a sequalae of acute and chronic pancreatitis. The pathophysiology is centered on left-sided portal hypertension with collateral blood flow developing in the splenoportal or gastroepiploic systems. Most patients with subsequent IGV are asymptomatic, but in high-risk symptomatic groups, EUS guided CYA glue injection and intravascular coil embolization is an emerging therapy that has the potential to achieve higher rates of hemostasis and lower rebleeding rates compared to sclerotherapy or balloon-occluded retrograde transvenous obliteration. A recent study demonstrated that out of 100 patients who underwent EUS-guided coil and CYA glue injection, 93 had complete obliteration (on Doppler study) of gastric fundal varices on follow-up EUS examination (Bhat, GIE 2016). Patients who do not achieve hemostasis after CYA injection and coil should be considered for splenic artery embolization or splenectomy, which is currently the gold standard for management of splenic vein thrombosis complicated by variceal hemorrhage. A large comparison trial would be most beneficial to validate this treatment modality compared to existing conventional therapies.

Duodenal Varices: A Rare Manifestation of Portal Hypertension

We report a case of haematemesis &amp; melaena due to ectopic varices located in the duodenum in a patient with NASH related CLD. Duodenal varices are a rare but potentially serious consequence of portal hypertension in the event of a bleeding. The etiology of duodenal varices can be classified into hepatic (e.g. cirrhosis) or extra hepatic (e.g. portal, splenic or superior mesenteric vein thrombosis). Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are widely accepted as primary therapies for esophageal variceal bleeding whereas bleeding gastric fundal varices are usually treated with cyanoacrylate injection or shunt procedures. However there is no widely accepted treatment modality for duodenal varices. In the case presented, we used injection sclerotherapy with ethanolamine oleate, to obliterate varices and control bleeding. A short review on the etiology pathogenesis and management of ectopic varices is presented.&#x0D; J Bangladesh Coll Phys Surg 2019; 37(3): 156-159