Treatment Of Gastric Fundal Varices Research Articles

Pre-emptive TIPS for the treatment of bleeding from gastric fundal varices: Results of a randomised controlled trial

Background & AimsBleeding from gastric fundal varices (isolated gastric varices type 1/gastroesophageal varices type 2) represents a major problem because of a high incidence of rebleeding and death with standard-of-care therapy (endoscopic obliteration with tissue adhesives plus pharmacological therapy). Transjugular intrahepatic portosystemic shunts (TIPSs) are recommended as a rescue therapy. Pre-emptive ‘early’ TIPS (pTIPS) significantly improves control of bleeding and survival in patients at high-risk of dying or rebleeding from esophageal varices. MethodsThis randomised controlled trial investigate whether the use of pTIPS improves rebleeding-free survival in patients with gastric fundal varices (isolated gastric varices type 1 and/or gastroesophageal varices type 2) compared with standard therapy. ResultsThe study did not achieve the predefined sample size because of low recruitment. Nevertheless, pTIPS (n = 11) was more effective compared with combined endoscopic and pharmacological therapy (n = 10) in improving rebleeding-free survival (per protocol analysis: 100 vs. 28%; p = 0.017). This was mainly because of a better outcome in patients with Child-Pugh B or C scores. There were no differences in serious adverse events or in the incidence of hepatic encephalopathy among the different cohorts. ConclusionThe use of pTIPS should be considered in patients with Child-Pugh B or C scores bleeding from gastric fundal varices. Impact and implicationsThe first-line treatment of gastric fundal varices (GOV2 and/or IGV1) is the combination of pharmacological therapy and endoscopic obliteration with glue. TIPS is considered the main rescue therapy. Recent data suggest that, in patients at high-risk of dying or rebleeding (Child-Pugh C or B scores + active bleeding at endoscopy) from esophageal varices, the use of pTIPS, performed during the first 72 h from admission, results in an increased rate of control of bleeding and survival compared with combined endoscopic and pharmacological therapy. Herein, we present a randomised controlled trial comparing pTIPS with combined endoscopic (injection of glue) and pharmacological therapy (first, somatostatin or terlipressin; carvedilol after discharge) in the treatment of patients bleeding from GOV2 and/or IGV1. Although we were not able to include the calculated sample size because of the scarcity of these patients, our results show that the use of pTIPS is associated with a significantly higher actuarial rebleeding-free survival when analysed as per protocol. This is because of the greater efficacy of this treatment in patients with Child-Pugh B or C scores.

Outcome of patients treated with N-Butyl-2-cyanoacrylate in gastric variceal bleeding.

Objective: Aim of study was to determine outcomes of patients treated with N-butyl-2-cyanoacrylate. Study Design: Retrospective study. Setting: Department of Gastroenterology at Liaquat University of Medical and Health Sciences, Jamshoro. Period: December 2019 to March 2020. Material & Methods: A Retrospective study was conducted between by viewing medical records and endoscopy reports. Total 31 patients were enrolled with gastric variceal bleed that underwent endoscopic injection of N-butyl-2-cyanoacrylate we examined the mortality rate, hemostasis, Hospital stay, need of blood transfusion, and effectiveness of procedure. Results: A Total of 31 patients, out of which 18 (58.1 %) were male; the mean age was 55.23±8.778 years. Of these patients 23 (74.2 %), had concomitant esophageal varices, Child-Pugh class-A, B, C were seen in 4, 20 & 7 patients (12.9, 64.5 % & 22.6) respectively. Average duration of hospital stay was 5 to 8 days in 22 cases (71.0 %). Less than 3 pints of PRBC were transfused in 17 cases (54.8 %). Hemostasis was achieved in 27 patients (87%). Overall mortality rate was 3 out of 31(9.7%). one patient was referred for TIPSS. No complications from cyanoacrylate injection were observed. Conclusion: Standardized injection technique and regimen ensures the success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices in experienced hands.

The Efficacy and Safety of Endoscopically Guided Stapled Fundal Mini-Gastrectomy for the Treatment of Bleeding Fundal Varices: A Single Tertiary Care Center Experience

Introduction: Gastric varices develop in 5–33% of patients with portal hypertension. Gastric variceal bleeding is a major problem accused for a lot of deaths in cirrhotic sufferers, so its management and early prophylaxis is a must. Surgery turns into the only hope for patients with huge varices or resistant cases to repeated endoscopic management. Fundectomy and devascularization may be a good option in this class of patients. The aim of this study is to evaluate endoscopically guided stapled fundal minigasterectomy with periesophagogastric devascularization and splenectomy in treatment of gastric fundal varices. Patients and methods: This study included twenty two selected patients with gastric varices admitted to Gastroenterology, Liver and Laparoscopic unit, General surgery department, Tanta University Hospitals, during the period from January 2014 to January 2016. All cases were operated by endoscopically guided stapled fundal minigasterectomy with periesophagogastric devascularization and splenectomy. The evaluation included operative characteristics, operative findings and morbidity and postoperative complications. Results: The operative time ranged from 75 minutes to 180 minutes, with a mean of 106 + 15 minutes. Intraoperative bleeding occurred in one patient (4.55%) due to injury of one of the retroperitoneal veins treated by underrunning sutures and blood transfusion. There was no operative or postoperative mortality and only one patient developed recurrent fundal varices (4.55%) without bleeding attacks during the follow up period. Follow up ranged from 1 to 2 years with a mean of 1.5 years. Conclusion: Endoscopically guided stapled fundal minigasterectomy with peri-esophagogastric devascularization is a safe and effective method in the treatment and prophylaxis of fundal varices, and should be a used in treating bleeding fundal varices and in prophylaxis of huge ones.

The Efficacy and the Safety of Prophylactic N-Butyl-2-Cyanoacrylate Injection for Gastric Varices Using a Modified Injection Technique.

Primary prophylactic N-butyl-2-cyanoacrylate (NBC) injection for nonbleeding gastric varices (GVs) remains controversial. In addition, there is still no consensus concerning the technique, its safety, and long-term results. To analyze the safety and the efficacy of NBC for primary prophylaxis of GVs using a modified injection technique. Between February 2004 and June 2014, a total of 72 patients with GVs with a high risk of bleeding, who received undiluted NBC injection using a modified "sandwich" method for primary prophylaxis in General Hospital of Chengdu Military Command, were enrolled in this retrospective study. All patients were followed up at 1 to 2 weeks, 3 months, 6 months, and thereafter every 6 months or whenever required, using endoscope detection. The rate of obliteration, bleeding, recurrence, and complications was evaluated. According to the standard Sarin classification, 28 patients were IGV1 and 44 patients were GEV2. Hepatitis B virus infection was the major cause of portal hypertension. The mean number of sessions were 1.4 (1 to 3) and the mean volume of NBC per session was 3.5 mL (1 to 6 mL). One injection per session was used in 41 patients (56.9%) and 2 or more injections were used in the remaining 31 patients (43.1%). During the follow-up (27 mo; range, 12 to 67 mo), complete obliteration of GVs was achieved in 93.1% of the patients (67/72). One session of NBC injection was enough to obliterate GVs in 49 patients (68.1%), and 2 or more sessions were needed in 23 patients (31.9%). In addition, the bleeding and the recurrence rate were 11.1% (8/72) and 15.3% (11/72), respectively, during the follow-up. The cumulative bleeding-free rate at 1, 3, and 5 years was 95.8%, 91.7%, and 88.9%, respectively. Worsening of esophageal varices was observed in 13 patients (9 in GEV2 and 4 in IGV1). No serious complications, such as distal embolism, were observed in all patients. Prophylactic endoscopic NBC injection using a modified injection technique may be a safe and effective treatment for gastric fundal varices with a high risk of bleeding.

EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video)

Conventional endoscopic treatment of gastric fundal varices (GFV) with cyanoacrylate (CYA) glue may be complicated by embolization and rebleeding. We evaluated the long-term outcomes of EUS-guided injection of coils and CYA glue for therapy of GFV. A retrospective chart review of patients treated for GFV was performed. The main outcomes measured were hemostasis, obliteration on surveillance EUS, post-treatment bleeding rate, and adverse events. From March 2009 to 2015, 152 patients with GFV were treated. Seven (5%) had active hemorrhage, 105(69%) had recent bleeding, and 40 (26%) were treated for primary prophylaxis. Treatment was technically successful in 151 patients (>99%). Mean number of coils was 1.4 (range, 1-4 coils), and mean volume of CYA was 2 mL (range, 0.5-6). Follow-up was available for 125 patients with treated GFV (mean, 436 days; range, 30-2043). Among 100 patients with follow-up EUS examinations, complete obliteration (on Doppler study) of GFV was confirmed in 93 (93%). Post-treatment bleeding from obliterated GFV occurred in 3 of 93 patients (3%). Twenty-five patients who had clinical and/or EGD follow-up had 3 post-treatment bleeding episodes after a median follow-up of 324 days (range, 41-486). Among the 40 patients treated for primary prophylaxis, 28 underwent follow-up EUS and 27(96%) had confirmed obliteration. Mild postprocedure abdominal pain occurred in 4 of 125 patients (3%), and clinical signs of pulmonary embolization were seen in 1 patient (1%). Another 4 of 125 patients (3%) presented with minor delayed upper GI bleeding from coil/glue extrusion. EUS-guided combined coil and CYA glue injection of high-risk GFV appears to be highly effective for hemostasis in active bleeding and primary and secondary bleeding prophylaxis. Once obliteration was achieved, post-treatment bleeding from GFV occurred in only 3% during long-term follow-up. Combination therapy appears safe and may reduce the risk of CYA embolization.

209 Endoscopic Ultrasound (EUS)-Guided Treatment of Gastric Fundal Varices With Combined Coiling and Cyanoacrylate Glue Injection (5 Year Outcome Data)

209 Endoscopic Ultrasound (EUS)-Guided Treatment of Gastric Fundal Varices With Combined Coiling and Cyanoacrylate Glue Injection (5 Year Outcome Data)

A Sinister Cause of Hematemesis

Question: A 52-year-old man with myelofibrosis presented to the emergency room with hematemesis. Earlier that day, he had experienced cough, rhinorrhea, and pharyngitis. On the evening of admission, he vomited blood, prompting him to seek medical attention. He denied fevers, chills, chest pain, abdominal pain, melena, hematochezia, prior history of upper gastrointestinal bleeding, nonsteroidal anti-inflammatory drug ingestion, or alcohol abuse. He was afebrile and hemodynamically stable. Physical examination was significant for splenomegaly and brown, guaiac-positive stool. His abdomen was nontender and nondistended without overt evidence of hepatomegaly. Pertinent laboratory results were as follows: blood urea nitrogen, 34 mg/dL; International Normalized Ratio, 1.3; white blood cell count 4.6 K/μL; platelets, 194 K/μL; and hemoglobin, 12.5 g/dL, which decreased to 9.6 g/dL on repeat 6 hours later. On presentation, he was given an intravenous bolus of esomeprazole 80 mg and initiated on an intravenous esomeprazole drip at 8 mg/h. An urgent upper endoscopy revealed isolated gastric varices with recent evidence of bleeding (Figure A, yellow arrow). He was given a bolus of intravenous octreotide 50 μg followed by an intravenous octreotide drip at 50 μg/h and ceftriaxone 1 g/d. The patient was transferred to the intensive care unit for further monitoring. What was the cause of this patient’s gastric varices (GV) and what is the next appropriate step? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT of the abdomen and pelvis revealed marked splenomegaly and prominent gastric (Figure B, C, arrow), paragastric, splenic, and mesenteric varices (Figure B, C, arrowhead). The patient underwent a liver biopsy, which revealed extramedullary hematopoiesis without evidence of fibrosis or nodular regenerative hyperplasia. Measurement of hepatic venous pressure gradient was 8 mmHg, confirming absence of right-sided portal hypertension. In our patient, sinistral portal hypertension and gastric variceal bleeding occurred secondary to splenomegaly from increased splenic blood flow owing to myelofibrosis-induced extramedullary hematopoiesis. Isolated GV are less prevalent than esophageal or gastroesophageal varices. Our patient had type 1 varices (IGV1), which are confined to the fundus. A common cause of IGV1 is splenic vein thrombosis and this diagnosis should be excluded. Initial management of gastric variceal bleed includes antibiotics, vasoactive drugs, and selective transfusion.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Beyond this initial management, studies have documented the use of splenectomy, splenic embolization, endoscopic variceal obturation (EVO) using tissue adhesives such as cyanoacrylate (CA), endoscopic injection sclerotherapy (EIS), variceal band ligation (EBL), transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration.2Goh B.K. Chen J.J. Tan H.K. et al.Acute variceal bleed in a patient with idiopathic myelofibrosis successfully treated with endoscopic variceal band ligation.Dig Dis Sci. 2007; 52: 173-175Crossref PubMed Scopus (2) Google Scholar CA has demonstrated higher hemostasis and lower rebleeding rates compared with EBL and EIS. A recent study has shown that endoscopic ultrasonographic (EUS)-guided therapy for fundal varices with CA and coils may improve efficacy and decrease embolization of glue.3Binmoeller K.F. Weilert F. Shah J.N. et al.EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos).Gastrointest Endosc. 2011; 74: 1019-1025Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar CA is not currently available in the United States. However, many experts agree that, in patients with bleeding gastric fundal varices, the use of CA is preferred where available, with EBL as an alternative.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Splenectomy can be definitive treatment in patients with GV associated with sinistral portal hypertension.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar In patients with myelofibrosis and splenomegaly, splenectomy is reserved for those with drug-refractory, symptomatic splenomegaly associated with frequent transfusions, portal hypertension, or severe thrombocytopenia. In our patient, splenectomy was chosen over EVO or transjugular intrahepatic portosystemic shunt owing to lack of available CA in the United States and the lack of elevated right-sided portal pressures. Postoperatively, his white blood cell count was 6.7 K/μL and platelet count was 279 K/μL. He received low-molecular-weight heparin for splenic and portal vein thrombosis, as well as hydrea and interferon. Repeat endoscopy 1 year after surgery showed no evidence of any varices. This case highlights the need for larger scale, randomized, controlled trials to guide management of gastric variceal bleeding. In addition, not all effective endoscopic and interventional techniques to treat GV are widely available, making it difficult for providers to follow current recommendations.

Balloon‐occluded retrograde transvenous obliteration using a microballoon catheter for intractable gastric fundal varices

Balloon-occluded retrograde transvenous obliteration (B-RTO) is recognized as the standard therapy for patients with gastric fundal varices in Japan; however, the procedure is difficult when drainage veins other than the gastrorenal shunt developed. The efficacy and safety of B-RTO using a microballoon catheter for such patients were evaluated. The subjects were 99 patients with gastric fundal varices who fulfilled the criteria for receiving endoscopic and/or interventional therapies. Among these, 95 patients underwent B-RTO. Of the 95 patients, 14 were treated with the use of microballoon catheters, including nine in whom the left inferior phrenic vein was found as a secondary drainage vein in addition to the gastrorenal shunt, and five in whom a gastrorenal shunt was absent. The B-RTO procedure performed using a microballoon catheter inserted through the left inferior phrenic vein in 13 patients, and through the pericardiophrenic vein in one patient. The B-RTO procedure using microballoon catheters was successful in 13 of the 14 patients (93%), while in the remaining one patient, multiple drainage veins were visualized on venography. Complete obliteration of the varices was achieved in all the 13 patients by injection of 5% ethanolamine oleate iopamidol at a median volume of 25 mL (range, 11 to 40 mL) through the catheters. None of the patients showed injuries of the drainage veins or any systemic complications. B-RTO using a microballoon catheter is useful for the treatment of gastric fundal varices in which drainage veins other than the gastrorenal shunt developed.

Endotherapy of Gastric Fundal Varices: Intravariceal Injection of N-Butyl-2-Cyanoacrylate

The tissue glue N-butyl-2-cyanoacrylate has been successfully used in many countries for the treatment of gastric fundal variceal bleeding. However, significant rebleeding rates and serious complications including embolism have been reported due to differences in injection techniques. The authors demonstrate a standardized injection technique and regimen that ensures the success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices. This article is part of an expert video encyclopedia.

Forward-view Endoscopic Ultrasound: A Systematic Review of Diagnostic and Therapeutic Applications.

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and therapeutic procedures have been performed by a curved linear array (CLA) echoendoscope since the early 1990's. This particular echoendoscope, allowing real time visualization of aspiration needles and of other devices, has substantially remained unchanged since its introduction to the market. In a context of rapidly expanding indications for EUS-guided procedures, a dedicated forward view (FV) echoendoscope has been developed and tested under different clinical conditions. The FV echoendoscope is equipped with front endoscopic and EUS view, allowing deployment of needles and other devices through the working channel in straight direction. Several new diagnostic and therapeutic applications may thereby potentially be feasible with the FV echoendoscope and the established ones may prove easier to accomplish. The published literature with the FV echoendoscope has been systematically reviewed and the results are presented analytically and discussed in detail. EUS-FNA and therapeutic procedures, including pancreatic pseudocyst drainage, treatment of gastric fundal varices, celiac plexus neurolysis, and duct drainage were reported. The FV echoendoscope showed some unique advantages, opening new possibilities such as EUS-FNA in difficult gastrointestinal tracts and combined endoscopic/EUS treatment with frontal approach. However, no statistically significant evidence of superiority of the FV echoendoscope vs. the CLA echoendoscope was found in pancreatic pseudocyst drainage. No complications specifically attributable to the use of the FV echoendoscope were reported.

EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos)

There have been numerous reports of glue embolization after endoscopic cyanoacrylate (CYA) glue treatment of gastric fundal varices (GFV), with some cases fatal. Coils with attached synthetic fibers may decrease or eliminate this risk and may decrease the amount of CYA needed to achieve obliteration. Assess the feasibility, safety, and outcomes of transesophageal EUS-guided therapy of GFV with combined coil and CYA injection. Retrospective query of a prospectively maintained database. Tertiary care medical center. Patients with hemorrhage from large GFV. A standardized approach by using EUS-guided coil and CYA treatment. Hemostasis, rebleeding rate, complications. Thirty patients with GFV were treated between March 2009 and January 2011. At index endoscopy, 2 patients had active hemorrhage and 14 had stigmata of recent hemorrhage. EUS-guided transesophageal treatment of GFV was successful in all. Mean number of GFV treated was 1.3 per patient, and the mean volume of 2-octyl-CYA injected was 1.4 mL per varix. Hemostasis of acute bleeding was 100%. Among 24 patients with a mean follow-up of 193 days (range 24-589 days), GFV were obliterated after a single treatment session in 23 (96%). Rebleeding occurred in 4 patients (16.6%), with none attributed to GFV. There were no procedure-related complications and no symptoms or signs of CYA embolization. Single-center, pilot study. Transesophageal EUS-guided coil and CYA treatment of GFV is feasible and deserves further study to determine whether this novel approach can improve safety and efficacy over standard endoscopic injection of CYA alone.

Foam sclerotherapy using polidocanol for balloon-occluded retrograde transvenous obliteration (BRTO)

To evaluate the clinical safety and effectiveness of foam sclerotherapy using polidocanol for the treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration (BRTO). From November 2005 to June 2009, foam sclerotherapy using polidocanol for the treatment of gastric fundal varices by BRTO was performed in 16 patients (male/female 11:5; age range 46-84years, median 67years). Foam was made of 3% polidocanol (Aethoxysklerol; Kreussler Pharma, Wiesbaden, Germany), room air, and contrast media, with a ratio of 1:2:1, respectively. The amount of polidocanol (2-24mL; median 7mL) depended on the volume of varices. Technical success was achieved in 15 of 16 patients (93.8%). Technical failure occurred in one patient. All patients were without pain during sclerotherapy. One patient experienced pulmonary edema after the procedure but completely recovered with medical treatment. There was no procedure-related mortality. Patients were followed by endoscopy, computed tomography, or both. Four patients were lost to follow-up. Clinical success was achieved in 10 of 11 patients (91%). Rebleeding occurred in one case during follow-up. Foam sclerotherapy using polidocanol is clinically safe and effective for the treatment of gastric fundal varices during BRTO.

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported. Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen. Retrospective. Two tertiary referral centers. A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen. (1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration. Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate. Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively. Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

Management of gastric fundal varices without gastro-renal shunt in 15 patients

To examine the portal hemodynamics of gastric fundal varices (GV) without gastro-renal shunt (GRS), and to retrospectively investigate the effects of various kinds of treatment on eradication. Ninety-four liver cirrhosis patients at high-risk of GV were treated in our hospital and enrolled in this study. We retrospectively examined their characteristics, liver function, and portal hemodynamics of GV. We performed balloon-occluded retrograde transvenous obliteration (BRTO) at first. If it was not technically possible to perform BRTO, endoscopic injection sclerotherapy using alpha-cyanoacrylate glue (CA) or percutaneous transhepatic obliteration (PTO) was performed. Among the 94 patients, a GRS was present in 79 (84.0%), and absent in the remaining 15 (16.0%). The subphrenic vein was connected to the inferior vena cava as the drainage vein in 13 (86.7%) out of the 15 cases without GRS. We performed BRTO in 6 patients, CA in 4 patients and PTO in 5 patients. The eradication rate was 100% for each procedure, but the rate of early recurrence within 6 mo was 16.7% for BRTO, 50.0% for CA and 40.0% for PTO, respectively. We should examine the hemodynamics before treatment of GV irrespective of the existence of GRS. If this hemodynamic examination reveals that the drainage vein connects directly to the inferior vena cava in GV without GRS, BRTO may be an effective treatment for GV with GRS.

Gastric fundal varices: new aspects of nonsurgical treatment in Japan

Bleeding from gastric varices is a life-threatening event that presents a therapeutic challenge for clinicians. This Viewpoint discusses the advance in nonsurgical treatment of gastric fundal varices, including the new radiologic technique of balloon-occluded retrograde transvenous obliteration.

Standardized Injection Technique and Regimen Minimizes Complication and Ensures Safety of N-Butyl-2-Cyanoacrylate Injection for the Treatment of Gastric Fundal Varices

Standardized Injection Technique and Regimen Minimizes Complication and Ensures Safety of N-Butyl-2-Cyanoacrylate Injection for the Treatment of Gastric Fundal Varices

A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans

Background N-butyl cyanoacrylate injection has been shown to be effective and safe for the endoscopic treatment of gastric varices. N-butyl cyanoacrylate is not available in the United States, but use of a similar agent, 2-octyl cyanoacrylate, recently was approved for skin closure. This pilot study prospectively evaluated the efficacy and safety of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices. Methods Twenty-five patients with large gastric fundal varices with either stigmata of recent hemorrhage, a history of bleeding, or high-risk varices underwent intravariceal injection of undiluted 2-octyl cyanoacrylate. The end points for this study were cessation of active bleeding, successful obliteration of visible varices, and prevention of bleeding. Results Within 2 weeks of treatment, 52% of patients had a history of significant variceal bleeding, and 12% had active gastric variceal bleeding at the time of injection. The rate of immediate hemostasis was 100%. Gastric variceal bleeding recurred in 4% of patients (mean follow-up 11 months). The overall mortality rate was 12%; the bleeding-related mortality rate was 4%. Conclusions Injection of 2-octyl cyanoacrylate appears to be efficacious and safe for both prevention and control of gastric variceal hemorrhage. Larger studies are required to further establish the use of 2-octyl cyanoacrylate for treatment of gastric fundal varices.

Balloon-occluded retrograde transvenous obliteration as adjunctive treatment for gastric fundal varices: case report

Balloon-occluded retrograde transvenous obliteration as adjunctive treatment for gastric fundal varices: case report

What is the best method of treatment for gastric fundal varices without active bleeding?

What is the best method of treatment for gastric fundal varices without active bleeding?

Management of balloon-occluded retrograde transvenous obliteration in the treatment of gastric fundal varices

Management of balloon-occluded retrograde transvenous obliteration in the treatment of gastric fundal varices