Injection Sclerotherapy For Esophageal Varices Research Articles

Modified gel immersion method during endoscopic ultrasonography and injection sclerotherapy for esophageal varices.

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Use of a transparent cap with a slit facilitates endoscopic injection sclerotherapy of esophageal varices.

Use of a transparent cap with a slit facilitates endoscopic injection sclerotherapy of esophageal varices.

Temporary hypotension and ventilation difficulty during endoscopic injection sclerotherapy for esophageal varices in a child with Fontan circulation: a case report

BackgroundEndoscopic procedures are rarely performed in children with congenital heart disease (CHD); therefore, the associated complications are unknown. We report an abrupt change in circulatory and respiratory condition during endoscopic injection sclerotherapy for esophageal varices.Case presentationA 9-year-old boy with a history of total anomalous pulmonary venous connection (TAPVC) repair and Fontan procedure for asplenia and a single ventricle with TAPVC underwent endoscopic injection sclerotherapy under general anesthesia for esophageal varices. Systolic blood pressure decreased from 70 to 50 mmHg following a sclerosant injection; a second injection reduced his peripheral oxygen saturation from 93 to 79% secondary to ventilation difficulty. Although we suspected anaphylaxis intraoperatively, postoperative imaging suggested that balloon dilation performed to prevent sclerosing agent leakage caused compression of the pulmonary venous chamber and trachea owing to the anomalous intrathoracic organ anatomy.ConclusionThorough understanding of the complex anatomy is important before performing endoscopic procedures in children with CHD to preoperatively anticipate possible intraoperative complications and select the optimal therapeutic approach and anesthesia management.

Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with the propensity score matching: Multivariate analysis with propensity score matching.

Peri-esophageal collateral veins have been reported to be associated with the recurrence of esophageal varices (EVs). In this study, we retrospectively analyzed whether endoscopic ultrasonography (EUS) findings obtained just before endoscopic injection sclerotherapy (EIS) are associated with the success rate of intravariceal injection, recurrence rate of EVs, and overall survival rate (OS) of patients. Furthermore, we investigated the independent predictors associated with these factors by multivariate analysis. A total of 91 patients with risky EVs treated by EIS were analyzed. The primary endpoint was to identify independent predictors associated with the success rate of intravariceal injection, recurrence rate, and OS by multivariate analysis, to confirm the usefulness of EUS examination. The secondary endpoint was to clarify differences in recurrence rate and OS between patients who underwent additional argon plasma coagulation (APC) and those who did not, by the propensity score matching method. Luminal diameter of EVs and F factor were predictors of the success rate of intravariceal injection. APC was predictor of OS and recurrence of EVs. EUS findings were not associated with these factors. Propensity score matching (APC, 23; without APC, 23) showed that recurrence rate was significantly improved in the APC group (P = 0.050) and that OS had the tendency to be higher in the APC group (P = 0.068). Endoscopic ultrasonography findings before EIS were associated with successful intravariceal injection but were not associated with recurrence rate or OS. Additional APC could improve OS and reduce the recurrence of EVs.

Different Doses of Oxycodone for Endoscopic Injection Sclerotherapy of Esophageal Varices.

BackgroundThe aim of the present study was to evaluate the effects of different doses of oxycodone during endoscopic injection sclerotherapy (EIS) for esophageal varices with painless sclerosing agents.Material/MethodsA total of 119 patients were randomly divided into 3 groups: Group A, midazolam and 0.075 mg/kg oxycodone (n=40); Group B, midazolam and 0.1 mg/kg oxycodone (n=40); and Group C, midazolam and 0.125 mg/kg oxycodone (n=39). The main observation index was the incidence of body movement during the perioperative period. The secondary indices were additional propofol usage; postoperative analgesic usage; other adverse effects, such as hypoxia, myoclonus, and cough; and satisfaction scores for surgeons and patients.ResultsThe incidence rates for body movement during the perioperative period in groups A, B, and C were 33%, 13%, and 0, respectively (P<0.001). The satisfaction scores for surgeons and patients were highest in Group C (0.125 mg/kg oxycodone). The incidence rates for hypoxia before EIS were 15%, 8%, and 33% (P=0.026) and during EIS were 23%, 3%, and 0% (P<0.001), respectively. There were no significant between-group differences with respect to other adverse effects.ConclusionsThe ideal dose of oxycodone for perioperative analgesia during EIS for esophageal varices is 0.125 mg/kg.

Exacerbation of Portal Hypertensive Enteropathy after Endoscopic Injection Sclerotherapy for Esophageal Varices

Introduction: Portal hypertensive enteropathy (PHE) is a well-known small-bowel lesion that occurs with liver cirrhosis (LC) and is associated with increased hepatic venous pressure. However, it is unclear how esophageal varices (EV) treatment actually affects PHE. We aimed to analyze the effects of EV treatment on PHE. Methods: Among LC patients who underwent capsule endoscopy (CE) more than twice to confirm PHE at our hospital from February 2009 to September 2018, we targeted those with no change in the Child-Pugh classification after EV treatment for the prevention of bleeding. Patients were assigned to groups based on the EV treatment method (endoscopic injection sclerotherapy [EIS] group or endoscopic variceal ligation [EVL] group). We analyzed the PHE findings before and after treatment, and we investigated changes in the collateral vein using computed tomography imaging. Results: We analyzed 42 LC patients (27 men; mean age, 65.3 years); 20 were in the EIS group and 22 were in the EVL group. Exacerbation of PHE was significantly prevalent in the EIS group (90%) compared to that in the EVL group (50%). CE of PHE showed significantly prevalent exacerbation of villous edema in the EIS group (65%) compared to that in the EVL group (23%). Stenosis or disappearance of the feeding vessel (55%) and exacerbation of the hepatofugal collateral vein (35%) were significantly prevalent in the EIS group. Conclusions: EIS exacerbates PHE, especially villous edema, in LC patients with changes in collateral circulation.

Propofol is a more effective and safer sedative agent than midazolam in endoscopic injection sclerotherapy for esophageal varices in patients with liver cirrhosis: a randomized controlled trial.

The efficacy of sedation during endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs) in patients with liver cirrhosis remains unclear. The aim of this study is to compare the efficacy and safety between propofol- and midazolam-based sedation for EIS. Twenty-three patients with EVs were prospectively and randomly assigned to midazolam-based (Midazolam group) or propofol-based (Propofol group) sedation. All patients underwent a number connection test (NCT) to evaluate minimal hepatic encephalopathy (MHE) on the day before and at 2 and 24 hours following EIS. The primary endpoint was exacerbation of MHE after EIS, which was defined as deterioration of the NCT. The secondary endpoints were postoperative awareness, technical success rate, frequency of body movement, patient and operator satisfaction, cardiorespiratory dynamics during EIS, and adverse events. Exacerbations of MHE at 2 hours after EIS compared with those before EIS were not significantly different between the two groups. In both groups, the deterioration of NCT scores before and 2 hours after EIS was observed (Propofol group: 60.0 vs. 70.0 s, P = 0.026; Midazolam group: 42.5 vs. 67.0 s, P = 0.002). There were no significant differences in awareness, technical success rate, or patient satisfaction. However, the frequency of body movement in the Propofol group was significantly lower than that in the Midazolam group (1 vs. 4, P = 0.045), and operator satisfaction in the Propofol group was significantly higher than that in the Midazolam group (P = 0.016). No adverse events were observed. Propofol-based sedation exacerbated MHE after EIS similarly to midazolam-based sedation in patients with liver cirrhosis. However, propofol-based sedation provided stable sedation with a lower frequency of body movements and high operator satisfaction.

Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study

BackgroundDexmedetomidine (DEX) is a novel, highly selective α2-adrenoceptor agonist that elicits sedative, amnestic, sympatholytic and analgesic effects in patients. Several Japanese investigators have reported the clinical usefulness of DEX for...

Evidence-based clinical practice guidelines for liver cirrhosis 2015.

The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding arethe endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

Evaluation of Duodenal Angioectasia with Portal Hypertension

Background: A few studies have investigated duodenal lesions in patients with portal hypertension. Aim is to investigate duodenal angioectasia in patients with portal hypertension. Methods: Sixty patients with duodenal angioectasia and portal hypertension were investigated between April 2009 and March 2012. The subjects were 29 males and 31 females ranging in age from 50 to 84 years (mean: 67.5). Endoscopic findings of duodenal angioectasia were investigated. We evaluated the therapeutic strategy for cases of bleeding duodenal angioectasia. Result: The underlying pathologies of portal hypertension were liver cirrhosis in 56 patients, idiopathic portal hypertension in three patients and extrahepatic portal vein obstruction in one patient. Forty-one of the 60 patients had previously received endoscopic injection sclerotherapy for esophageal varices and the other nineteen patients had a coexistent high risk of esophageal varices. Gastric antral vascular ectasia was discerned in 29 cases. The location of the duodenal angioectasia was the duodenal bulb in 30 cases, descending portion in 13 cases and both the duodenal bulb and descending portion in 17 cases. Endoscopic findings of duodenal angioectasia were classified as follows: punctulate erythema (<1 mm), with or without oozing, and patchy erythema (a few mm), with or without oozing. Endoscopically, bleeding from the duodenal angioectasia was observed in 16 of 60 (26.7%) patients: punctulate erythema in 6 cases and patchy erythema in 10 cases. Bleeding from the patchy erythema type was discerned in 10 of 16 patients (62.5%). However, there was no bleeding in 43 cases of punctulate erythema involving the bulb. Argon plasma coagulation was successfully performed for 6 of 16 cases of bleeding duodenal angioectasia and the other 10 cases were followed-up with endoscopic observations. Conclusions: Duodenal angioectasia in patients with portal hypertension is considered to be one of the lesions of portal hypertensive duodenopathy.

Pulmonary Functions after Injection Sclerotherapy of Esophageal Varices and after Band Ligation

Aim of the study: To study changes in pulmonary function tests after esophageal variceal injection sclerotherapy in comparison to changes after esophageal variceal band ligation. Patients & methods: This study was designed as non randomized controlled study. Thirty patients with hepatic cirrhosis & portal hypertension who were admitted to Hepatology, Gastroenterology and Infectious Diseases department , Benha university hospital for elective esophageal variceal therapy (secondary prophylaxis) were classified into group I:15 patients treated with sclerotherapy by using 5-15 ml ethanolamine oleate and group II:15 patients treated with band ligation. Patients were subjected for full clinical evaluation including history, general, chest, and abdominal examination. Laboratory and radiological investigation including complete blood count, liver function tests, kidney function tests and blood sugar and plain chest x-ray (P.A. and lateral views) were done. Pulmonary function tests and arterial blood gasses were done before, one day after and one week after the procedure. Results: The results revealed , significant decrease in vital capacity in group I one day after injection ( p ˂ 0.05),but no significant decrease in vital capacity in group II. There was a significant decrease in PaO2 in group I one day after injection sclerotherapy ( p ˂ 0.05) but no significant changes in group II and no significant changes in PaCO2 in both groups one day after the procedures. The study has also revealed no significant changes in FVC,FEV1/FVC and PaCO2 in group I and group II after procedures. The study revealed significant linear correlation between the decreases in PaO2 and the percentage decrease in vital capacity( p ˂ 0.05). One week after procedure, pulmonary functions that has been affected in group I returned back to baseline values. Conclusions: esophageal injection sclerotherapy produces restrictive defect (decrease in PaO2 and vital capacity) in pulmonary functions one day after injection and improved within one

硬化療法後に食道粘膜下血腫を生じ気管切開を要した食道静脈瘤の1例

硬化療法後に食道粘膜下血腫を生じ気管切開を要した食道静脈瘤の1例

An Audited Experience of Therapeutic Endoscopy in Jos, Nigeria

Background: Therapeutic endoscopy in Nigeria is still in its infancy despite its obvious advantages of minimal access trauma, less post operative pain and shorter hospital stay. Although many gastrointestinal procedures are now being performed endoscopically, there are very few reports of experience with therapeutic endoscopy in Nigeria and the range of procedures are limited most times to upper gastrointestinal interventions. This study was aimed at auditing our experience with therapeutic endoscopy in a developing country. Patients and methods: This was a prospective analysis of all consecutive patients with endoscopic diagnoses of oesophageal varices, benign oesophageal strictures and colorectal polyps that had injection sclerotherapy and rubber band ligation for the varices, oesophageal dilatation for strictures and snare polypectomy for the colorectal polyps. Results: A total of 87 patients had therapeutic endoscopic interventions. Their ages ranged from 11 to 53yrs with a mean age of 37.4 +/- 9.3yrs. There were 63 males and 24 females (M: F = 2.7: 1). Seventy patients (80.5%) had rubber band ligation, while 8 (9.2%) had injection sclerotherapy of oesophageal varices. Six patients (6.9%) had rectal and colonic polypectomies while three patients (3.4%) had dilatation of benign distal oesophageal strictures. Massive upper gastrointestinal bleeding was recorded in one patient complicating injection sclerotherapy. There was no mortality in this study. Conclusion: Therapeutic endoscopy is a safe and worthwhile method of treating gastrointestinal diseases in our environment and the types of pathologies treatable this way is bound to increase as the expertise and equipment become more widely available.

Endoscopic Surveillance and Primary Prophylaxis Sclerotherapy of Esophageal Varices in Biliary Atresia

Evidence-based recommendations on endoscopic screening and prophylactic treatment of esophageal varices in patients with biliary atresia (BA) are scarce. We assessed the efficiency of endoscopic surveillance and risk factors of esophageal varices and associated upper gastrointestinal bleeding. A total of 47 consecutive children with BA and portoenterostomy underwent yearly endoscopies and prophylactic injection sclerotherapy of esophageal varices between 1987 and 2009. The median follow-up was 1.7 years (range 0.5-18.9) and overall 2-year survival 71%. Disease characteristics, clearance of jaundice, laboratory tests reflecting liver function and hypersplenism, as well as sonographic signs of portal hypertension were related to endoscopic findings and bleeding episodes. Grade 2 to 3 varices developed with similar frequency after failed (18/28, 64%) and successful portoenterostomy (10/19, 53%) in 28 patients. Following failed portoenterostomy, esophageal varices were encountered significantly earlier (8 [4-23] vs. 19 [4-165] months, P = 0.004), and they reappeared after eradication more often (16/16 vs. 4/10, P = 0.001). Varices bled only after failed portoenterostomy (13/28 vs. 0/19, P < 0.001). Increased serum bilirubin concentration >40 μmol/L at 3 months after portoenterostomy was a risk factor of upper gastrointestinal bleeding (odds ratio [OR] 17, 95% confidence interval [CI] 1.7-175, P = 0.017). In future studies as well as clinical surveillance of BA patients' varices, successful and failed portoenterostomy patients should be approached as separate groups with divergent prognoses. After failed portoenterostomy, surveillance should start early, for example, at 6 months.

Endoscopic injection sclerotherapy for bleeding varices in children with intrahepatic and extrahepatic portal venous obstruction: Benefit of injection tract embolisation

The outcome of sclerotherapy for bleeding oesophageal varices may be influenced by injection technique. In a previous study at our institution, sclerotherapy was associated with a high re-bleeding rate and oesophageal ulceration. Embolisation of the injection tract was introduced in an attempt to reduce injection-related complications. To determine the outcome and effectiveness of injection tract embolisation in reducing injection-related complications, we retrospectively reviewed a series of 59 children who underwent injection sclerotherapy for oesophageal varices (29 for extrahepatic portal vein obstruction (EHPVO) and 30 for intrahepatic disease) in our centre. Sclerotherapy resulted in variceal eradication in only 11.8% of the children (mean follow-up duration: 38.4 months). Variceal eradication with sclerotherapy alone was achieved in 20.7% and 3.3% of EHPVO and intrahepatic disease patients, respectively. Injection tract embolisation was successful in reducing the number of complications and re-bleeding rates. Complications that arose included: transient pyrexia (16.7%); deep oesophageal ulcers (6.7%); stricture formation (3.3%); and re-bleeding before variceal sclerosis (23%). Injection sclerotherapy did not eradicate oesophageal varices in most children. Injection tract embolisation by sclerosant was associated with fewer complications and reduced re-bleeding rates.

Vaginal bleeding in a patient with type C liver cirrhosis without a past history of laparotomy: successful treatment with partial splenic artery embolization.

A 47-year-old female patient with type C liver cirrhosis underwent endoscopic injection sclerotherapy for esophageal varices 13years ago. The patient had no past history of hysterectomy or any other gynecological disorders. She was admitted to our hospital because of persistent vaginal bleeding and exacerbation of anemia. A contrast-enhanced computed tomography scan revealed marked dilation of not only the inferior mesenteric vein, but also the left ovarian vein, the uterine vein and the internal iliac vein. A celiac arteriography showed that the blood in the splenic vein was flowing almost totally hepatofugally into the dilated inferior mesenteric vein. An ovarian venography demonstrated knob-shaped dilation of the left ovarian vein draining into the left internal iliac vein. A proximally wedged left ovarian venography visualized the right ovarian vein and the right internal iliac vein with contrast medium via a palisade venous plexus from the dilated uterine and ovarian veins. Partial splenic embolization (PSE) was performed to increase platelet count and to reduce splenic venous blood flow into the ovarian vein. Following the PSE, the platelet count increased, and the blood flow in the dilated ovarian vein and uterine vein diminished. In addition, the portal blood flow became hepatopetal, and remarkably increased. There has as yet been no case report in which vaginal bleeding developed in women with liver cirrhosis without any past history of hysterectomy or other gynecological disorders. The present case report may be warranted in view of the rarity of the condition.

A case of gastric varices with gastropericardiac shunt successfully treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein using a microballoon catheter.

Gastric fundal varices developed in a 72-year-old female patient with liver cirrhosis due to hepatitis C virus infection after endoscopic injection sclerotherapy for esophageal varices. Three-dimensional computed tomography (CT) imaging demonstrated that gastrorenal shunts were absent as the drainage vessels of the varices, and the blood flows drained mainly into the pericardiophrenic vein. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed using a microballoon catheter to prevent bleeding from the gastric varices. The left inferior phrenic vein detectable as the second drainage vessel by venography was embolized with metallic coils and ethanolamine oleate solution was injected into the varices following occlusion of blood flow with a microballoon located in the pericardiophrenic vein. CT examination performed 7days following B-RTO therapy revealed that the blood flow had disappeared with thrombus formation in the varices. B-RTO therapy with a microballoon catheter may be a useful therapy for gastric fundal varices even in cases without gastrorenal shunts, if the main drainage vessels are determined.

Endoscopic Regression and Evaluation of Injection Sclerotherapy for Esophageal Varices in Case of Hepatocellular Carcinoma with Portal Vein Invasion.

Endoscopic Regression and Evaluation of Injection Sclerotherapy for Esophageal Varices in Case of Hepatocellular Carcinoma with Portal Vein Invasion.

The first Japanese case of COACH syndrome

COACH syndrome is a disorder characterized by hypoplasia of cerebellar vermis, oligophrenia, congenital ataxia, coloboma and hepatic fibrosis, and 21 cases have been reported to date. Here we describe the first Japanese case of COACH syndrome, who was diagnosed at the age of 37 years and never progressed to liver failure. The patient was found to have delayed developmental milestones at the age of 5 months and mental retardation at the age of 7 years. She had been treated for hepatopathy of unknown origin from the age of 22 years. She was admitted to Hiroshima University Hospital at the age of 37 years after the identification of esophageal varices on a routine upper endoscopy. Computed tomography of the abdomen revealed portal hypertension and splenomegaly, and liver biopsy showed liver fibrosis. In addition, she had coordination disorder and dysarthria. Brain magnetic resonance images revealed hypoplasia of cerebellar vermis. The final diagnosis was COACH syndrome. She underwent endoscopic injection sclerotherapy for esophageal varices. From that point until her death from ovarian cancer at the age of 41 years, the liver function tests were stable without an episode of hematemesis. Physicians should be aware of COACH syndrome when they examine young patients who present with hepatopathy, portal hypertension of unknown origin and cerebellar ataxia.

Evaluation of Patients with Esophageal Varices After Endoscopic Injection Sclerotherapy Using Multiplanar Reconstruction MDCT Images

The purpose of our study was to assess the relationship between hemodynamic changes in portosystemic collaterals and the prognosis of patients with esophageal varices after endoscopic injection sclerotherapy using multiplanar reconstruction (MPR) MDCT images. The subjects of this prospective study were 53 patients who underwent endoscopic injection sclerotherapy for esophageal varices. We evaluated the reconstructed MPR images of portosystemic collaterals before and after endoscopic injection sclerotherapy. Patients were divided into three groups based on the rate of change in the diameter of the feeding vessel into complete eradication (group A), narrowing (group B), and no change (group C). We analyzed the relationship between hemodynamic change in portosystemic collaterals and prognosis. The left gastric vein, posterior gastric vein, and left gastric vein plus posterior gastric vein were the main feeding vessels (n=44 [83%] of patients, n=5 [9%], and n=4 [8%], respectively). The proportions of patients of groups A, B, and C were 19% (n=10), 24% (n=13), and 57% (n=30), respectively. The relapse-free rates at 2 years after endoscopic injection sclerotherapy were 100%, 65%, and 52% in groups A, B, and C, respectively (p<0.05). For group C, the relapse-free rate at 2 years after endoscopic injection sclerotherapy of patients with a large-diameter paraesophageal vein (>or= 3 mm, 63%) was significantly higher than in those with a small-diameter paraesophageal vein (<3 mm, 36%; p<0.05). However, there were no significant differences in the survival rate among the three groups. MPR MDCT images on portosystemic collaterals can accurately predict relapse of esophageal varices after endoscopic injection sclerotherapy.