Treatment Of Esophageal Varices Research Articles

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...

PTH-127 Endoscopic Variceal Band Ligation (EVBL) at The 37 Military Hospital, Accra-Ghana: Our Experience with The Euro-Ligator-Universal (Euro Multiband Ligator)

Introduction Bleeding gastro-eosophageal varices are the 3 rd commonest cause of UGI bleeding in Ghana and have a high mortality. EVBL is an effective, safe treatment for oesophageal varices but single use, preloaded ligators are unaffordable in developing countries. We report our early experience of the re-usable Euro-Ligator for variceal banding. Methods The Euro-Ligator is the first re-usable multiple band ligator. It operates on a different principle to other ligators. A rotating driver is locked into the instrument channel and pre-loaded bands are deployed as an inner cylinder is withdrawn. Training in the use of the Euro-Ligator was provided by a visiting team from the University Hospitals of Leicester, funded by the British Society of Gastroenterology. During a one day course (October ‘15) the endoscopy team at 37 Military received instruction in loading the bands, intubation, band deployment and disinfection. An instruction video of each step was produced. During the course 5 patients were successfully banded under the supervision of the visiting team. Dedicated lists for variceal banding were established. Results To date, 15 EVBL sessions have been performed on 7 patients (6 males, age range 16 to 62). In all, 60 bands have been deployed with a successful band deployment rate of 55/60 (91.6%). The mean number of bands used per session was 3.7. All procedures were elective day cases after an index bleed & performed under conscious sedation. No mortality was recorded during the procedures & all patients were discharged home the same day. We have not seen deep ulceration, perforation or aspiration pneumonia. One patient was lost to follow up after the index procedure and 1 patient died 2 weeks after the initial session from Hepatic Failure (Child Pugh C). In the remaining 5 patients under follow-up, haemostatic control has been achieved with no further bleeding episodes reported. Complete eradication has now been achieved in 1 patient. Conclusion This preliminary case report gives us some insight and working experience into the use of the multiband Euro-Ligator. We found the equipment easy to use and technically effective in the endoscopic treatment of oesophageal varices. We need to adhere to stringent disinfection and cleaning protocols to ensure long term safety in our patients and evaluate the clinical and cost effectiveness over a longer period. However, the Euroligator is a major advance in the management of bleeding oesophageal varices in the developing world Disclosure of Interest None Declared

Clinical factors that influence the outcome of selective devascularization in the treatment of portal hypertension.

There is a high incidence of death due to variceal hemorrhage in patients with portal hypertension. Factors to consider when choosing selective devascularization in the treatment of variceal hemorrhage remain a controversy. This study aims to generate the prevalent clinical risk factors that affect the outcomes of selective devascularization procedures. Elucidating these features may guide future treatment of esophageal varices in patients with portal hypertension. We retrospectively analyzed medical records of 455 patients who underwent selective devascularization procedures in our center. Patients were subject to splenectomy, selective devascularization with or without esophageal transection. The mode of surgery recurred in comparable rates in both the group with major complications postoperatively (high-risk group which consisted of 63 patients) or the group without major postoperative complications (low-risk group, 392). Risk factors that negatively influenced outcomes of surgery include severe symptoms (89% in high risk group and 71% in low risk group), large volume of blood loss in the hemorrhage before surgery (81% in high risk group and 16% in low risk group), sever liver cirrhosis (83% in high risk group and 67% in low risk group), previous endotherapy, prolonged prothrombin time, and poor liver function. Selective devascularization is a feasible option to treat variceal hemorrhage in patients with portal hypertension.

Changes in Cardiac Varices and Their Clinical Significance after Eradication of Esophageal Varices by Band Ligation.

Background and Aims. Cardiac varices (CVs) in patients with type 1 gastroesophageal varices (GOV1s) usually disappear with treatment for esophageal varices (EVs) by endoscopic injection sclerotherapy (EIS). However, whether this applies to patients treated with endoscopic band ligation (EBL) for EVs remains unclear. We evaluated the effect of EVs eradication by EBL on CVs. Methods. We included cirrhotic patients whose EVs had been eradicated using EBL and excluded those who had been treated using EIS, those who had received endoscopic therapy for CVs, and those who were combined with hepatocellular carcinoma. Results. A total of 123 patients were enrolled. The age was 59.7 ± 11.7 years, and 96 patients (78.0%) were men. Thirty-eight patients (30.9%) had EVs only, while 85 (69.1%) had GOV1s. After EVs eradication, the CVs disappeared in 55 patients (64.7%). EVs recurred in 40 patients, with recurrence rates at 1, 2, and 3 years of 16.0%, 29.6%, and 35.6%, respectively, the recurrence being more frequent in patients who had undergone EBL for secondary prophylaxis and in those with persisting CVs after EVs eradication (P = 0.003). Conclusions. CVs frequently disappeared when EVs were eradicated using EBL in patients with GOV1s. Persistence of CVs after EVs eradication by EBL was associated with EVs recurrence.

Lauromacrogol injection in sclerotherapy for esophageal varices

Objective To analysis of the effectiveness and safety of lauromacrogol injection in the endoscopic treatment of esophageal varices bleeding.Methods The effectiveness and postoperative complications of 166 patients receiving endoscopic sclerotherapy of lauromacrogol injection in the treatment of esophageal varices at our hospital were statistically analyzed.The efficacy and safety were evaluated.Results The hemostasis rate of endoscopic sclerotherapy of lauromacrogol injection in the treatment of esophageal varices was 90.36％.Only 17.88％ patients re-bled.Chest pain was the main postoperative complication.Conclusions Endoscopic sclerotherapy of lauromacrogol injection for esophageal varices under is effective and safe and could be easily accepted by the patients.It is worth being generalized. Key words: Lauromacrogol injection; Sclerotherapy; safety

The role of collateral veins detected by endosonography in predicting the recurrence of esophageal varices after endoscopic treatment: a systematic review.

Endoscopic therapy is the principal method of treatment for esophageal varices. The recurrence of varices is still common following endoscopic treatment. The aim was to identify predictive factors for variceal recurrence detected by endosonography. We performed a systematic review of studies published prior to June 2013. Studies analyzing gastroesophageal collateral veins as risk factors for variceal recurrence after endoscopic treatment were included. The primary outcome was to identify predictive factors for variceal recurrence investigated by endosonography. After a full-text review, 13 studies were included in our analysis. Analysis of risk factors was not possible for all studies included. Perforating veins and periesophageal collateral veins were related to a higher risk of variceal recurrence (OR=3.93; 95% CI 1.06-14.51; I (2)=96%; OR=2.29; 95% CI 1.58-3.33; I (2)=55%). Analysis of cardiac intramural veins and paragastric/cardiac collateral veins showed the same trend, but without reaching statistical significance because of the small group size and wide CI (OR=3.72; 95% CI 0.14-101.53; I (2)=91%; OR=1.85; 95% CI 0.84-4.07; I (2)=0%). Analysis of other collateral veins as risk factors for variceal recurrence and analysis of risk factors with regard to the endoscopic treatment method was not possible because of the limited number of cases and different methodologies. A positive association between variceal recurrence and type and grade of collateral veins, investigated by endosonography, was demonstrated. Endosonography is a promising tool for predicting recurrence of esophageal varices following endoscopic treatment. These findings should be interpreted with caution because of the heterogeneity of the studies.

The Clinical Use of Tissue Adhesives: A Review of the Literature

Sutures have traditionally been used in the emergency room and in the primary care setting for wound and laceration closure, but over the past several decades we have seen alternative methods of wound closure emerge. Tissue adhesives are starting to become the front-runner as the alternative to sutures. They possess many advantages and have shown great results when compared to sutures to include cost effectiveness, reduced infection rate, a reduced time requirement and improved cosmetic results. Over the past several years many other indications have started to emerge such as treatment for esophageal varices, application of skin grafts, and vascular embolization. The different chemical compositions and functions will also be reviewed. Disadvantages of tissue adhesives include lower tensile strength and a potential for systemic absorption or embolization. Overall, tissue adhesives provide an excellent means for wound closure in multiple settings and are the first choice method amongst clinicians across disciplines.

Correlation between Indocyanine green retention test and esophageal varices among patients with hepatocellular carcinoma

We recently read with great interest the manuscript entitled ‘‘Prophylactic impact of endoscopic treatment for esophageal varices in liver resection: a prospective study’’ [1] in which Dr. Yamazaki et al. demonstrated the usefulness of endoscopic prophylactic treatment of esophageal varices (EV) and evaluated different risk factors for post-operative progression and bleeding. The authors observed that in patients with hepatocellular carcinoma (HCC), various laboratory variables were significantly different according to the presence or absence of EV; for example, indocyanine green (ICG) retention rate at 15 min (ICG-r15) was 10.9 % (2.1–37.7) in patients without EV and 15.4 % (3.7–46.0) in patients with EV (P \ 0.001). Finally, they observed that ICG-r15 [ 30 % is independently correlated with the risk of worsening varices. We recently reported our experience [2] aimed to evaluate ICG 15-min retention test as a non-invasive marker of PH and EV in patients with compensated liver cirrhosis in which we demonstrated that among patients with well-preserved liver function, ICG retention tests indirectly correlate with the presence and degree of portal hypertension and its complications (EV). According to the observations of Dr. Yamazaki et al., ICG-r15 correlated with the presence of esophageal varices; we found two different ICG-r15 cut-off points able to accurately rule out and rule in the presence of EV (\10 % and C22.9 %, respectively). Liver-mediated uptake of organic anions (drugs or xenobiotics) is mainly mediated by organic anion transporting polypeptides (OATPs) and organic anion transporters (OATs); ICG presents a potent inhibitor effect on OATP isoforms and Na-taurocholate transporting polypeptide (NTCP). OATP1B3 and NTCP are the transporters involved in the hepatic uptake of ICG [3]. The organic anion transporter peptides (OATP) 1B1 and 1B3 are variably and progressively lost during liver carcinogenesis; a previous study performed on patients who underwent OLT because of HCC demonstrated a correlation between the loss of OATP 1B1/ 1B3 and tumor morphological features [4]. These molecular findings could, in our opinion, justify the higher ICG-r15 values observed by Dr. Yamazaki et al. in their population. Indeed, the ICG retention test, among patients with liver cirrhosis, represents both liver parenchymal reserve and hepatic blood flow; in patients with HCC, this interplay is altered by the introduction of a third variable (cancer biology) and could not be argued. This comment refers to the article available at doi:10.1007/s00535013-0841-y.

Hemodynamic analysis of portal hypertension in patients with liver cirrhosis

ObjectiveThe aim of this study was to evaluate the role of duplex Doppler ultrasound in portal vein and upper gastrointestinal endoscopy in the assessment of signs of portal hypertension in patients with liver cirrhosis.Patients and methodsThis study included 50 patients and 20 apparently healthy individuals as controls. All of them were subjected to a thorough assessment of history, complete clinical examination, and some important laboratory investigations. Also, color duplex Doppler ultrasound was performed for all the participants and upper gastrointestinal endoscopy only for the patients.ResultsWe found that portal vein diameter, congestion index, arterial pulsatility index, and arterial resistive index were significantly higher in the patients than in the controls, whereas portal vein flow velocity and the liver vascular index were significantly lower in the patients than in the controls.ConclusionDuplex Doppler ultrasonography remains the first step in the evaluation of patients with liver cirrhosis and portal hypertension. The best hemodynamic parameter in the assessment of portal hypertension is the congestion index, whereas arterial indices are less prone to variability and are more reproducible compared with venous indices. Upper gastrointestinal endoscopy is the gold standard in the treatment of esophageal varices and also effective in preventing recurrent variceal bleeding.

Pulmonary function changes after ethanolamine oleate injection VS band ligation in the treatment of esophageal varices

IntroductionThe complications of injection sclerotherapy can be divided broadly into two categories, those occurring at the site of injection and those resulting from systemic dissemination of the sclerosant through the paraesophageal and azygos veins; this has been shown radiologically. Endoscopic variceal ligation (EVL) was developed as an alternative endoscopic method of treating esophageal varices with the anticipation that EVL would be as effective as EIS, but with fewer complications. We aimed in this study to assess the safety of both procedures for the lung. Patients and methodsWe studied 28 patients with chronic liver disease and portal hypertension, 14 patients underwent injection sclerotherapy of ethanolamine oleate and the other 14 underwent band ligation. All patients underwent spirometery and ABG pre, 2days and 3weeks from the procedures. ResultsTwo days after the procedures the PEF and FEF 50 decreased highly significantly in EST patients when compared to EBL patients (P value less than 0.001), and FEV1, FVC, FEF25, FEF75, Pao2 and o2 sat decreased significantly in the same group by a P value of less than 0.05. After 3weeks from the procedures the VCin, VCex, FEV1, FVC and FEF25 decreased highly significantly in the EST group (P value was less than 0.001), and the FEF 50, PEF, PACO2, PAO2 and O2 SAT decreased significantly in the same group. And there was a significant decrease of flow, FEV1 and FVC 2days after the EST group with a highly significant decrease of PAO2 and O2SAT when compared to the same patients before the EST and we found a highly significant decrease of VC, FEV1, FVC, PAO2 and O2 SAT pre and 3weeks from EST. ConclusionsFrom this study we conclude that the band ligation is safe for the lung and may be an option to eradicate esophageal varices in chronic lung disease patients.

3次元超音波内視鏡検査による食道静脈瘤治療法の選択と内視鏡的静脈瘤結紮術 (EVLI) の適応

3次元超音波内視鏡検査による食道静脈瘤治療法の選択と内視鏡的静脈瘤結紮術 (EVLI) の適応

Recurrence of esophageal varices after endoscopic band ligation: single centre experience

Background and objective. Endoscopic band ligation is the main endoscopic treatment for esophageal varices, but the main problem after endoscopic treatment is variceal recurrence. The aim of this study was to evaluate and determine the esophageal varices recurrence rate and the time interval after endoscopic band ligation and to investigate possible risk factors affecting recurrence. Material and methods. The retrospective analysis of endoscopic band ligation procedures, performed in Vilnius University Hospital Santariskiu Clinics during the period 2006–2010, was made. 133 endoscopic band ligation procedures were included in the study. Results. After endoscopic band ligation, esophageal varices recurred in 45% of cases. The early recurrence of esophageal varices occurred in 46.7% of cases. Extrahepatic portal hypertension and a greater size of varices lead to the statistically significant early recurrence of esophageal varices after endoscopic band ligation. Conclusions. Endoscopic band ligation is associated with a high recurrence rate of esophageal varices and half of these cases were indentified as early variceal recurrence.

Prevention and management of gastroesophageal varices in cirrhosis.

Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.

Efficacy of endoscopic variceal ligation combined with partial splenic embolization for the treatment of esophageal varices

Efficacy of endoscopic variceal ligation combined with partial splenic embolization for the treatment of esophageal varices

Computed Tomography Findings of Spontaneous Porto-pulmonary Shunts in 3 Patients With Portal Hypertension

Spontaneous portopulmonary shunts in the setting of cirrhosis have been associated with the embolization of gelfoam during the treatment of esophageal varices, resulting in strokes. Currently there is minimal data describing the prevalence of spontaneous portopulmonary shunts. Our aim is to demonstrate computed tomography (CT) imaging findings of spontaneous portopulmonary venous anastomoses in patients with underlying portal hypertension. Clinical cases with accompanying CT images are presented and described. A review of the literature is discussed. CT is a useful method for identifying shunting, both spontaneous and surgical, of the portal circulation secondary to hypertension. A less known type of anastomosis involves the pulmonary circulation, specifically the pulmonary veins and left atrium, that can also be recognized with CT.

Does therapy of oesophageal varices influences the progression of varices?

Aim of this study was to determine the progression time of oesophageal varices in patients with cirrhosis and to study whether therapy of varices has an impact on the progression time. Parameters associated with the progression of oesophageal varices were analyzed as well. One hundred and eighty-one cirrhotic patients (Child A/B/C: 105/69/15; Child score 7.6+/-2.0, initial variceal grade 1.7+/-0.9) undergoing repeated endoscopy for follow-up and/or treatment of oesophageal varices were retrospectively analyzed. A multivariate logistic regression analysis was applied to identify independent determinants of progression of oesophageal varices. Of the 189 patients, 26 patients were on beta-blocker therapy only, 52 patients underwent ligation therapy only, and 37 patients received a combination of ligation and beta-blocker therapy of varices. The mean time of progression of oesophageal varices by one grade was 384+/-364 days. This interval did not vary significantly between patients who underwent no treatment or were on a beta-blocker and/or ligation therapy. The serum bilirubin (hazard ratio 1.030; 95% confidence interval, 1.004, 1.055; P<0.03) was the only parameter independently associated with the progression of varices. Initial eradication of varices was achieved after 2.2+/-1.5 ligation sessions. Rings of 6.1+/-2.5 were used in the first banding session and 11.5+/-8.9 rings were needed to achieve eradication of varices. Therapy of oesophageal varices does not influence the progression time of oesophageal varices in patients with cirrhosis of the liver.

Sedative-Free Treatment of Esophageal Varices - The Possibility of APC Using Nasal Endoscope

Sedative-Free Treatment of Esophageal Varices - The Possibility of APC Using Nasal Endoscope

The Endoscopic Treatment of Esophageal Varices with Gastric Extensions Using a Combined Ligation and Sclerotherapy Technique

The Endoscopic Treatment of Esophageal Varices with Gastric Extensions Using a Combined Ligation and Sclerotherapy Technique

Nutritional assessment after treatment of esophageal varices in patients with Cirrhosis

Nutritional assessment after treatment of esophageal varices in patients with Cirrhosis

A meta-analysis of endoscopic sequential ligation plus sclerotherapy for treatment of esophageal varices

A meta-analysis of endoscopic sequential ligation plus sclerotherapy for treatment of esophageal varices