Sclerotherapy Of Esophageal Varices Research Articles

Endoscopic submucosal dissection for early esophageal squamous cell carcinoma after ligation and sclerotherapy of esophageal and gastric varices

Esophageal cancer ranked ten of the most common cancers in China. With the advancement of high-quality endoscopy and chromoendoscopic technique, early esophageal cancer can be diagnosed more easily, even combined with esophageal-gastric fundal varices. Endoscopic resection of early esophageal cancer is a minimally invasive treatment method for early esophageal cancer, and endoscopic submucosal dissection (ESD) is one of the standard treatments for early esophageal cancer in view of the risk of bleeding, the patient in this study successfully received ESD treatment after using endoscopic variceal ligation and endoscopic injection of tissue glue and sclerosing agent before ESD surgery. ESD treatment is safe and feasible for early esophageal cancer patients with cirrhosis of esophageal-gastric fundal varices.

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.

The Roth Net at 40 years: celebrating the spirit of innovation

The Roth Net at 40 years: celebrating the spirit of innovation

Esophageal variceal ligation plus sclerotherapy vs. ligation alone for the treatment of esophageal varices.

BackgroundThis study aimed to evaluate the efficacy and adverse events of esophageal variceal ligation (EVL) vs. EVL combined with endoscopic injection sclerosis (EIS) in the therapy of esophageal varices.MethodsPatients from January 2017 to August 2021 who received EVL alone (control group) or EVL plus EIS (intervention group) were enrolled in this retrospective study. Efficacy, including rebleeding (clinically hematemesis or melena, confirmed by endoscopy as esophagogastric varices bleeding), variceal recurrence rate (the presence of esophagogastric varices which is needed to be treated again) the number of sessions performed to complete eradication of varices, and safety (adverse events) were compared. The variceal recurrence-associated factors were derived by univariate and multivariate logistic regression analyses.ResultsThe variceal recurrence and rebleeding rate in the intervention group showed significantly lower than the control group (2.6% vs 10.3%, P = 0.006 and 20.7% vs 37.5%, P = 0.029, P = 0.006, respectively, in the 12-month follow-up). The adverse events (fever, chest pain, swallowing, and esophageal stricture) showed no significant difference between the two groups (P > 0.05). Further research showed that the efficacy of the intervention group was better than the control group only achieved in prophylactically endoscopic treatment patients. The diameter of esophageal varices and gastric varices co-exist showed significant effects on variceal recurrence in intervention group [odds ratio (OR) = 15.856; 95% confidence interval (CI), 1.709–160.143; P = 0.016 and OR = 4.5; 95% CI, 1.42–20.028; P = 0.021; respectively].ConclusionsThe intervention group may obtain lower recurrence, rebleeding rate, and fewer sessions performed to complete eradication of varices (number of sessions) and similar incidence of adverse events, especially for prophylactically treatment. Among the intervention group, the diameter of esophageal varices and gastric varices were closely associated with variceal recurrence.

Sclerotherapy of oesophageal varices may induce chronic constrictive pericarditis in children.

Constrictive pericarditis is rare in children and can be difficult to diagnose. It has been described in adults after sclerotherapy of oesophageal varices but not in children. We report two cases of chronic constrictive pericarditis after sclerotherapy of oesophageal varices in children with portal cavernoma. Constrictive pericarditis should be considered as a cause of refractory ascites.

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.

Intravasal foam sclerotherapy of esophageal varices as a new method of endoscopic bleeding prevention

<h3>ОБОСНОВАНИЕ</h3> Цирроз печени (ЦП) — одно из распространенных заболеваний, которое в большинстве случаев сопровождается развитием синдрома портальной гипертензии и варикозным расширением вен пищевода (ВРВП). Одним из грозных осложнений синдрома портальной гипертензии являются кровотечения из ВРВП. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценка эффективности и безопасности нового метода эндоскопического склерозирования — интравазальной пенной склеротерапии и ее роли в профилактике кровотечений из ВРВП. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Проведен анализ эндоскопического интравазального пенного склерозирования у 29 пациентов с ЦП и ВРВП по методике НИИ им. Г.К. Жерлова (СибГМУ, Северск). <h3>РЕЗУЛЬТАТЫ</h3> За период с 2017 по 2019 г. на базе ФГБУЗ ФСНКЦ ФМБА данная методика применена у 29 пациентов, которым было выполнено 96 эндоскопических вмешательств с использованием интравазального метода пенной склеротерапии. Осложнений не было ни у одного пациента. Рецидивов кровотечений из ВРВП в раннем периоде после выполнения процедуры не отмечено. <h3>ЗАКЛЮЧЕНИЕ</h3> Интравазальная пенная склеротерапия ВРВ — безопасный метод первичной и вторичной профилактики кровотечений у пациентов с ЦП.

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.

Endoscopic Treatment as the Rescue Therapy for Recurrent Bleeding after Transjugular Intrahepatic Portosystemic Shunt (TIPS).

Background Transjugular intrahepatic portosystemic shunt (TIPS) is suggested as the salvage therapy for gastroesophageal variceal bleeding in cirrhosis. However, rebleeding might occur in some patients after TIPS. Currently, there is a lack of evidence in the endoscopic management of recurrent bleeding in these patients. Aims To evaluate the efficacy of endoscopic treatment in cirrhotic patients with recurrent bleeding after TIPS. Methods Cirrhotic patients with gastroesophageal varices who received endoscopic treatment for recurrent bleeding after TIPS were included. Results 6 patients were enrolled in this study. The median age of the patients was 47 years (range 27 to 65 years), and the duration of follow-up time was 346 (17-773) days. Stent stenosis or occlusion was found in 5 out of 6 patients after TIPS. Salvage endoscopic treatment, including esophageal variceal ligation (EVL), gastric variceal cyanoacrylate injection, esophageal variceal sclerotherapy, and balloon-occluded retrograde transvenous obliteration- (BRTO-) assisted endoscopic cyanoacrylate injection. Among included patients, 2 died shortly after EVL (14 and 19 days) due to variceal bleeding. Among other 4 patients, 2 had rebleeding episodes at 422 and 789 days, respectively. Conclusion Endoscopic treatment may be an option for recurrent bleeding after TIPS in selected patients. Further studies are needed to carefully define the indication and efficacy of this option.

Application of Extended Nursing Care in Sclerotherapy for Esophageal and Gastric Varices

Application of Extended Nursing Care in Sclerotherapy for Esophageal and Gastric Varices

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.

Prognosis of bleeding recurrence after endoscopic sclerotherapy of esophageal varices

To improve prediction of recurrent bleeding after endoscopic sclerotherapy of esophageal varices. A prospective, observational, case-control study was performed. Immediate and long-term results of endoscopic sclerotherapy of esophageal varices were studied in 91 patients for the period from 2002 to 2016. Multiple regression analysis with binary response model was applied to analyze the prediction models. Recurrent bleeding occurred in 80.5 (20; 182) days after sclerotherapy (range 0-2557 days). Spearman's correlation analysis revealed a significant relationship between bleeding recurrence and erythrocyte count (R= -0.32), Child-Pugh class of liver cirrhosis (R=0.49), Child-Pugh score (5-15) (R=0.54), content of amino acids, HPro/Pro ratio (R=0.71). Prognostic indicators were selected by stepwise inclusion of predictors. Thus, the final version of regression equation is as follows: Y=exp (-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)/[1+exp(-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)]. High risk of recurrent bleeding from esophageal varices within 1 year after endoscopic sclerotherapy is determined by Y-value >0.5. An accuracy of this model is 89.6%, Se 94.3%, Sp 79.2%, PPV 90.9%, NPV 86.4%, OR 63.3, LR + 4.53, LR - 0.07. Thus, the proposed method is highly informative, effective, available and can be widely used in clinical practice.

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.

Schistosomal portal hypertension: Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy

Background. Upper gastrointestinal bleeding is a major cause of morbidity and mortality in patients with portal hypertension secondary to schistosomiasis mansoni.Aim. To evaluate the efficacy of combined surgery and sclerotherapy versus endoscopic treatment alone in the prophylaxis of esophageal variceal rebleeding due to portal hypertension in schistosomiasis.Material and methods. During a two-years period consecutive patients with schistosomiasis and a recent bleeding history were evaluated for prospective randomization. Absolute exclusion criteria were alcoholism or other liver diseases, whereas platelet count < 50,000/mm3, INR > 1.5 or presence of gastric varices were relative exclusion criteria. By random allocation 25 (group A) have received endoscopic sclerotherapy for esophageal varices alone and 22 (group B) combined treatment: esophagogastric devascularization with splenectomy followed by sclerotherapy. Interim analysis at 24 months has shown significant statistical differences between the groups and the randomization was halted.Results. Mean age was 38.9 ± 15.4 years and 58.46% were male. Mean follow-up was 38.6 ± 20.1 months. Endoscopic comparison of the size of esophageal varices before and after treatment did not show significant differences among the two groups. Treatment efficacy was assessed by the rate of recurrent esophageal variceal bleeding, that was more common in group A- 9/25 patients (36.0%) vs. 2/22 (9.0%) in group B (p = 0.029). Other complications were odynophagia, dysphagia and esophageal ulcer in group A and ascites and portal vein thrombosis in the surgical group.Conclusion. In portal hypertension due to schistosomiasis, combined surgical and endoscopic treatment was more effective for the prevention of recurrent esophageal variceal bleeding.

Endoscopic injection sclerotherapy for pediatric bleeding esophageal varices complicated by gastric vein, main portal vein, splenic mesenteric junction, and splenic vein occlusion: a case report

BackgroundEndoscopic injection sclerotherapy (EIS) is a life-saving procedure for pediatric patients with bleeding gastric varices (GV) associated with advanced liver cirrhosis and severe portal hypertension. Because of the lack of an endoscopic banding ligation device for pediatric patients, EIS is usually performed for bleeding esophageal varices (EV) in infants with congenital biliary atresia.Case presentationWe present a case of a 15-month-old female infant with type I biliary atresia with jaundice (total serum bilirubin, 22.2 mg/dL), hypoalbuminemia (serum albumin level, 2.58 g/dL), coagulopathy (prothrombin time > 20 s compared with that of a normal control), ascites, splenomegaly, portal hypertension (portal vein velocity, 3.9–5.6 cm/sec of hepatopetal flow), and repeated bleeding of the varices after receiving three doses of intravascularly administered Histoacryl 1 ampoule mixed with Lipiodol UF 8 mL in the EV. Prominent GV and EV were occluded by EIS. The sclerosing agent was also present in the main portal vein, splenic mesenteric junction, and splenic vein, causing an engorged inferior mesenteric vein. The patient underwent total hepatectomy and living donor liver transplantation (LDLT) by left lateral segment graft (segments 2, 3, and 4 of the middle hepatic vein trunk) and left portal vein graft to the recipient inferior mesenteric vein anastomosis. Portal vein stent placement via segment 4 of the portal vein stump was performed from the inferior mesenteric vein to the umbilical portion of the left portal vein. The patient is still alive and doing well after the LDLT.ConclusionsEIS is a life-saving procedure in cases involving bleeding EV complicated by gastric, main portal vein, splenic mesenteric junction, and splenic vein occlusions; hence, it should be kept in mind as a treatment for EV complications in pediatric patients.

Rare Complications of Portal Hypertension in a Patient With Underlying Focal Nodular Hyperplasia

Introduction: Esophageal variceal ligation (EVL) and sclerotherapy are both considered standards of care in management of esophageal variceal hemorrhage. Minor complications are not uncommon but occasionally, severe and potentially life-threatening sequelae may develop. Case presentation: Patient is a 30-year-old female with history of variceal bleeding due to portal hypertension secondary to noncirrhotic focal nodular hyperplasia (FNH) and resultant portal vein thrombosis that began at age 13 until she underwent banding at age 20. She was also treated with a splenorenal shunt as well as a superior mesenteric vein to inferior vena cava shunt to help reduce portal venous pressure. Evaluation for anemia with esophagogastroduodenoscopy (EGD) revealed an extremely large esophageal varix in the distal esophagus with active bleeding, which initially improved with sclerotherapy. Ten days after, she vomited blood and fainted. Methods: Repeat EGD noted profuse variceal bleeding, requiring intubation for airway protection. Attempts to band the varices were unsuccessful, requiring repeat sclerotherapy. 27 mL of sodium tetradecyl was injected throughout the esophagus. Post-procedure chest X-ray revealed a large left-sided pneumothorax, requiring a chest tube, and esophageal perforation. Portal venous shunt was attempted; however, the anastomosis was thrombosed, so the cryopreserved vein was ligated. Post-operative esophagram showed no obvious leak. CT chest/abdomen/pelvis showed bilateral pleural effusions. Left pigtail catheter was placed and drained 150 mL and grew E. faecalis as well as Candida kefyr; patient was placed on zosyn and fluconazole. Results: Patient was transferred to medical ICU intubated on CPAP, hemodynamically stable. Patient recovered with all catheters removed following prolonged antimicrobial support. She was stable on discharge and placed on beta blocker therapy without further incident. Conclusion: This case is unusual for many reasons. Firstly, the etiology of portal hypertension secondary to FNH; secondly, the continuous complications of portal hypertension despite previous shunting; and thirdly, her development of a massive upper gastrointestinal bleed a week after successful EVL. Although sclerotherapy is still occasionally used after unsuccessful EVL, we must be cognizant of rare but potentially devastating complications. For this patient, prompt recognition followed by appropriate and aggressive management fortunately resulted in a successful outcome with long-term survival.

Portal hypertension complicated by bleeding from esophageal and gastric varices: the present state of the problem of treatment and prevention

Background. Objective: to evaluate the effectiveness of comprehensive treatment and prevention of bleeding from esophageal and gastric varices in portal hypertension, including with the use of minimally invasive methods. Material and me­thods. The results of treatment were analyzed in 972 patients with portal hypertension who were treated in the HI “City Clinical Hospital 4 of Grodno” in the period from 2012 to 2016. Results. Endoscopic sclerotherapy of bleeding esophageal and gastric varices was successfully used in 67 patients with portal hypertension. Endoscopic ligation was performed in 12 patients. Sengstaken-Blakemore tube was used in 198 patients, while 22.7 % of them observed a relapse of bleeding after 12 hours. Endoscopic sclerotherapy for bleeding prevention was applied in 90 patients. Ten operations of azygoportal disconnection in the modification of Paciora were performed due to the ineffectiveness of other methods of hemostasis, 7 patients died. Seventeen operations of azygoportal disconnection in the modification of Sugiura-Futagawa and Hassab were carried out in 2012–2017, 1 patient died on the 11th day due to the progression of hepatic insufficiency. Sixteen operations of laparoscopic azygoportal disconnection, 15 transjugular intrahepatic portosystemic shunts were also performed. Thirty-day in-hospital mortality was not observed in these groups. Over 5 years, out of 277 patients with bleeding from esophageal and gastric varices, 121 died, lethality was 43.7 %. Among 695 patients with portal hypertension hospitalized in the department of gastroenterology, 11 died, lethality was 1.6 %, total lethality — 13.6 %. Conclusions. Methods of endoscopic sclerotherapy and ligation in the treatment and prevention of acute bleeding from esophageal varices are preferred. Traditional laparoscopic and X-ray endovascular surgical technologies are effective reserve methods for the treatment and prevention of bleedings from esophageal and gastric varices.

Therapeutic effect of endoscopic variceal ligation plus sclerotherapy for esophageal varices with liver cirrhosis: a randomized controlled trial

Objective To investigate the safety and efficacy of endoscopic varices ligation (EVL) plus endoscopic varices sclerotherapy (EVS) for esophageal varices hemorrhage in patients with liver cirrhosis. Methods Fifty-two liver cirrhosis patients with esophageal varices bleeding were randomly divided into EVL group (n=24) and EVLS group (n=28) according to random numbers generated by computer after first EVL. The EVL group continued undergoing EVL, and the EVLS group was treated by EVS. The interval of treatment was 2 weeks till varices disappeared. All patients were followed up for 18 months with endoscopy and endoscopic ultrasonography (EUS). The efficacy, changes of esophageal varices and perforating veins, varices recurrence and rebleeding were observed. Results There was no significant difference of complete cure rate between EVLS group and EVL group[67.9% (19/28) VS 62.5% (15/24), P>0.05]. The mean session of treatment (2.68±1.0 VS 1.83±0.7, P 0.05], and the varices recurrence rate was higher in EVL group than that in EVLS group[77.3% (17/22) VS 44.0% (11/25), P<0.05]. Child-Pugh class B patients in EVL group had a higher varices recurrence rate compared to that in EVLS group[75.0% (9/12) VS 31.5% (5/16), P<0.05]. Endoscopic recurrences occurred in patients with non-occlusive perforating veins. Conclusion EVL plus EVS sequential procedure is safe and effective for treatment of esophageal varices hemorrhage, especially for Child-Pugh class B patients. Perforating veins may play a key role in the development of esophageal varices and recurrence after endoscopic therapy. EUS findings can direct the endoscopic therapy and predict the variceal recurrence. Key words: Esophageal varices; Endoscopic rubber banding for esophageal varices; Sclerotherapy for esophageal varices; Endoscopic ultrasonography

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.

Endoscopic Placement of Sengstaken-Blakemore Tube for Bleeding Esophageal Varices

Placement of a Sengstaken-Blakemore tube can oftentimes prove technically difficult in the emergent setting. Ascertaining correct position prior to insufflation of the gastric balloon is imperative, and oftentimes leads to significant treatment delay while awaiting xray confirmation. We present a case demonstrating a novel technique of endoscopic placement. A fifty-five year old male with a history of decompensated alcohol cirrhosis and hepatorenal syndrome developed hematemesis and hemorrhagic shock. Emergent endoscopy was performed and due to anatomical limitations, sclerotherapy of bleeding esophageal varices was performed with moderate success. Due to continued bleeding and high risk of rebleeding, a Sengstaken-Blakemore tube was placed under direct visualization with the use of a snare and gastroscope. The snare was used to grasp the tip of the Sengstaken-Blakemore tube and pulled tight into the scope with the tube positioned directly along side of the scope. Next, the gastroscope was then carefully advanced through the oropharynx and upper esophagus with the snare grasping the tip of the Sengstaken-Blakemore tube and pulling it through into the stomach. The scope was advanced to the antrum of the stomach and retroflexed to ensure the gastric balloon was completely located in the stomach. Next, the gastric balloon was inflated with 250 ml of air under direct visualization. After the Sengstaken-Blakemore tube was secured, the snare was then opened and removed from the endoscope. While the balloon was inflated, the endoscope was then easily withdrawn without displacing the Blakemore tube. Bleeding was successfully controlled. Watch the video: https://goo.gl/wqwVTv