Treatment Of Bleeding Gastric Varices Research Articles

Trans-splenic percutaneous glue embolization of bleeding gastric varices in the setting of malignant sinistral portal hypertension

Sinistral portal hypertension, also known as left-sided portal hypertension, is a rare cause of gastric variceal bleeding which occurs secondary to occlusion of the splenic vein. We present a case of venous occlusion and sinistral portal hypertension secondary to distal pancreatic cancer requiring treatment of gastric variceal bleeding. After failing conservative management, transvenous intervention was attempted, but a venous communication with the gastric varices was unable to be identified on multiple venograms. A percutaneous trans-splenic approach using a 21-G needle and ultrasound guidance was successful in directly accessing an intraparenchymal vein feeding the gastric varices, and glue embolization was performed directly through the access needle with excellent results.

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Gastric Variceal Bleeding in a Patient with a Gastrorenal Shunt: A Case Report

Background 
 Portal hypertension (pHTN) is primarily caused by liver cirrhosis, which can lead to varices at portosystemic anastomoses.1,2 Gastric variceal bleeding (GVB) is rare but can be life-threatening with a mortality up to 50% for each bleeding episode. When endoscopic banding is ineffective and TIPS placement is contra-indicated due to risk of post-TIPS encephalopathy, coil-assisted retrograde transvenous obliteration (CARTO), which has shown great success in some studies, can be an effective treatment.5,8,9,10 This case demonstrates successful use of CARTO to treat GVB in a patient with a gastrorenal shunt (GRS) who presented with pHTN. 
 
 Case Overview 
 A 62-year-old female with cirrhosis due to nonalcoholic steatohepatitis (NASH) presented with pHTN and GVB. The patient had a massive GRS, which permitted access through the systemic venous circulation to treat the bleeding varices. Furthermore, the patient had hepatic encephalopathy (HE), making TIPS placement a poor choice due to risk of HE exacerbation. CARTO was performed to treat the bleeding varices and had the added benefit of decreasing risk of HE. 
 
 Discussion/Results 
 This case highlights CARTO in a patient with a 22mm GRS using a dual catheter system. Eighteen detachable 035 coils were first deployed in the GRS, followed by complete occlusion with a Gelfoam slurry to obliterate the gastric varices. Studies have described CARTO, all of which have shown incredibly high technical (complete embolization by angiography and/or CT) and clinical (no variceal rebleeding) success rates. This patient returned for follow-up CT and endoscopic imaging, which confirmed technically and clinically successful CARTO. 
 
 Conclusion and Potential Impact 
 CARTO appears to be a safe alternative to TIPS when treating GVB caused by pHTN, especially in patients who have HE and a GRS. Thus, CARTO should be discussed as a treatment option for these patients. Although portal pressure increases post-CARTO, the improvement of HE can lead to an improved safety profile with future TIPS.

An excerpt from the 2023 AASLD practice guidelines: TIPS, variceal embolization, and retrograde transvenous embolization for the treatment of variceal hemorrhage

This is the American Association for the Study of Liver Diseases (AASLD) comprehensive guideline on the application of endovascular interventional radiological procedures in the treatment of variceal bleeding, which supplements Risk Stratification and Management of Portal Hypertensive Bleeding in Cirrhosis by describing recent advances in invasive surgery. Transjugular intrahepatic portosystemic shunt (TIPS) dates back to the 80s of the 20th century, and over the past few years, several new technical improvements have been made to TIPS stents. Another major treatment for gastric variceal bleeding in North America is the use of different forms of retrograde transvenous embolization. This guideline is intended to provide healthcare professionals with an in-depth understanding of the use of TIPS and/or variceal embolization/occlusion in the treatment of variceal bleeding, with the goal of facilitating multidisciplinary discussions on treatment strategies among hepatologists, gastroenterologists, interventional radiologists, and surgeons. Additionally, it provides a data-based approach to the endovascular treatment of variceal bleeding. However, it differs from the AASLD guidelines by being supported by a systematic review of the literature, a formal rating of the quality of the evidence, and the strength of the recommendations. Consequently, this guideline was developed by a consensus of an expert panel under the supervision of the AASLD Practice Guidelines Committee and provides guidance statements based on a comprehensive review and analysis of the literature on the relevant topic. Importantly, the AASLD Practice Guidelines Committee selected this topic because, for the most part, there are not a sufficient number of randomized controlled trials on this topic to provide meaningful systematic reviews and meta-analyses.

1852. Recurrent Bacteremia after Endoscopic Injection of N-butyl-2-cyanoacrylate for Gastric Variceal Bleeding

Abstract Background Gastric variceal bleeding is associated with a high mortality rate, and sclerotherapy using N-butyl-2-cyanoacrylate is the treatment of choice. The risk of recurrent bacteremia after N-butyl-2-cyanoacrylate injection has rarely been reported. We aimed to evaluate the frequency of this complication in a real-world setting. Methods We analyzed retrospective data from a single-center cohort of patients with liver cirrhosis who underwent N-butyl-2-cyanoacrylate injection for the treatment of bleeding gastric varices from January 2010 to March 2021. Recurrent bacteremia was defined as repeated bacteremia caused by the same microorganism after the resolution of the first event occurring at least two weeks from the date of the final positive blood culture of the first event. Results A total of 232 patients receiving 338 sessions of N-butyl-2-cyanoacrylate injection were enrolled. All patients received antibiotics prophylaxis; third-generation cephalosporins were used. The average age of patients was 59.5 ± 12.2 years and the mean Model for End-Stage Liver Disease (MELD) score was 14.8 ± 7.3. Of the patients following cyanoacrylate injection, 62 patients developed primary bacteremia at a median of 294 (range, 3−3710) days from N-butyl-2-cyanoacrylate injection. Nine out of 62 patients developed recurrent bacteremia following sclerotherapy with N-butyl-2-cyanoacrylate. The identified organisms were: Extended-Spectrum ß-Lactamase (ESBL)-producing Escherichia coli (3), ESBL-producing Klebsiella pneumoniae (2), non-ESBL-producing Klebsiella pneumoniae (2), Pseudomonas aeruginosa (1), and Methicillin-resistant Staphylococcus aureus (1). The median number of episodes of recurrent bacteremia per patient was 3 (range, 2−8) during the median 972 (range, 78−1997) days of follow-up. Four of these nine recurrent bacteremia patients died. Conclusion Recurrent bacteremia occurred in 3.9% of cirrhotic patients following cyanoacrylate injection for the treatment of gastric variceal bleeding. Foreign-body-type infection of the polymerized N-butyl-2-cyanoacrylate should be suspected in patients who had received previous endoscopic treatment with N-2-butyl-cyanoacrylate and fails to disclose another source of infection. Disclosures All Authors: No reported disclosures.

Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists.

Background:Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding.Aim:This article intends to highlight the potential differences in the endoscopic management of EGVB in China.Methods:A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience.Results:A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response “patients receive emergency endoscopic intervention within 12 hours” was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience.Conclusions:There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.

Clip-Assisted Endoscopic Cyanoacrylate Injection: A Novel Technique for Acute Gastroesophageal Variceal Bleeding.

Background and Aim: Endoscopic injection sclerotherapy is effective for the treatment of gastric variceal bleeding, but may cause fatal ectopic embolism. Spontaneous portosystemic shunts are one of the risk factors for ectopic embolism. This present study aims to evaluate the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection for the treatment of acute gastroesophageal variceal bleeding. Methods: The medical records of patients with gastroesophageal varices (GOVs) who underwent clip-assisted cyanoacrylate injection at the Ningbo First Hospital from March 2017 to August 2020 were reviewed. The outcomes were immediate hemostasis rate, early rebleeding rate, late rebleeding rate, and procedure-related complications. The gastrorenal and splenorenal shunts were evaluated by the computed tomography angiography. Results: A total of 9 patients with GOVs (GOV1 and GOV2) were analyzed, and 4 of the patients had spontaneous portosystemic shunts. The average number of clips used in each patient was 2.11 ± 1.96, and an average of 5.11 ± 1.76 mL of cyanoacrylate was injected into each patient. All patients completed immediate hemostasis. Two patients experienced rebleeding, including 1 case of early rebleeding and 1 case of late rebleeding (both due to cyanoacrylate extrusion) during a median follow-up of 367 days (interquartile range 270-855 days). Five patients underwent follow-up endoscopy; eradicated gastric varices (GVs) were revealed in 1 patient, and shrunken GVs were found in 4 patients. No serious complications, including ectopic embolism, were observed. Conclusion: The present study showed the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection in acute GOV bleeding, but these results require verification by randomized controlled studies with larger sample numbers.

Predictors of early re-bleeding and mortality in patients with first attack of gastric variceal hemorrhage

Background: Gastric varices (GV) bleed less frequently than esophageal varices however, gastric variceal bleeding is more severe with higher mortality and rebleeding rates. Treatment of Gastric variceal bleeding (GVB) by tissue adhesive mainly cyanoacrylate glues has been used for Gastric variceal obturation. We aimed to determine predictors of early rebleeding and mortality in patients with the first attack of GVB. Materials and methods: The study included 120 patients with a first attack of GVB.The patients subjected to thorough history, full examination, laboratory, and radiological investigations. Child Turcott Pugh score (CTP), and model of end stage liver disease (MELD) score were calculated. Upper gastrointestinal (GI) endoscopy with gastric variceal obturation (GVO) by cyanoacrylate glues were done for all included patients. Follow up during hospitalization and 6 weeks after discharge to determine early rebleeding (within 14 days) and early mortality (within 6 weeks). Results: Among 120 included patients in the study, 24 patients (20%) were presented with early rebleeding and 19 patients (15.83%) were presented with early mortality. Multi-variable logestic regression analysis showed that, Child Pugh Score was an independent prognostic factor associated with early rebleeding and early mortality. It was found that, current smoking, increased bilirubin, INR, creatinine, decreased albumin, presence of ascites, higher CTP and MELD scores are significantly more in early rebleeding and early mortality groups, while lower platelet count in early rebleeding only. Moreover, hepatic encephalopathy, and higher transaminases are more in early mortality group. There was no significant difference in gastric variceal signs between the study groups except that increase mortality in patients with more than one varix. Conclusion: Child Turcott Pugh score was an independent prognostic factor associated with early rebleeding and early mortality in patients with GVB.

Splenic artery embolization for the treatment of gastric variceal bleeding caused by splenic vein thrombosis in necrotizing pancreatitis: report of a case

Introduction: Splenic vein thrombosis(SVT) is a relatively common finding in pancreatitis and SVT associated gastric variceal bleeding(GVB) could be sometimes a life-threatening complication. Traditionally splenectomy is considered the treatment of choice for SVT, however, surgical procedure in necrotizing pancreatitis is difficult and risky because of severe inflammation, adhesion, and bleeding tendency. Herein, we report a case of GVB secondary to SVT complicated by necrotizing pancreatitis which was successfully treated with splenic artery embolization(SAE).

A retrospective cohort study of intensive gastric variceal ligation versus endoscopic gastric variceal obturation in the management of gastric variceal bleeding.

Gastric variceal bleeding is often more serious and can be fatal. Currently, international consensus recommendations for the treatment of gastric variceal bleeding vary according to endoscopic classification. Few studies have investigated ligation versus gastric variceal obturation (GVO) for the treatment of gastric varices. The study included 79 patients with cirrhosis-induced bleeding from esophageal and fundal varices who were treated at the Second Hospital of Hebei Medical University between January 2016 and December 2020 and who met the inclusion criteria. Among them, 42 patients were included in the intensive gastric varices ligation (IGVL) group, and 37 were included in the GVO group. We conducted a retrospective cohort study to analyze the effectiveness and safety of these 2 treatments. The rebleeding rate after initial treatment was significantly lower in the IGVL group than in the GVO group (23.8% vs. 48.6%, P<0.05). No significant between-group difference was observed in overall mortality (14.3% vs. 32.4%), 6-week mortality (0.0% vs. 2.7%), or 1-year mortality (11.9% vs. 13.5%, all P>0.05). The >1-year mortality and bleeding-related mortality rates were significantly higher in the GVO group than in the IGVL group (23.3% vs. 2.7%, P<0.05; 27.0% vs. 9.5%, P<0.05). The incidence of adverse events was 57.1% in the IGVL group and 48.6% in the GVO group, with no significant difference (P>0.05). Independent predictors for rebleeding after initial treatment were the use of GVO as endoscopic treatment, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment. Rebleeding after initial treatment was lower after IGVL than GVO. Independent predictors for rebleeding after initial treatment were endoscopic treatment method, total bilirubin >17.1 µmol/L, liver cancer, and diabetes. For mortality, the independent predictors were male sex, liver cancer, ascites, and rebleeding after initial treatment.

S0635 A Comparative Study of the Efficacy of Endoscopic Injection of Cyanoacrylate Glue vs Other Interventional Modalities for Treatment of Acute Gastric Variceal Bleeding: A Systematic Review and Meta-Analysis

INTRODUCTION: Cyanoacrylate glue is currently the main endoscopic therapeutic option for treatment of bleeding gastric varices. Recent studies have demonstrated that a multitude of different techniques appear to have similar efficacy and safety. This study aimed to conduct a systematic review and meta-analysis to evaluate the efficacy of cyanoacrylate glue injection versus other endoscopic and interventional modalities, including band ligation, sclerotherapy, or transjugular intrahepatic portosystemic shunt (TIPS) in the management of gastric variceal bleeding. METHODS: Multiple databases were searched through November 2018 for studies involving adults with portal hypertension and/or cirrhosis with bleeding gastric varices. Data was gathered to compare cyanoacrylate glue versus band ligation, sclerotherapy, or TIPS in achieving control of active bleeding from gastric varices within the first 24 hours. Secondary outcomes analyzed included rebleeding rate and adverse event rate. RESULTS: A comprehensive search identified 1068 potential articles with 14 comparative studies fulfilling inclusion criteria for data extraction. These studies included 1270 total patients: 634 patients underwent cyanoacrylate glue injection, 325 patients underwent endoscopic band ligation, 219 patients underwent TIPS, and 92 patients underwent sclerotherapy. Pooled analysis was performed, and odds ratios were obtained. Control of active bleeding within the first 24 hours was statistically significant favoring cyanoacrylate in all three comparisons of cyanoacrylate glue vs. band ligation, sclerotherapy, and TIPS, respectively (Figure 1). Rate of adverse events showed no significant differences among the three comparison groups (Figure 2). Rate of rebleeding also showed no significant difference among the groups (Figure 3). CONCLUSION: This meta-analysis highlights that cyanoacrylate glue injections were superior to band ligation, sclerotherapy, or TIPS in controlling active gastric variceal bleeding within the first 24 hours. Cyanoacrylate glue injections also showed no significant differences in adverse events or rebleeding rates when compared against the other interventions. These results suggest that cyanoacrylate glue injection should remain a primary therapeutic option for the treatment of gastric variceal bleeds. However, comparative studies remain limited, and further analyses evaluating the many therapeutic options available for the treatment of gastric varices against each other are warranted.Figure 1.: Bleeding Control of Gastric Varices within 24 hours in Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.Figure 2.: Rate of Adverse Events after Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.Figure 3.: Rate of Rebleeding after Therapy with Cyanoacrylate Glue Injection vs. Band Ligation, Sclerotherapy, or TIPS.

S2192 Over-the-Scope Clip as Rescue Treatment for Bleeding Gastric Varices

INTRODUCTION: We present a case of gastrointestinal bleeding in a patient with pancreatitis-induced splenic vein thrombus. This case highlights an important etiology of gastric varices, a known complication of treating them, as well as a method for treating refractory bleeding. CASE DESCRIPTION/METHODS: An 18-year-old male with ALL s/p post allogeneic HSCT, chronic pancreatitis, bowel perforations s/p ileostomy presented with gastrointestinal bleeding. The patient had hospitalizations at other institutions with intermittent melena and occasional hematemesis. After multiple upper endoscopies that did not identify the etiology of bleeding, he was referred to our hospital for double balloon enteroscopy. His hemoglobin was down to 5.9 g/dL (baseline 9-10 g/dL). EGD was performed with plan for double balloon enteroscopy, but a large blood clot was seen in the stomach. A nodular area in the fundus was actively bleeding. Given concern for an isolated gastric varix (IGV-1), EUS-guidance was used to inject coils and N-butyl-2-cyanoacrylate into the gastric varices with adequate hemostasis. Follow-up imaging noted extensive portal and splenic vein embolization from the glue. The patient developed recurrent melena and an emergent TIPS placement with coronary vein coil embolization was performed. Recurrent gastrointestinal bleeding was again noted. CT angiography was obtained and revealed a splenic vein thrombus. The patient underwent a balloon-occluded antegrade transvenous obliteration with glue/coil embolization of a smaller vessel feeding the gastric varix. However, GI bleeding was again noted. A repeat endoscopy was subsequently performed with placement of three over the scope clips (OTSC) on the varix for successful hemostasis. DISCUSSION: Gastric varices are often associated with cirrhosis but can occur in patients with non-cirrhotic portal hypertension (i.e., splenic vein thrombosis). Cyanoacrylate glue injection is recommended for acute bleeding from IGV. A known complication of glue injection is the risk of embolization (approximately 1–2%). Endoscopic ultrasound guided coil deployment can act as a scaffold at the time of glue injection to reduce this risk. OTSC have been used successfully in esophageal variceal bleeding. We report the first successful use of OTSC for gastric varices which should be considered as salvage therapy.Figure 1.: Gastric varices with hemostasis after endoscopic ultrasound-guided coil and glue injection.Figure 2.: Portal vein embolization after endoscopic ultrasound-guided coil and N-butyl-2-cyanoacrylate injection.Figure 3.: Recurrent gastric variceal bleeding with hemostasis after successful over the scope clip deployment.

Endoscopic Ultrasound for the Treatment of Gastric Variceal Bleeding in a Patient with Portal Cavernoma

Endoscopic Ultrasound for the Treatment of Gastric Variceal Bleeding in a Patient with Portal Cavernoma

Treatment of Bleeding Gastric Varices by Endoscopic Cyanoacrylate Injection: A Developing-country Perspective.

IntroductionGastric varices (GV) are less commonly seen but bleed more severely than esophageal varices (EV). Transjugular intrahepatic portosystemic shunt (TIPS), alcohol injection, and N-butyl-2-cyanoacrylate (NBCA) are generally used for GV bleed management. NBCA is usually injected endoscopically and is known to be quite successful in the treatment of GV bleeding. This study was conducted with the objective of determining the outcomes in patients with GV treated with NBCA.MethodsWe conducted a retrospective review of medical records and reports of endoscopy performed between March 2015 and June 2018 at a large tertiary care center. Patients of any age and gender having a history of chronic liver disease, those presenting with hematemesis or melena, and those who were found to have GV bleed on endoscopy and treated with NBCA were included. All the endoscopy procedures were undertaken within 24 hours of admission. Informed written consent was obtained from all the patients before the procedure. The outcomes were measured in terms of rate of mortality, hemostasis achieved, duration of stay at the hospital, and requirement of blood transfusion.ResultsA total of 31 patients met the inclusion criteria; (58.1%) were males and 13 (41.9%) were females. The mean age was 55.23 ±8.77 years; 12.9% were Child-Pugh class-A, 64.5% were class B, and 22.6% were class C. Out of the 31 patients, 27 (87%) patients achieved hemostasis. Moreover, 22 (71%) patients had hospital stay ranging between 5-8 days. The overall mortality rate was 9.7% (3 patients). No complication was reported from NBCA injection.ConclusionThe injection of NBCA can provide a safe and effective method for the management of GV bleeding as demonstrated by the results of our study, which showed hemostasis in a majority of the cases after the initial injection with no procedure-related complications, a reduced hospital stay, and a reduced rate of mortality.

Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate.

Background and study aims Bleeding from gastric varices (GV) carries high morbidity and mortality. Current endoscopic therapies are premised on cyanoacrylate injection which is technically challenging and carries risk of embolization. We present a case series of endoscopic ultrasound (EUS)-guided coil injection in combination with hemostatic absorbable gelatin sponge (AGS) for treatment of bleeding gastric varices. Patients and methods This was a retrospective review of EUS-guided coil injection for bleeding GV since November 2017. After EUS-guided needle puncture, hemostatic coils were serially injected until significant reduction of Doppler flow. Under fluoroscopic guidance, test contrast was injected to confirm absence of run-off, at which time AGS, converted into a liquid slurry, was injected as hemostatic reinforcement. Results Ten consecutive patients underwent EUS-guided coil embolization reinforced by AGS. Technical success, defined as uncomplicated injection of coils and sponge was achieved in 100 % (10/10). Mean follow-up was 6 months 73–397 days; No patients rebled or required reintervention on GV. The complication rate was 10 % (1/10; severe abdominal pain without radiographic findings); otherwise, there were no cases of systemic embolization. Nine of 10 patients (90 %) had follow-up EUS (mean 80 days); 100 % (9/9) revealed near-obliteration of GV. Conclusion EUS-guided coil embolization in combination with hemostatic AGS is a novel method for management of bleeding GV with high clinical and technical success rates, low risk for complications and favorable safety profile when compared to cyanoacrylate. This technique theoretically minimizes embolic complications and need for re-intervention. Further studies are required to compare this modality.

868 Coils and Dermabond: A Large County Hospital Experience With Gastric Varices

INTRODUCTION: Bleeding from gastric varices (GV) is associated with high mortality and morbidity. EUS-guided injection of coils, cyanoacrylate glue or both is an emerging modality for treatment of gastric varics. We present our experience using EUS injection of coils (Nester Embolization Coil; Cook Medical) and 2-Octyl-cyanoacrylate (Dermabond) glue in the treatment of bleeding gastric varices in a large county hospital setting. METHODS: Medical records of consecutivepatients undergoing EUS guided treatment of gastric varices with glue and coils between mth/yer to mth/year were reviewed.Patient characteristics were recorded including presence of cirrhosis, variceal characteristics (size, location), and intervention type. Outcomes included technical success (defined as deployment of glue and coils inside the varix with cessation of blood flow on Doppler evaluation), rebleeding events, and subsequent one month follow up were recorded. RESULTS: Total of 16 patients were treated with EUS guided injection of coils and/or glue. Three (18.8%) had active bleeding and four (25%) had stigmata of recent bleeding at the index endoscopy. The remaining 9 (46.2%) had history of bleeding from gastric varices. 15/16 patients were treated with both coils and glue injection. One patient with small varices was treated with glue injection alone. Technical success was achieved in all 16 (100%) patients. None of the patients had active bleeding at the end of the procedure. The mean number of coils inserted was 3.9 and the mean volume of glue injected was 2.1 mL. Rebleeding, defined as having repeat endoscopy for gross gastrointestinal bleeding, occurred in 3 patients within one month of the initial EUS. In one patient, rebleeding was from gastric varices and was again treated with coils and glue injection. There were no significant adverse events including pain or embolization of glue or coils. One patient had extrusion of coils into the lumen of the stomach with no active bleeding identified. CONCLUSION: In this series, we demonstrate the high technical success and efficacy of EUS guided coil and glue injection in treatment of bleeding or secondary prophylaxis of gastric varices.

Sandwich method with or without lauromacrogol in the treatment of gastric variceal bleeding with liver cirrhosis: A meta-analysis.

Background:To compare the efficacy and safety of the modified sandwich method with lauromacrogol in the treatment of gastric variceal bleeding (GVB) caused by liver cirrhosis with the traditional sandwich method no accompanied by lauromacrogol via a meta-analysis.Methods:The Cochrane Library, Pubmed, the China National Knowledge Infrastructure (CNKI) database, the Chinese Wanfang database, and the Chongqing VIP database were searched to identify cohort studies comparing modified to traditional sandwich method in the treatment of GVB with liver cirrhosis. The relative risk for hemostasis rate, gastric varices (GV) remission rate, re-bleeding rate, the incidence of post-operative complications (pain, fever, ulcer or erosion, ectopic embolism), and all-cause mortality were calculated. The mean difference for average tissue adhesive dosage per case was calculated. Relevant data were analyzed with the Reviewer Manager 5.3.5.Results:Four cohort studies with a total of 587 patients were included in this meta-analysis. In the treatment of GVB with liver cirrhosis, compared with the traditional sandwich method, the modified sandwich method was associated with a higher GV remission rate (RR: 1.24, 95% CI: 1.09–1.42; P = .001) according to the pooled results. There were no statistically significant differences between the 2 methods in the rate of hemostasis, re-bleeding, pain, fever, ulcer or erosion, ectopic embolism, and all-cause mortality (P ≧ .05).Conclusions:This meta-analysis indicated that the modified sandwich method with lauromacrogol is more effective than the traditional sandwich method without lauromacrogol. Due to the limited number of studies and samples, more RCT studies are needed to further validate the efficacy and safety of the modified sandwich method with lauromacrogol in the treatment of GVB with liver cirrhosis.

A Case of Gastric Variceal Bleeding: Diagnosis and Treatment of a Rare Anatomical Variant

Assessment of the gastric variceal drainage system is important in selecting proper treatment options and interventional techniques. Our case describes a unique approach to the treatment of gastric variceal bleeding due to the anatomy of this patient.

Endoscopic Ultrasound-Guided Coil Injection Therapy for Gastric Variceal Bleeding Not Amenable to Interventional Radiology-Guided Therapies

Gastric varices account for 10%–30% of all variceal bleeds and are associated with significant morbidity and mortality. Interventional radiology–guided therapies such as balloon-occluded retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration can provide hemostasis when traditional endoscopic treatments such as cyanoacrylate injection fail. However, their applicability in certain cases can be limited because of anatomical constraints. We describe the use of endoscopic ultrasound–guided coil and absorbable gelatin sponge injection for the treatment of bleeding gastric varices arising from pancreatitis-induced splenic vein thrombosis not amenable to interventional radiology–guided therapies.

Role and safety of human thrombin injection for the treatment of bleeding gastric varices.

Human thrombin appears to be a new effective tool in the armamentarium of management of bleeding gastric varices, but there arepaucity of data on its use. Thus, we share our experience with human thrombin in the treatment of bleeding gastric varices. It was a prospective interventional study conducted between September 2015 and December 2017. Patients with upper gastrointestinal bleeding from gastric varices were included, while patients with previous history of cyanoacrylate glue injection or band ligation were excluded. A total of 20 patients including 13 males (mean age 32.65 [18-52] years) presenting with gastric variceal bleeding requiring endoscopic injection of human thrombin were studied. The underlying diagnosis was cirrhosis in 8 patients, and extrahepatic portal vein thrombosis, noncirrhotic portal fibrosis, and chronic pancreatitis in 6, 4, and 2 patients, respectively. Isolated gastric varices were found in 6 patients while 14 patients had gastroesophageal varices (GOV) (GOV1-3, GOV2-11). Patients received 1 to 3 sessions (mean = 1.3) of thrombin with a mean total dose of 700IU (range = 500-2000IU). Mean follow up was 16.8months (range 3-28months). Hemostasis in the acute setting was successfully managed in all the 20 patients on initial presentation. On serial follow up, 4 out of 20 patients required repeat endoscopic session for gastric varices. No thrombin injection-related complication was recorded. Endoscopic therapy with thrombin appears safe and effective in the management of bleeding gastric varices.

Safety of endoscopic N-Butyl-2 Cyanoacrylate injection for the treatment of bleeding gastric varices in children.

Objective:To determine the safety and efficacy of N-butyl 2-cyanoacrylate in bleeding gastric varices in children.Methods:This retrospective observational study was conducted in the Department of Gastroenterology and Pediatric Surgery in Liaquat National Hospital Karachi between January 2010 and January 2017. Gastric fundal varices were obliterated in pediatric population with single shot of N-butyl-2 Cyanoacrylate 0.50ml diluted with 0.50ml of Lipoidal with use of forward-viewing video endoscope with 22-gauge needle. The primary outcome was primary hemostasis, Secondary outcome was complications, re-bleeding and mortality.Results:Thirty patients was included in the study, 18(60%) were male with mean age of 7.12± 2.9 years. Non cirrhotic portal hypertension was the most common etiology in 15 (50%) patients, followed by liver cirrhosis secondary to hepatitis B and D co-infection in 6(20%) patients. Primary hemostasis was achieved in 29 (96.7%), while 3(10%) patients developed re-bleeding after 48 hours, and hemostasis was achieved after second session of endoscopic obliteration. Abdominal pain and fever developed in 3(10%) patients which was managed conservatively. Mortality was observed in 1(3%) of cases due to sepsis after shunt surgery.Conclusion:Endoscopic fundal varix obliteration with N Butyl-2 cyanoacrylate was safe and effective in treatment of gastric variceal hemorrhage in children.