A proposal for a scoring system for hemoglobinuria following ethanolamine oleate sclerotherapy in children with venous malformations.

Background:Gastric variceal bleeding is a common and serious complication of liver cirrhosis and carries a high mortality. Endoscopic variceal ligation (EVL) is widely used, but its efficacy for gastric varices is limited by incomplete variceal capture and a high rate of post-ligation rebleeding.Objectives:To evaluate the effectiveness and safety of metal clip-assisted endoscopic variceal ligation (MEVL) versus traditional ligation (TL) in adults with cirrhotic gastric varices.Design:Single-center retrospective observational cohort study, reported according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement.Methods:Adults with cirrhosis and gastroesophageal (gastroesophageal varices)-type varices undergoing elective ligation for primary or secondary prophylaxis at Henan Provincial People’s Hospital between May 2019 and December 2023 were included; emergency endoscopies were excluded. Non-selective beta-blocker co-therapy was standardized. Baseline imbalance was addressed by propensity score matching and inverse probability of treatment weighting (IPTW), pre-specified as the primary balancing method. Multivariable logistic regression, Cox proportional hazards modeling, and post hoc power were computed in SPSS 26 and Python 3.11.Results:Ninety-nine patients were analyzed (MEVL n = 46; TL n = 53) with comparable baseline characteristics. One-session eradication was achieved in 33 of 46 MEVL patients (71.7%) compared with 26 of 53 TL patients (49.1%), favoring MEVL after IPTW adjustment (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.03–6.27; p = 0.042) and on Cox regression (adjusted hazard ratio 1.53, 95% CI 1.00–2.35; p = 0.049). Early rebleeding between 120 h and 6 weeks occurred in 0 of 46 MEVL patients versus 5 of 53 TL patients (9.4%; p = 0.059; post hoc power 87%); the adjusted OR for any rebleeding favored MEVL (0.24, 95% CI 0.07–0.82; p = 0.023). All-cause mortality (3/46 vs 6/53) and adverse reactions (11/46 vs 14/53) did not differ.Conclusion:MEVL was associated with higher one-session eradication than TL, with no increase in adverse reactions. A reduction in cumulative rebleeding was suggested by adjusted logistic regression but was not confirmed by time-to-event Cox analysis; this finding should be interpreted as exploratory rather than definitive. Multicenter prospective validation is required.Clinical trial registration:Since this is a retrospective, non-randomized study, it was not registered as a clinical trial.

The best endoscopic treatment for gastric varices is currently unclear. We performed a network meta-analysis combining direct and indirect comparisons among the different techniques currently in use. We identified 10 randomized controlled trials (RCTs; 760 patients) comparing endoscopic cyanoacrylate injection, endoscopic thrombin injection, endoscopic ultrasound (EUS)-guided cyanoacrylate injection, EUS-guided coil injection, EUS-guided coil+cyanoacrylate injection, and large-volume band ligation. The primary outcome was rebleeding rate, and secondary outcomes were complete obliteration of gastric varices and adverse event rate. The results were expressed in terms of risk ratio (RR) with 95%CIs. EUS-guided cyanoacrylate and EUS-guided coil+cyanoacrylate injection showed significantly lower rates of rebleeding than direct endoscopic cyanoacrylate injection (RR 0.39, 95%CI 0.27-0.58 and RR 0.15, 95%CI 0.03-0.90, respectively). None of the treatments were significantly superior in terms of complete obliteration of gastric varices but EUS-guided cyanoacrylate injection, large-volume band ligation, and thrombin injection had lower adverse event rates compared with endoscopic cyanoacrylate injection (RR 0.59, 95%CI 0.48-0.72; RR 0.38, 95%CI 0.19-0.75; and RR 0.30, 95%CI 0.15-0.61, respectively). EUS-guided cyanoacrylate injection with or without coils was associated with lower rebleeding rates than conventional endoscopic cyanoacrylate injection. However, the quality of evidence was very low and further RCTs are needed before firm conclusions can be drawn regarding the relative efficacy and safety of these treatments.

Feasibility and Effectiveness of Cyanoacrylate-Assisted BRTO for Gastric Varices and Splenorenal Shunts.

Efficacy and safety of EUS guided coil embolization with gelatin sponge versus coil embolization with glue for gastric varices.

Patient-Friendly Summary of the ACR Appropriateness Criteria®: Radiologic Management of Gastric Varices.

Bleeding from isolated gastric varices type 1 (IGV-1) with gastrorenal shunts (GRS) carries a high risk. Although EUS-guided coil-assisted cyanoacrylate (CYA) injection is effective, coil use raises concerns regarding long-term safety and cost. This study was performed to evaluate the feasibility, efficacy, and safety of EUS-guided coil-free direct CYA injection for managing IGV-1 with GRS. This single-center, retrospective case series included 15 consecutive patients with IGV-1 and GRS who underwent EUS-guided coil-free direct CYA injection between November 2024 and May 2025. Under real-time EUS/Doppler guidance, the primary feeding vessel was punctured, and a modified "sandwich" technique was employed; conventional gastroscopic direct CYA injection (CGD-CYA injection) was performed for residual varices in selected patients. The primary outcomes were technical success, variceal obliteration at 6months, and 6-week rebleeding rates. The technical success rate was 100% (15/15). Fourteen patients (93.33%) achieved complete variceal obliteration on follow-up imaging (median 210days). The early rebleeding rate (within 6weeks) was 13.33%, with no late rebleeding occurring thereafter. The rebleeding-free survival rate was 80.00% during follow-up.The median EUS-guided CYA injection volume was 4.00mL. No major adverse events, including symptomatic ectopic embolism, were observed. Minor adverse events-transient fever (33.33%) and abdominal pain (40.00%)-were self-limiting. EUS-guided coil-free direct CYA injection appears to be a feasible and safe alternative for managing IGV-1 with GRS, demonstrating high technical success and effective obliteration. CGD-CYA injection serves as a valuable supplementary treatment for residual varices, further improving obliteration efficacy. Despite an observed early rebleeding rate, the technique may potentially offer a valuable option, particularly in resource-limited settings.

Beyond glue injection: rethinking strategy in gastric variceal bleeding.

Upper gastrointestinal bleeding remains an important gastrointestinal condition despite a decline in its incidence, the introduction of acid-suppressive therapy, and advances in endoscopic techniques. Based on etiology, it is classified as variceal or nonvariceal bleeding, with peptic ulcers constituting the majority of nonvariceal bleeding. Before endoscopy, it is essential to stabilize the patient by administering appropriate fluids, blood transfusions, proton pump inhibitors, vasoconstrictors, and antibiotics, followed by an early endoscopic examination and treatment whenever possible. Endoscopic management can be facilitated by accessories such as transparent caps, water-jet pumps, overtubes, and multi-bending endoscopes. Studies have reported emerging tools, including machine learning models for risk prediction, swallowable bleeding sensors, and hemostasis guided by endoscopic ultrasound or Doppler. Endoscopic hemostasis includes injections, mechanical therapy, electrocautery, and topical therapies. Once the bleeding source is identified, an appropriate endoscopic modality can be selected according to the lesion. For nonvariceal bleeding, injections, coagulation, and mechanical methods are used when endoscopic hemostasis is indicated. Band ligation is commonly used to treat esophageal variceal bleeding, whereas gastric variceal bleeding is typically treated with cyanoacrylate injections. If endoscopic therapy fails or rebleeding occurs, angiography with embolization or surgery may be required, and in acute variceal bleeding, a transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration can be considered. Second-look endoscopy may be performed selectively in patients at high risk of rebleeding or when repeat evaluation is needed. In peptic ulcer disease, early biopsy should be performed when malignancy is suspected, and Helicobacter pylori testing and eradication should be ensured.

Gastrointestinal (GI) bleeding is a frequent and potentially life-threatening emergency for which endoscopy remains the primary diagnostic and therapeutic modality. However, a subset of patients experiences persistent or recurrent bleeding, that requires stabilization before endoscopy or presents with lesions, that are inaccessible or unsuitable for endoscopic treatment. This review outlines the role of radiological intervention in these clinical settings. This article reviews the use of computed tomography angiography as the principal preprocedural imaging modality, focusing on its ability to localize active bleeding, characterize the underlying etiologies, and delineate the vascular anatomy relevant to catheter-based interventions. The indications, techniques, and outcomes of transcatheter arterial embolization for non-variceal GI bleeding are also summarized, including the application of superselective catheterization and commonly used embolic materials. This review describes the hemodynamically targeted interventional approaches for variceal GI bleeding associated with portal hypertension. The technical principles and clinical roles of the transjugular intrahepatic portosystemic shunt (TIPS) for portal decompression and balloon-occluded retrograde transvenous obliteration (BRTO) and its variants for gastric varices are discussed. Percutaneous variceal embolization has also been reviewed as an adjunctive option in selected situations in which endoscopic therapy, TIPS, or BRTO is not feasible or unsuccessful. Overall, this review summarizes the current imaging strategies and interventional techniques for GI bleeding, emphasizing patient selection based on bleeding etiology, vascular and portal venous anatomy, and hemodynamic status.

Patient: Female, 62-year-oldFinal Diagnosis: Liver cirrhosisSymptoms: Liver failureClinical Procedure: —Specialty: Anesthesiology • SurgeryObjective: Unusual or unexpected effect of treatmentBackgroundPortal vein thrombosis (PVT) in patients with cirrhosis is a significant challenge to liver transplantation and increases post-transplant morbidity and mortality, requiring advanced surgical techniques that include thrombectomy, venous grafts, and anticoagulation. This report describes the case of a 62-year-old woman with liver cirrhosis and portal systemic thrombosis within the transjugular intrahepatic portosystemic shunt (TIPS) prior to orthotopic liver transplantation (OLT), and with portal vein glue embolization in the explanted liver.Case ReportOur patient was diagnosed with cirrhosis 2 years prior to OLT, which was complicated by gastric varices. She subsequently underwent glue embolization of varices and TIPS placement 1 year prior to OLT. Four months prior to OLT, she was admitted to the hospital for sepsis evaluation. Computed tomography angiography (CTA) revealed a thrombus extending from the TIPS to the cavo-atrial junction. A concurrent portal vein thrombus was seen extending into the splenic vein. This led to a thrombectomy procedure, with follow-up CTA revealing a small amount of residual thrombus within TIPS. She was transferred to our institution for an OLT. We present a novel case that involved successful OLT along with TIPS removal and mechanical thrombectomy. Cirrhotic patients pose a challenge during liver transplantation due to their rebalanced and unstable coagulation state.ConclusionsPortosplenic thrombosis in patients with cirrhosis was previously noted to be a barrier to liver transplantation. This report shows that liver transplant can be successful with multidisciplinary preoperative and postoperative surgical and medical management.

Spleen-preserving distal pancreatectomy (SPDP) is performed for benign or low-grade malignant tumors of the pancreatic body and tail. The Warshaw technique (WT), involving the division of the splenic artery and vein, is associated with splenic infarction and gastric varices. Recently, SPDP with splenic artery resection and splenic vein preservation (SVP) has been introduced. However, its safety and feasibility remain unclear. This study compared the perioperative outcomes between the SVP and WT approaches. We retrospectively reviewed the data on patients who underwent laparoscopic or robot-assisted SPDP between January 2019 and December 2024. Of these, seven patients underwent SVP and 24 underwent WT. The clinical outcomes, complications, and postoperative imaging findings were evaluated. The baseline characteristics were comparable between the groups. The operative time, blood loss, postoperative inflammatory markers, and clinically relevant postoperative pancreatic fistula showed no significant differences. Contrast-enhanced CT on postoperative day 7 demonstrated splenic infarction in 2 of 4 SVP patients (50%) and 14 of 22 WT patients (63.6%, p = 0.625). Gastric varices were observed only in the WT group (22.7%, p = 0.555). Splenic vein thrombosis did not occur in the SVP group. The SVP approach is thus considered to be safe and feasible, with perioperative outcomes comparable to WT. Larger studies with long-term follow-up are warranted.

Endoscopic ultrasound-guided coil and glue embolization of gastric varices targeting feeder vessel versus submucosal variceal complex: A pragmatic comparative analysis (with videos).

Assessment of Esophageal and Gastric Varices in Patients With Cirrhosis for Clinical Trials: A Centralized Blinded Evaluation System

Endoscopic ultrasound (EUS)-guided coil deployment is widely used for fundal gastric varices and is associated with a higher variceal obliteration rate andreducedcyanoacrylatevolume. However, its benefit in type 1 gastroesophageal varices (GOV1) remains unclear. This study aimed to evaluate whether deploying coil has privilege in GOV1 gastroesophageal varices. Based on retrospectively collected data, cirrhotic patients receiving EUS-guided coil and cyanoacrylate injection for GOV1 varices were enrolled in the case group, and patients treated with cyanoacrylate injection under straight-view endoscopy comprised the control group. Variceal obliteration rate, cyanoacrylate glue volume, rebleeding rate, and other clinical outcomes were compared between the two groups. A total of 42 patients with GOV1 varices were enrolled in the final analysis (21 patients in the case group and 21 in the control group). The complete variceal obliteration rate was 100.0% in the case group and 55.0% in the control group. Less cyanoacrylate glue was required in the case group than in the controls (1.67mL vs. 2.52mL, p < 0.01). The case group showed a trend toward a lower 3-month rebleeding rate than the control group, with no significant difference (4.8% vs. 28.6%, p = 0.093). Deployment of coils under EUS guidance appears to be beneficial in patients with GOV1 varices.

Background and aimsImprovement in hepatic reserve after balloon-occluded retrograde transvenous obliteration (BRTO) in patients with gastric varices (GVs) has not been fully established. The relationship between increases in liver volume (LV) or splenic volume (SV) after BRTO and prognosis is still unclear. In this study, we aimed to evaluate the factors associated with improvement in hepatic reserve after BRTO in GV patients and the relationship between changes in LV or SV after BRTO and prognosis.MethodsWe retrospectively enrolled 258 patients who recieved their first BRTO for GV treatment at 12 institutions between January 2004 and May 2019. Hepatic reserve, LV, and SV were evaluated before and 6 months after BRTO.ResultsChanges in hepatic reserve were evaluated in 160 patients. Albumin levels and prothrombin time-international normalized ratio improved significantly, while platelet counts decreased significantly at 6 months after BRTO. Multivariate logistic regression analysis showed that history of hepatocellular carcinoma and modified albumin-bilirubin (mALBI) grade were independent factors associated with the improvement of albumin-bilirubin (ALBI) score. The ALBI score significantly improved in patients with mALBI grade 2b or 3 (p < 0.001), but not in patients with mALBI grade 1 or 2a. Eighty-three patients who underwent abdominal computed tomography examination 6 months after BRTO had significantly increased LV and SV (LV, p < 0.01; SV, p < 0.01). The patients with a > 10% increase in SV had significantly poorer prognosis than the others (p = 0.03).ConclusionsBRTO for GVs leads to improvement of hepatic reserve. Patients with increased SV after BRTO had poor prognosis.Trial registrationNot aplicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12876-026-04893-4.

Acute variceal bleeding treatment in patients with portal hypertension combines vasoactive drugs, prophylactic antibiotics, hepatic encephalopathy prophylaxis and upper gastrointestinal endoscopy for variceal treatment (elastic band ligation and/or tissue adhesive injection), on top of non-specific measures. Failure to control bleeding must lead to salvage TIPS (Transjugular Intrahepatic Portosystemic Shunt) discussion, after esophageal tamponade (balloon or stent).Pre-emptive TIPS within 72h must systematically be considered in high-risk patients to reduce rebleeding and mortality. Pre-emptive TIPS must also be discussed in case of gastric variceal bleeding.Following the acute bleeding episode, secondary prophylaxis combines non-selective betablockers and recurrent endoscopic treatments (except after TIPS).Liver transplantation must be discussed in certain cases of refractory bleeding or early relapse after TIPS implantation.

Management of Bleeding Gastric Varices: A Practical Approach to an Impractical Problem.

Introduction: Gastric varices are one of the most significant portal hypertension disorders, characterized by severe disease progression and high mortality. Diagnosis of gastric varices is primarily based on endoscopic findings, while radiologic pattern has been understudied. Objective: Identification of prognostically significant signs of the risk of bleeding from varicose veins of the stomach and construction of an individual stratification model based on computed tomography data. Materials and methods: The medical records and CT scan results of 181 patients with portal hypertension were retrospectively analyzed. They were divided into groups with a disease duration of less than 1 year (control group – 109 patients) and more than 5 years (main group – 72 patients). During follow-up, bleeding from gastric varices was noted in 41 patients. All patients underwent CT scanning using standard multiphase scanning techniques, supplemented by hydro-CT. Statistics : Statistical analysis was performed using Epi Info™ (version 7.2.6.0), Excel (Microsoft Office 2024), and SPSS Statistics (version 26). Results: Significant differences between the main and control groups were observed in the following parameters: hepatic functional reserve according to the Child-Pugh classification; diameter of gastric varices greater than 7 mm on CT (х 2 =5,486; p&lt;0,05); degree of variceal protrusion greater than 5 mm on CT (х 2 =7,533; p&lt;0,01); and the presence of portal hypertensive gastropathy on CT (х 2 =6,444, p&lt;0,05). Variables were stratified and assessed using a Cox regression model. The prognostic index calculation formula allows for the identification of high, moderate, and low bleeding risks. Discussion: Most studies focus on esophageal or combined gastroesophageal varices, with limited analysis of gastric variceal features. Our study proposes an integrated prognostic index for gastric variceal bleeding based on computed tomography data. Conclusion: The obtained results confirm the high informative value of CT in assessing the condition of gastric varices. The use of a CT-based bleeding prognostic index allows for individualized patient management.

Conventional balloon-occluded retrograde transvenous obliteration often fails to achieve complete occlusion in cases with complex collateral drainage, leading to variable outcomes. The cooperative anti-reflux and double interruption system, a coaxial dual-balloon device, was developed to achieve more stable venous occlusion. This study aimed to evaluate the clinical and hepatic functional benefits of double-balloon balloon-occluded retrograde transvenous obliteration compared with the conventional single-balloon method for gastric varices. This single-center retrospective study included 48 patients with gastric varices who underwent balloon-occluded retrograde transvenous obliteration between February 2008 and March 2020. Eighteen patients received the single-balloon method, and 30 underwent the double-balloon procedure. Clinical and technical success rates, complications, and hepatic function parameters (Child-Pugh and albumin-bilirubin scores) were compared up to 12 months after balloon-occluded retrograde transvenous obliteration. The clinical success rate was significantly higher with cooperative anti-reflux and double interruption system than with the single-balloon method (90.0% vs. 50.0%, p = 0.004), whereas technical success rates were high in both groups (100% vs. 88.9%). In the cooperative anti-reflux and double interruption system group, hepatic functional reserve improved markedly, with significant decreases in albumin-bilirubin (Δalbumin-bilirubin: -0.283 vs. +0.001, p < 0.05) and Child-Pugh scores (ΔChild-Pugh: -0.19 vs. +1.09, p < 0.05) during 5-12 months of follow-up. Complication rates were comparable between groups. Double-balloon balloon-occluded retrograde transvenous obliteration using the cooperative anti-reflux and double interruption system significantly improves clinical success and long-term hepatic function compared with the conventional method, providing a safe and effective treatment for gastric varices. This dual-balloon approach ensures stable occlusion and uniform sclerosant distribution even in cases with complex collateral drainage, leading to more reliable treatment outcomes and enhanced hepatic functional recovery.