Management Of Gastric Varices Research Articles

Prevalence, causes and management of gastric varices – a literature review

Summary: Gastric varices, although less prevalent than esophageal varices, exhibit greater morbidity and mortality. This comprehensive literature review investigates the prevalence of gastric varices, diverse classifi cation systems, and available management options. The spectrum of management modalities encompasses primary and secondary prevention, acute gastric variceal bleeding strategies, and preventive measures against rebleeding. A meticulous exploration of PubMed and Google Scholar over the past decade (2013 to 2023) shaped the inclusion criteria for adults aged 18 and above dia gnosed with gastric varices, with or without variceal bleeding. Exclusion criteria eliminated non-gastric variceal causes of upper gastrointestinal bleeding and qualitative articles, resulting in 43 relevant records from the 190 initially identified. The diverse management landscape caters to the specifi c type of gastric varix, contributing to a varied treatment approach. Notably, endoscopic ultrasound- -guided coil embolization coupled with glue injection has emerged as a promising intervention, demonstrating superior outcomes in addressing gastric varices. The evolving understanding of these varices and advancing therapeutic strategies underscore the dynamic nature of research in this critical medical domain. Key words: gastric varices – upper gastrointestinal bleeding – classifi cation – hemostasis – etiology – management options

Management of Gastric Varices: GI Perspective

AbstractThere is a paucity of literature on the management of gastric varices and current guidelines rely heavily on expert opinion. Optimal treatment of gastric varices requires a multidisciplinary team including gastrointestinal endoscopist, hepatologist, and interventional radiologists. Initial management relies on endoscopic diagnosis followed by therapeutic modalities based on the experience of the endoscopist and the institution. Definitive management may be endoscopic, endovascular, or a combination of the two disciplines. In this review, we discuss endoscopic management of gastric varices with direct endoscopic glue injection, endoscopic ultrasound-guided management, limitations, and adverse events. We conclude by describing a case of gastric variceal bleeding managed with endoscopy when interventional radiographic techniques were not feasible.

EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video)

Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

Management of Gastric Varices: IR Perspective

AbstractGastric varices are a sequela of portal hypertension. If left untreated, life-threatening bleeding can occur. While endoscopic treatment is traditionally considered as a first-line interventional option, endovascular techniques have emerged to become the superior option in certain clinical scenarios, either as a first-line therapy or a salvage therapy. Endovascular techniques for managing gastric varices include transjugular intrahepatic portosystemic shunt (TIPS) placement, balloon-occluded retrograde transvenous obliteration (BRTO), coil, and plug-assisted retrograde transvenous obliteration, as well as a combination of both. Studies have shown that endovascular techniques can effectively control bleeding from gastric varices, with high success rates and low complication rates, and significantly reduce recurrence. TIPS placement has shown to be more effective in controlling bleeding from gastroesophageal varices, while BRTO, coil, or plug-assisted embolizations are more suitable for patients with isolated gastric varices. Endovascular interventions are a valuable option for managing gastric varices, especially in patients who are not candidates for endoscopic treatment or who have failed previous endoscopic interventions. In this two-part series editorial, we aim to initially review the complex anatomy and classification of gastric varices, medical management, and current endovascular interventional techniques, and how they compare with one another. In part 2, we draw a parallel between endovascular versus endoscopic techniques, and highlight and critically review current literature as it pertains to gastric variceal management.

An uncommon complication during management of gastric varices

A 69-year-old woman presented to the emergency department with melena for 3 days. She has a medical history of hepatitis B virus-related cirrhosis. The esophagogastroduodenoscopy showed a gastric varix, GOV-2, with an ulcer on its surface. Histoacryl injection was attempted, but massive bleeding ensued just as the needle touched it. Five milliliters of a 1:1 mixture of N-butyl-2-cyanoacrylate and lipiodol were injected into the varix (1 mm per injection, at the same site). The patient was then transferred to the intensive care unit. Shortness of breath with frequent dry cough developed 1 day later. The patient was slightly tachycardic at 97 beats per minute, tachypneic at 27 times per minute, and normotensive at 132/54 mmHg, with SpO2 of 98%. Physical examination showed bilateral clear breath sounds. Laboratory investigations showed a hemoglobin level of 7.1 g/dL, platelet count of 15 × 103/μL, and D-dimer of 1285.4 ng/ml. Arterial blood gas analysis showed pH 7.436, pCO2 34.9 mmHg, pO2 120.6 mmHg (under O2 nasal cannula 3 L/min), and bicarbonate 23.8 mEq/L. The chest X-ray showed branching opacities over left hilum (Figure 1). What is the diagnosis? Non-contrast chest computerized tomography showed hyperdense material in the left pulmonary branches (Figure 2), and the diagnosis of acute pulmonary embolism after histoacryl injection was made. The patient was under mechanical ventilation support for total 18 days, with only supportive treatment during this period. She was discharged smoothly without any oxygen support. Histoacryl injection therapy is effective for the gastric varices. The overall complication rate ranged from 0.5% to 5%,1 and pulmonary embolism is an unusual but potentially life-threatening one,2 especially in patients with large varices requiring large volumes of sclerosant.3 Other contributory factors include the rate of injection and ratio of the constituent components of the sclerosant.3 Although a leak through an arteriovenous pulmonary shunt or an open foramen ovale had been proposed,4 there was no such abnormality in our case. Hyperdense segments of the pulmonary arteries with respect to the surrounding vessels are the image features on chest X-ray (the so-called “vascular cast sign”), and a confirmatory non-contrast computerized tomography will be more suitable than a contrasted one in detecting the radio-opaque lipiodol.5 All endoscopists should keep this rare complication in mind, and timely recognition—if it occurs, unfortunately—relies on the physician's timely awareness. The authors declare no conflict of interest. According to the institutional review board (IRB), there is no need of IRB approval for an image article in our hospital. A written informed consent was obtained before starting, and the authors followed the principles outlined in the WMA Declaration of Helsinki throughout the writing process.

Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis.

There is a paradigm shift in the management of gastric varices with the availability of endoscopic ultrasound and radiologic interventions. The optimal choice of intervention remains a dilemma for most treating physicians. We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and ScienceDirect for studies comparing endoscopic glue injection, endoscopic thrombin injection (THB), variceal band ligation, EUS-guided coiling, EUS-guided glue injection, EUS-guided coiling with glue (EUS-C+G), balloon occluded retrograde transvenous obliteration (BRTO), and transjugular intrahepatic portosystemic shunt (TIPS) for gastric varices in adults. The data on four outcomes - obliteration of varices, rebleeding, adverse effects, and mortality - were pooled using a random-effects model. Treatment estimates were calculated as odds ratios (ORs) along with their 95% confidence interval (CI). The relative ranking of interventions for various outcomes was calculated as their surface under the cumulative ranking curve (SUCRA). We identified 34 studies (10 randomized controlled trials, 24 non-randomized trials) with 2783 patients. Based on SUCRA plots, BRTO (SUCRA 95.1) had the highest rate of variceal obliteration followed by EUS-C+G (SUCRA 80.9). The risk of rebleeding was lowest with BRTO (SUCRA 85.1) followed by EUS-C+G (SUCRA 78.8). Moderate-severe adverse effects were least likely with THB (SUCRA 92.5) and highest with TIPS (SUCRA 3.7). In terms of mortality, EUS-C+G (73.5) had the lowest probability of overall mortality followed by TIPS (69.1). In this network meta-analysis, we found BRTO and EUS-guided therapies to be superior to endoscopic glue injection. However, the level of evidence remains low.

Management of gastric varices: still a matter of debate?

Variceal bleeding is one of the most severe and feared complications of liver cirrhosis because it markedly increases the risk of mortality from cirrhosis. The transjugular intrahepatic portosystemic shunt (TIPS) has emerged as a life-saving procedure. By diverting blood from portal to systemic circulation, TIPS swiftly decreases portal hypertension. The efficacy of TIPS in preventing oesophageal variceal rebleeding is supported by strong evidence.1,2 However, there is less consensus regarding gastric variceal bleeding.

A117 MANAGEMENT OF VARICEAL BLEEDING WITH ENDOSCOPIC INJECTION OF N-BUTYL-2-CYANOACRYLATE IN PREGNANCY

BackgroundAlthough variceal bleeding is rare in pregnancy, pregnant woman with non-cirrhotic portal hypertension are at greater risk of variceal hemorrhage due to increased splanchnic blood flow. Variceal hemorrhage is associated with increased risk of maternal and fetal mortality. Most documented cases of variceal bleeding in pregnancy report the use of elastic ligation for hemostatic management. Histoacryl glue has become increasingly utilized in the acute management and secondary prophylaxis of gastric and ectopic varices in the general population.AimsEvidence surrounding the use of Histoacryl glue in pregnancy is limited. We report two cases of variceal bleeding during pregnancy managed successfully with glue.MethodsVarices were confirmed endoscopically. Images were obtained and reviewed. Aliquots of injected glue were recorded. Maternal and fetal outcomes were monitored during pregnancy and post-partum.Results Case 1: A 39-year-old G4P3L0, presented at 20 weeks gestation following several episodes of hematemesis. Urgent esophagogastroduodenoscopy (EGD) revealed hyperemia and portal hypertensive gastropathy in the fundus. A gastric varix with high-risk stigmata was injected with a total of 9mL of 50/50 Histoacryl/Lipodol and bleeding stopped. The patient returned to the hospital two weeks following discharge with melena. Repeat EGD showed mild portal hypertensive gastropathy with a clot at the site of the previous bleeding. No further intervention was required, and the patient delivered at 37 weeks via elective caesarian-section. Case 2: A 41-year-old G2P0L1 presented at 26 weeks gestation with severe anemia refractory to five units of blood transfusion. Urgent EGD showed a large gastric varix with recent stigmata of hemorrhage, but no active bleed. A total of 13 mL of 75/50 Histoacryl/Lipidol was injected into the varix with no further bleeding. She delivered by elective caesarian-section at 37 weeks gestation. Repeat EGD performed following delivery showed a larger varix with fresh clot at the inferior portion of the fundus. Due to concern for re-bleeding, a total of 4 mL of 50/50 Histoacryl/Lipidol was injected at the site. CT scan post-partum showed prominent gastric varices with glue visualized within the peripheral branches of the portal vein (Figure 1).ConclusionsOur cases highlight the successful management of gastric varices using Histoacryl glue in pregnancy. Risks associated with Histoacryl glue include glue embolization, local venous thrombosis, as well as extrusion of glue and ulceration. The general complication rate is quoted between 0.5%-5%. One of the two cases was associated with a maternal complication, with evidence of new portal vein thrombosis following injection. The safety of sclerotherapy in pregnancy with cyanoacrylate remains unclear, and further evaluation of the management of gastric varices in this unique population are required. Funding AgenciesNone

Update on the management of gastric varices.

Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.

Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis.

Background and AimBleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta‐analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices.MethodsWe conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial‐specific risk ratios (RRs) were estimated and pooled using random‐effect model meta‐analysis.ResultsWe included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N‐butyl‐2‐cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all‐cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36–0.98; I2 = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35–0.68, I2 = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs.ConclusionThe use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all‐cause mortality and better hemostasis compared with other therapies.

Gastric Variceal Bleeding: Is Endoscopic Ultrasound the Next Game Changer in the Management of Gastric Varices?

Gastric varices (GV) are present in 15-25% of cirrhotic patients with type 1 gastroesophageal varices (GOV1) being the most common[1,2]. In comparison to esophageal varices, the incidence of gastric variceal bleeding is low (10-20%) and is not proportional to portal venous pressure as noted in the esophageal varices, which has a rebleeding rate of up to 30% noted in GV[2,3]. The GV bleeding is difficult to control due to the presence of a thick mucosal layer over the GV, which does not collapse during bleeding.

Cost-effectiveness of endoscopic ultrasound-guided coils plus cyanoacrylate injection compared to endoscopic cyanoacrylate injection in the management of gastric varices.

BACKGROUNDCyanoacrylate (CYA) injection can be performed using a standard upper endoscopy technique or under endoscopic ultrasound (EUS) guidance alone or in combination with coils. There is little information available on the economic impact of these treatment methods.AIMTo compare the cost-effectiveness of treating gastric varices by CYA injection via upper endoscopy vs coils plus CYA guided by EUS.METHODSThis was an observational, descriptive, and retrospective study. Patients were allocated into two groups: A CYA group and coils plus CYA group. The baseline characteristics were compared, and a cost analysis was performed.RESULTSOverall, 36 patients were included (19 in the CYA group and 17 in the coils + CYA group). All patients in the CYA group had acute bleeding. They underwent a higher mean number of procedures (1.47 vs 1, P = 0.025), and the mean volume of glue used was 2.15 vs 1.65 mL, P = 0.133. The coils + CYA group showed a higher technical success rate (100% vs 84.2%), with a complication rate similar to the CYA group. The majority of CYA patients required hospitalization, and although the mean total per procedure cost was lower (United States $ 1350.29 vs United States $ 2978), the mean total treatment cost was significantly different (United States $ 11060.89 for CYA vs United States $ 3007.13 for coils + CYA, P = 0.03).CONCLUSIONThe use of EUS-guided coils plus cyanoacrylate is more cost-effective than cyanoacrylate injection when the total costs are evaluated. Larger, randomized trials are needed to validate the cost-effectiveness of the EUS-guided approach to treat gastric varices.

S2203 Off-Label Use of Hemospray in Bleeding Non-Cirrhotic Portal Hypertensive Gastric Varices: A Bridge to Definitive Therapy

INTRODUCTION: With a mortality rate as high as 26%, acute gastric variceal bleeding remains an important medical emergency. Given the paucity of data, management of non-cirrhotic portal hypertension associated varices has been challenging. Current management relies on technically challenging and time consuming techniques to achieve early endoscopic hemostasis via injectable adhesives, fibrin and thrombin injections, mechanical banding, and application of sclerosants. Recent studies favor endoscopic use of topical hemostatic spray (TC-325) - a therapeutic with FDA approval in nonvariceal gastrointestinal bleeding and increasingly being used off-label in the management of gastric varices. Despite excellent short-term efficacy, hemostatic powders are limited by high rebleed rates and thus primarily serve as a bridge toward definitive therapy. CASE DESCRIPTION/METHODS: A 55-year-old gentleman with metastatic pancreatic cancer complicated by splenic vein thrombosis with isolated gastric varices, presented with epigastric pain, melena and evidence of hemodynamic compromise. Laboratory investigation revealed a hemoglobin of 6.6 g/dL. The patient was admitted to the MICU and treated with empiric antibiotics, IV fluids, pantoprazole and octreotide drips. After blood transfusion EGD was performed revealing multiple large isolated gastric varices (IGV-1) with red spots as well as active bleeding from a gastric fundus varix. The bleeding gastric varix was not amenable for band ligation or injection of sclerosants. Hemospray was generously applied to the bleeding culprit and surrounding varices, with successful hemostasis. The patient was not a candidate for splenectomy thus underwent splenic artery embolization by interventional radiology. He was continued on pantoprazole and octreotide drips for 72 hours, without evidence of rebleeding, and was discharged in stable condition. DISCUSSION: Options for treatment of bleeding isolated gastric varices are limited in the United States. Our case highlights the successful, off-label use of hemospray as a bridging intervention in non-cirrhotic gastric varices until definitive treatment with artery embolization could be performed. This contrasts with bleeding cirrhotic portal hypertensive varices that are managed with TIPS (Transjugular intrahepatic portosystemic shunt) or BRTO (Balloon-occluded retrograde transvenous obliteration). More studies are needed to validate the use of topical hemostatic powder (TC-325) in the management of non-cirrhotic gastric variceal bleeding.Figure 1.: Varix in the gastric fundus with active bleeding.Figure 2.: Gastric varices prior to administration of hemospray.Figure 3.: Gastric varices without active bleeding following administration of hemospray.

Management of Gastric Varices with BRTO Assisted Endoscopic High-Dose Histoacryl Injection: A Case Report and Review

Management of Gastric Varices with BRTO Assisted Endoscopic High-Dose Histoacryl Injection: A Case Report and Review

Utility of Coil-Assisted Retrograde Transvenous Obliteration II (CARTO-II) for the Treatment of Gastric Varices.

PurposeTo investigate the technical feasibility, safety and clinical outcomes of coil-assisted retrograde transvenous obliteration II (CARTO-II) for gastric varices (GV).Materials and MethodsThirty-six consecutive patients who had undergone CARTO-II between June 2016 and April 2018 were included in the study. In the CARTO procedure, coil embolization of the drainage vein is performed “before” injection of the sclerosant to replace the use of balloon catheter. In the CARTO-II procedure, coil embolization of the drainage vein was performed “after” injection of the sclerosant to prevent migration of the sclerosant. CARTO-II was performed with ethanolamine oleate iopamidol, and the balloon catheter was immediately removed after coil placement. Technical and clinical success rates, number of coils used, presence or absence of severe complications, timing of the procedure, and rate of GV recurrence after the procedure were analyzed retrospectively.ResultsIn all patients, GV sclerosis, coil placement and removal of the balloon catheter were successfully completed. The technical success rate was 100%. No patients experienced severe complications such as coil migration or pulmonary embolization. The mean number of metallic coils used per procedure was 3.36. Mean length of the procedure was 132.8 min. Contrast-enhanced computed tomography after CARTO-II confirmed complete variceal thrombosis in all cases. The recurrence rate of GV during follow-up was 2.8% (mean follow-up, 207 days).ConclusionCARTO-II was feasible and safe and could be performed relatively quickly. The number of coils used and the rate of GV recurrence were both low. CARTO-II may have an important role to play in the management of GV.

1949 Modern Coils and Glue: An Evolving EUS Application in the Management of Gastric Varices

INTRODUCTION: Ethylene vinyl alcohol (EVOH) is a liquid embolic agent approved for cerebrovascular lesions. DMSO solvent dissipates into the blood, causing the EVOH copolymer and suspended tantalum to precipitate in situ into a spongy, coherent embolus. Their role in the management of gastric varices is still unknown. We are presenting our experiences with this novel echoendoscope (EUS) guided use of EVOH to achieve gastric variceal obturation (GVO). CASE DESCRIPTION/METHODS: Case 1 : 44-year-old male with decompensated cirrhosis presented with melena. EGD showed large gastric varix (GOV-2). EUS- guided coiling and EVOH glue injection was planned. Gastric varices were identified using a linear echoendoscope at 7.5 MHz and 22G FNA needle was then advanced into varix with position confirmed by aspirating blood. Three embolization microcoils (5 mm/mm2, 8 mm/4mm, 7 mm/3mm; proximal end diameter/distal end diameter) were placed into the varix followed by needle flush with a 0.8 ml DMSO (dimethyl sulfoxide). Post DMSO flush, 5 mL EVOH glue was injected with excellent flow reduction on EUS doppler. 0.8 ml of DMSO was again used to flush the needle. Patient tolerated procedure well and had no signs of bleeding prior to discharge. Case 2 : 39-year-old male with history of alcoholic and HCV cirrhosis and hepatocellular carcinoma, two prior banding procedures for bleeding esophageal varices, gastric varices, presented with signs and symptoms of decompensated cirrhosis, hematemesis and melena. EGD with banding was done for large esophageal varices with stigmata with successful hemostasis. Large gastric varix (GOV-1) was also discovered. Coiling and glue was injected with similar EUS guided technique as above (sixteen embolization microcoils of varying sizes (8 mm/4 mm, 7 mm/3 mm, 5 mm/2 mm); 3 mL EVOH glue injection). Post procedural EUS doppler imaging showed excellent flow reduction. DISCUSSION: EVOH is well-known as catheter based embolic therapy for neurovascular lesions. Its application under EUS image guidance for gastric varices has not been reported yet to our knowledge thus making our case as unique. However larger, prospective multicenter trials with EVOH will be required to study rebreeding rates and long-term outcomes in the management of gastric varices.

Su1521 – Combination Therapy Vs Monotherapy for Eus-Guided Management of Gastric Varices: A Systematic Review and Meta-Analysis

Su1521 – Combination Therapy Vs Monotherapy for Eus-Guided Management of Gastric Varices: A Systematic Review and Meta-Analysis

Update on management of gastric varices.

Gastric varices (GV) have different physiology and clinical characteristics compared to oesophageal varices (OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies’ recommendations are based are scrutinised in this review and areas of research are identified.

Endoscopic Ultrasound (EUS)-Guided Therapy of Gastric Varices: A Systematic Review and Pooled Analysis

Introduction: Gastric varices (GV) contribute to high mortality in patients with advanced cirrhosis due to life-threatening bleeding and endoscopic management options are limited. Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in management of GV but poses several complications including worsening encephalopathy and may not be feasible in cases with portal vein thrombosis. Endoscopic ultrasound (EUS)-guided therapy with glue injection and/or coil placement is a novel method for treatment and eradication of GV. Our aim is to report the efficacy and safety of EUS-guided therapy for treatment of GV. Methods: A systematic review of existing literature on EUS-guided therapy was performed. Outcomes of interest were: pooled rates of technical success, clinical success as indicated by absence of early posttreatment bleeding (early 6 months), durable success rate (obliteration of varices confirmed by EUS), and procedure-related adverse events (pain, embolization, and bleeding within 120 hours). Pooled analysis was performed using the OpenMetaAnalyst software. Results: A total of 6 retrospective studies (263 patients with mean age 61.4 years, 64% males, 89% with cirrhosis) were analyzed. Active bleeding was noted in 12% on endoscopy, while 69% had stigmata of recent bleed. Average follow-up post endoscopy was 20.4 months. Technical success rate of the EUS-guided therapy was 99%. Clinical success was noted in 95.8%. EUS-guided therapy resulted in obliteration of GV in 80.3% of patients (95% CI: 64.5%-96.1%, I2 94.5%). Among patients with EUS confirmed obliteration of GV, 79% needed only a single EUS session. Among patients with EUS and/or clinical follow-up, recurrent bleeding from GV was observed in 9.3% (22/236, early 11, late 11). Of these, 50% underwent additional EUS-guided therapy successfully. Overall peri-procedural adverse event rate was 10%. The systemic embolization reported in 7% was asymptomatic and mostly associated with glue injection. There were no reported strokes. Only 1 death was directly attributed to the procedure. Conclusion: EUS-guided therapy of GV has high technical and clinical success rates with durability, and should be considered as an alternative to conventional endoscopic therapies and TIPS in carefully selected patients.

Mo1232 Cost-Effectiveness of Cyanoacrylate Glue Injections Versus Endoscopic Ultrasound Guided Treatment in the Management of Gastric Varices

Mo1232 Cost-Effectiveness of Cyanoacrylate Glue Injections Versus Endoscopic Ultrasound Guided Treatment in the Management of Gastric Varices