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Sharma S, Agarwal S, Madhu D, Rana R, Gupta A, Gopi S, Gunjan D, Saraya A. Distinct course of portal hypertension in patients with cirrhosis with gastric variceal bleeding as their first decompensation: a propensity score-matched study. Hepatol Int 2022; 17:427-433. [PMID: 36534299 DOI: 10.1007/s12072-022-10451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Limited data exist on course of portal hypertension in patients with cirrhosis with gastric variceal (GV) bleeding as their index decompensation. We evaluated long-term outcomes in this subgroup and compared them with a propensity score-matched cohort of patients with esophageal variceal (EV) bleeding. METHODS Patients with cirrhosis with GVs (IGV-1 and GOV-2) bleeding as their index decompensation were analyzed in this retrospective study. Incidence of new-onset clinical decompensations and survival were estimated and compared with a cohort of patients with EVs bleeding matched for etiology and disease severity using competing risk analysis. RESULTS Baseline characteristics of patients with GVs related bleeding (n = 51) (mean age-48.1 ± 12.9 years, 80% males, non-viral cirrhosis: 80.3%) were similar to the cohort of EVs bleeding (n = 51) (mean age-45.9 ± 14.2, 88% males, non-viral cirrhosis: 78.4%). The 1-year and 3-year rates of new-onset ascites were (17.9%, 34.2%) and (23.9%, 49%) in patients with GVs and EVs related index bleeding, respectively (Gray's test, p = 0.035). The 1-year and 3 year rate of rebleed was (35.6%, 46.3%) and (13.9%, 35.7%) in patients with GVs and EVs related index bleeding, respectively (Gray's test, p = 0.1). While overall survival was similar across both the groups (GV: 29.6% vs EV: 21.6%, p = 0.495), rebleeding-related deaths occurred exclusively in patients with GV (rebleeding-related deaths: GV: 40% vs EVs: 0%; non-bleeding liver-related deaths: GV: 60% vs EV: 100%; p = 0.048). CONCLUSIONS Rebleeding predominates the course of portal hypertension in patients with cirrhosis presenting with GVs related bleeding, whereas ascites is the most significant event on follow-up in those with EVs related bleeding.
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Affiliation(s)
- Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Madhu
- Lisie Institute of Gastroenterology, Lisie Hospital, Ernakulam, Kochi, India
| | - Randeep Rana
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anany Gupta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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2
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Luo X, Hernández-Gea V. Update on the management of gastric varices. Liver Int 2022; 42:1250-1258. [PMID: 35129288 DOI: 10.1111/liv.15181] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/13/2023]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.
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Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, CIBEREHD, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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3
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Bridwell RE, Long B, Ramzy M, Gottlieb M. Balloon Tamponade for the Management of Gastrointestinal Bleeding. J Emerg Med 2022; 62:545-558. [PMID: 35065859 DOI: 10.1016/j.jemermed.2021.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/26/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid intervention. In critically ill patients who are refractory to other therapies, balloon tamponade devices can be lifesaving. OBJECTIVE We provide a review of balloon tamponade devices for gastric and esophageal variceal bleeding for emergency clinicians. DISCUSSION Balloon tamponade is intended for hemodynamically unstable patients with massive gastrointestinal bleeding and inability to perform endoscopy, failed endoscopy, delay in endoscopy, or the need to stabilize before transfer. There are 3 main tamponade devices: the Linton-Nachlas tube, the Sengstaken-Blakemore tube, and the Minnesota tube. Each tamponade device has some unique features including the number of balloons and ports. We describe the technique with pearls and pitfalls for placement. CONCLUSIONS It is essential for emergency physicians to be familiar with balloon tamponade for acute gastrointestinal bleeding. We review the common balloon tamponade devices, and this article is intended to serve as a resource for those interested in expanding their knowledge of balloon tamponade. © 2022 Elsevier Inc.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Mark Ramzy
- Department of Emergency Medicine and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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4
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Shah KY, Ren A, Simpson RO, Kloster ML, Mikolajczyk A, Bui JT, Lipnik AJ, Niemeyer MM, Ray CE, Gaba RC. Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes. J Vasc Interv Radiol 2021; 32:282-291.e1. [PMID: 33485506 DOI: 10.1016/j.jvir.2020.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/11/2020] [Accepted: 10/11/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). MATERIALS AND METHODS A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. RESULTS The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. CONCLUSIONS The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.
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Affiliation(s)
- Ketan Y Shah
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612.
| | - Albert Ren
- University of Illinois College of Medicine, Chicago, IL
| | | | | | - Adam Mikolajczyk
- Department of Medicine, University of Illinois Health, Chicago, IL
| | - James T Bui
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Matthew M Niemeyer
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Charles E Ray
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
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5
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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6
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Yokoyama K, Yamauchi R, Shibata K, Fukuda H, Kunimoto H, Takata K, Tanaka T, Inomata S, Morihara D, Takeyama Y, Shakado S, Sakisaka S. Endoscopic treatment or balloon-occluded retrograde transvenous obliteration is safe for patients with esophageal/gastric varices in Child-Pugh class C end-stage liver cirrhosis. Clin Mol Hepatol 2018; 25:183-189. [PMID: 30408943 PMCID: PMC6589850 DOI: 10.3350/cmh.2018.0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/11/2018] [Indexed: 01/20/2023] Open
Abstract
Background/Aims There is a controversy about the availability of invasive treatment for esophageal/gastric varices in patients with Child-Pugh class C (CP-C) end-stage liver cirrhosis (LC). We have evaluated the validity of invasive treatment with CP-C end-stage LC patients. Methods The study enrolled 51 patients with CP-C end-stage LC who had undergone invasive treatment. The treatment modalities included endoscopic variceal ligation in 22 patients, endoscopic injection sclerotherapy in 17 patients, and balloon-occluded retrograde transvenous obliteration (BRTO) in 12 patients. We have investigated the overall survival (OS) rates and risk factors that contributed to death within one year after treatment. Results The OS rate in all patients at one, three, and five years was 72.6%, 30.2%, and 15.1%, respectively. The OS rate in patients who received endoscopic treatment and the BRTO group at one, three, and five years was 67.6%, 28.2% and 14.1% and 90.0%, 36.0% and 18.0%, respectively. The average of Child-Pugh scores (CPS) from before treatment to one month after variceal treatment significantly improved from 10.53 to 10.02 (P=0.003). Three significant factors that contributed to death within one year after treatment included the presence of bleeding varices, high CPS (≥11), and high serum total bilirubin levels (≥4.0 mg/dL). Conclusions The study demonstrated that patients with a CPS of up to 10 and less than 4.0 mg/dL of serum total bilirubin levels may not have a negative impact on prognosis after invasive treatment for esophageal/gastric varices despite their CP-C end-stage LC.
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Affiliation(s)
- Keiji Yokoyama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Ryo Yamauchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kumiko Shibata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hiromi Fukuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hideo Kunimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kazuhide Takata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Takashi Tanaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Shinjiro Inomata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Daisuke Morihara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Yasuaki Takeyama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Satoshi Shakado
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Shotaro Sakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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7
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Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
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Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
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8
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Gastric Varices Bleed at Lower Portosystemic Pressure Gradients than Esophageal Varices. J Vasc Interv Radiol 2018; 29:636-641. [DOI: 10.1016/j.jvir.2017.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/12/2017] [Accepted: 10/12/2017] [Indexed: 02/07/2023] Open
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9
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Kim SK, Lee KA, Sauk S, Korenblat K. Comparison of Transjugular Intrahepatic Portosystemic Shunt with Covered Stent and Balloon-Occluded Retrograde Transvenous Obliteration in Managing Isolated Gastric Varices. Korean J Radiol 2017; 18:345-354. [PMID: 28246514 PMCID: PMC5313522 DOI: 10.3348/kjr.2017.18.2.345] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/27/2016] [Indexed: 12/11/2022] Open
Abstract
Objective Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience. Materials and Methods We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups. Results There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months. Conclusion BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy.
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Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA.; Department of Radiology, Kyung Hee University College of Medicine, Seoul 02447, Korea
| | - Kristen A Lee
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Kevin Korenblat
- Division of Gastroenterology, Department of Internal Medicine, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
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10
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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations. Dig Dis Sci 2017; 62:305-318. [PMID: 28058594 DOI: 10.1007/s10620-016-4399-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/29/2016] [Indexed: 12/16/2022]
Abstract
We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.
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11
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Kim SK, Sauk S, Guevara CJ. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Carlos J. Guevara
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
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12
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Jiang Q, Wang MQ, Zhang GB, Wu Q, Xu JM, Kong DR. Transjugular intrahepatic portosystemic shunt combined with esophagogastric variceal embolization in the treatment of a large gastrorenal shunt. World J Hepatol 2016; 8:850-857. [PMID: 27458505 PMCID: PMC4945505 DOI: 10.4254/wjh.v8.i20.850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 04/26/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with stomach and esophageal variceal embolization (SEVE) in cirrhotic patients with a large gastrorenal vessel shunt (GRVS).
METHODS: Eighty-one cirrhotic patients with gastric variceal bleeding (GVB) associated with a GRVS were enrolled in the study and accepted TIPS combined with SEVE (TIPS + SEVE), by which portosystemic pressure gradient (PPG), biochemical, TIPS-related complications, shunt dysfunction, rebleeding, and death were evaluated.
RESULTS: The PPGs before TIPS were greater than 12 mmHg in 81 patients. TIPS + SEVE treatment caused a significant decrease in PPG (from 37.97 ± 6.36 mmHg to 28.15 ± 6.52 mmHg, t = 19.22, P < 0.001). The percentage of reduction in PPG was greater than 20% from baseline. There were no significant differences in albumin, alanine aminotransferase, aspartate aminotransferase, bilirubin, prothrombin time, or Child-Pugh score before and after operation. In all patients, rebleeding rates were 3%, 6%, 12%, 18%, and 18% at 1, 3, 6, 12, and 18 mo, respectively. Five patients (6.2%) were diagnosed as having hepatic encephalopathy. The rates of shunt dysfunction were 0%, 4%, 9%, 26%, and 26%, at 1, 3, 6, 12, and 18 mo, respectively. The cumulative survival rates in 1, 3, 6, 12, and 18 mo were 100%, 100%, 95%, 90%, and 90%, respectively.
CONCLUSION: Our preliminary results indicated that the efficacy and safety of TIPS + SEVE were satisfactory in cirrhotic patients with GVB associated with a GRVS (GVB + GRVS).
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13
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Lakhoo J, Bui JT, Lokken RP, Ray CE, Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study. J Vasc Interv Radiol 2016; 27:1001-11. [PMID: 27106732 DOI: 10.1016/j.jvir.2016.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/09/2016] [Accepted: 02/13/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). MATERIALS AND METHODS In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. RESULTS GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1-1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). CONCLUSIONS In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.
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Affiliation(s)
- Janesh Lakhoo
- University of Illinois College of Medicine, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - James T Bui
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - R Peter Lokken
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Charles E Ray
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612.
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Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014; 203:668-73. [PMID: 25148174 DOI: 10.2214/ajr.13.12211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Stomal varices can cause life-threatening gastrointestinal hemorrhage in patients with portal hypertension. Optimal therapy is not well defined. The purpose of this study was to determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of hemorrhagic stomal varices. MATERIALS AND METHODS All patients who underwent TIPS creation for hemorrhagic stomal varices refractory to medical or endoscopic therapy over a 20-year period (1992-2012) were included. Ten patients (mean age, 63 ± 12 years) were identified. Retrospective chart review was used to document demographic characteristics, procedure details, technical and clinical success, complications, recurrent hemorrhage, and need for repeat interventions. Patients underwent follow-up for an average of 2 years (range, 22 days-9.6 years). RESULTS All patients had cirrhosis and portal hypertension. Average corrected sinusoidal pressures were 11 ± 2.4 mm Hg (range, 6-15 mm Hg) before TIPS placement and 4.3 ± 1.8 mm Hg (range, 2-8 mm Hg) after TIPS placement. Five patients (50%) underwent adjunctive embolization of stomal varices through the TIPS, which did not affect outcome. Complications included one patient each with a contrast allergy and renal failure. Six patients experienced complete resolution of bleeding without further intervention (60%). Four patients had recurrent stomal hemorrhage. Two of the four needed TIPS revision for occlusion; one underwent oversewing of the ostomy; and in one the hemorrhage resolved with conservative measures after confirmation of TIPS patency. CONCLUSION TIPS creation, with or without adjunctive variceal embolization, is a safe and effective treatment of refractory hemorrhagic stomal varices. Reintervention for recurrent bleeding may be required and appears effective.
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15
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Furuichi Y, Moriyasu F, Sugimoto K, Taira J, Sano T, Miyata Y, Sofuni A, Itoi T, Nakamura I, Imai Y. Obliteration of gastric varices improves the arrival time of ultrasound contrast agents in hepatic artery and vein. J Gastroenterol Hepatol 2013; 28:1526-31. [PMID: 23611144 DOI: 10.1111/jgh.12234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM Liver cirrhosis (LC) is accompanied by hepatic arterializations, intrahepatic shunts, and hyperdynamic circulations. These changes shorten the arrival time (AT) of ultrasound contrast agents to the hepatic vein (HV). Whether treatment of gastric fundal varices (GVs) by balloon-occluded transvenous obliteration (B-RTO) improves the AT in LC patients was prospectively investigated. METHODS A total of 32 LC patients with GVs and 10 normal controls (NCs) were enrolled. This study was approved by the clinical research ethics committee. Images of hepatic artery (HA), portal vein (PV), and HV were monitored after an injection of a contrast agent using quantification software. The AT before and after B-RTO in LC patients and that in NCs were compared. RESULTS All GVs were treated effectively, and indocyanine green retention rate was improved (P < 0.0001). The mean values of the HA, PV, and HV ATs in the NCs were 21.9 ± 3.3, 28.2 ± 2.0, and 40.5 ± 2.1 s, respectively. Those in LC patients were 17.4 ± 4.4, 21.9 ± 5.6, and 26.3 ± 6.7, respectively, which were shorter than those in NCs (P < 0.01, P < 0.002, P < 0.0001, respectively). However, these ATs were significantly prolonged 1 week after B-RTO, with mean values of 18.7 ± 4.8, 23.8 ± 6.0, and 30.0 ± 7.2 s (P = 0.043, P < 0.01, P < 0.001). CONCLUSION Obliteration of GVs shifted the AT in LC patients to the normalization, raising the possibility of improvement of arterialization and intrahepatic shunt.
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Affiliation(s)
- Yoshihiro Furuichi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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16
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Park EJ, Jang JY, Lee JE, Jeong SW, Lee SH, Kim SG, Cha SW, Kim YS, Cho YD, Cho JY, Kim HS, Kim BS, Kim YJ. The risk factors for bleeding of fundal varices in patients with liver cirrhosis. Gut Liver 2013; 7:704-11. [PMID: 24312712 PMCID: PMC3848544 DOI: 10.5009/gnl.2013.7.6.704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 01/26/2013] [Accepted: 03/21/2013] [Indexed: 12/15/2022] Open
Abstract
Background/Aims The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices. Methods In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied. Results There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1±7.7 mm Hg vs 19.7±5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3±5.8 mm Hg vs 17.0±8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016). Conclusions Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.
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Affiliation(s)
- Eui Ju Park
- Institution for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Seoul, Korea
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Chandrasekar TS, Menachery J, Gokul BJ, Murugesh M, Vivek Sandeep TC. Novel predictors for immediate puncture site bleed during endoscopic glue injection for gastric varices without using lipiodol. Indian J Gastroenterol 2013; 32:200-3. [PMID: 23408259 DOI: 10.1007/s12664-012-0301-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/27/2012] [Indexed: 02/04/2023]
Abstract
Endoscopic obturation of gastric varices using tissue adhesive glues like cyanoacrylate is an accepted modality for the treatment of gastric varices. This study was undertaken to determine whether it was possible to predict immediate puncture site bleed on withdrawal of needle catheter during endoscopic glue injection without lipiodol. We prospectively analyzed 100 consecutive patients with cirrhosis who underwent glue injection. Glue injection was successful in all the patients. Immediate puncture site bleed was observed in only four cases and all of them correlated with negative catheter pull sign and positive red catheter sign. Catheter pull sign and red catheter sign were excellent predictors of immediate puncture site bleed during endoscopic glue injection and should be routinely tested.
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Affiliation(s)
- T S Chandrasekar
- Medindia Institute of Medical Specialities, 83, Valluvarkottam High Road, Nungambakkam, Chennai- 34, India.
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Saad WEA, Darcy MD. Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2012; 28:339-49. [PMID: 22942552 DOI: 10.1055/s-0031-1284461] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.
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Lim YS. Practical approach to endoscopic management for bleeding gastric varices. Korean J Radiol 2012; 13 Suppl 1:S40-4. [PMID: 22563286 PMCID: PMC3341459 DOI: 10.3348/kjr.2012.13.s1.s40] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 12/02/2011] [Indexed: 02/07/2023] Open
Abstract
Bleeding from gastric varices is generally more severe than bleeding from esophageal varices, although it occurs less frequently. Recently, new endoscopic treatment options and interventional radiological procedures have broadened the therapeutic armamentarium for gastric varices. This review provides an overview of the classification and pathophysiology of gastric varices, an introduction to current endoscopic and interventional radiological management options for gastric varices, and details of a practical approach to endoscopic variceal obturation using N-butyl-2-cyanoacrylate.
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Affiliation(s)
- Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
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20
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Abstract
Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital.
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21
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Gastrointestinal bleeding: Endoscopic cyanoacrylate therapy for gastric variceal bleeding. Nat Rev Gastroenterol Hepatol 2010; 7:190-1. [PMID: 20376092 DOI: 10.1038/nrgastro.2010.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bleeding from gastric varices is relatively common and can be life threatening. The optimal treatment strategy for gastric variceal hemorrhage is controversial. Both interventional radiology and endoscopic therapies require a high level of clinical expertise. Which type of therapy is best? A recent study compared endoscopic cyanoacrylate glue injection with the insertion of a transjuglar intrahepatic portosystemic shunt.
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22
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Tripathi D. Therapies for bleeding gastric varices: is the fog starting to clear? Gastrointest Endosc 2009; 70:888-91. [PMID: 19879402 DOI: 10.1016/j.gie.2009.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 06/06/2009] [Indexed: 02/08/2023]
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23
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A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL. Gastrointest Endosc 2009; 70:668-75. [PMID: 19559427 DOI: 10.1016/j.gie.2009.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 02/01/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic injection of N-butyl-2-cyanoacrylate is the preferred method to treat acute gastric variceal bleeding (GVB). However, its rebleeding rate remains high. OBJECTIVE To compare an injection containing 0.5 mL of cyanoacrylate (group A) with an injection containing 1.0 mL of cyanoacrylate (group B). DESIGN A single-center, randomized, controlled trial. SETTING A tertiary referral center. MAIN OUTCOME MEASUREMENT Occurrence of rebleeding. PATIENTS Patients with acute gastric variceal bleeding. RESULTS Forty-four patients in group A and 47 patients in group B were studied; their clinical characteristics were similar. The treatment stopped active bleeding in approximately 90% of cases in both groups. The rebleeding rate was 29.8% (14/47) in group B compared with 38.6% (17/44) in group A (P = .504; 95% CI, -10.592 to 28.280). On multivariate analysis, concomitant hepatocellular carcinoma, infection, and the size of the gastric varices were independent determinants of rebleeding. More patients in group B than in group A had postinjection fever (>37.5 degrees C) (23/47 vs 12/44, P = .059). Treatment failure, complications, 30-day mortality, and survival did not differ between the 2 groups. CONCLUSIONS Due to the small number of study patients, a double dose of cyanoacrylate injection for GVB cannot be proven to have better hemostatic efficacy than a single dose. Multicenter studies with larger patient numbers are necessary to determine whether a double dose is in fact more efficacious.
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24
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Long-term effect of endoscopic injection therapy with combined cyanoacrylate and ethanol for gastric fundal varices in relation to portal hemodynamics. ACTA ACUST UNITED AC 2009; 35:8-14. [DOI: 10.1007/s00261-008-9497-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 12/09/2008] [Indexed: 12/15/2022]
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25
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Endoscopic therapy for bleeding gastric varices: to clot or glue? Gastrointest Endosc 2008; 68:883-6. [PMID: 18984100 DOI: 10.1016/j.gie.2008.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Accepted: 04/28/2008] [Indexed: 02/06/2023]
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26
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Abstract
Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.
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Affiliation(s)
- Priya Grewal
- The Division of Liver Diseases, Recanati-Miller Transplantation Institute, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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Tripathi D, Jalan R. Transjugular intrahepatic portosystemic stent-shunt in the management of gastric and ectopic varices. Eur J Gastroenterol Hepatol 2006; 18:1155-60. [PMID: 17033434 DOI: 10.1097/01.meg.0000236875.52730.b8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Uncertainty exists about the ideal therapy for gastric and ectopic varices owing to relatively few controlled studies. Endoscopic therapy with tissue adhesives and thrombin appear promising. Transjugular intrahepatic portosystemic stent-shunt has a role in patients with refractory gastric variceal bleeding in the presence of a patent portal vein. The addition of coil embolization may be particularly useful for ectopic varices, as these can continue to bleed despite successful portal pressure reduction. The high efficacy of transjugular intrahepatic portosystemic stent-shunt has to be balanced against the potential for increased encephalopathy. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastro-renal shunts and large gastric varices. Early results are promising, and balloon occluded retrograde transvenous obliteration may be valuable in patients who bleed at lower portal pressures, in the encephalopathic patient, or where the portal vein is not patent. Its use may be limited by availability or lack of technical expertise, and caution is required in patients with large oesophageal varices.
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Affiliation(s)
- Dhiraj Tripathi
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK.
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28
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Tripathi D, Ferguson JW, Therapondos G, Plevris JN, Hayes PC. Review article: recent advances in the management of bleeding gastric varices. Aliment Pharmacol Ther 2006; 24:1-17. [PMID: 16803599 DOI: 10.1111/j.1365-2036.2006.02965.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension.
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Affiliation(s)
- D Tripathi
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK.
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29
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Oberti F. Comment prévenir et traiter les hémorragies par varices gastriques, ou ectopiques ou par gastropathie congestive. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B53-72. [PMID: 15150498 DOI: 10.1016/s0399-8320(04)95241-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Frédéric Oberti
- Service d'Hépato-Gastroentérologie, Centre Hospitalo-Universitaire Angers, 49100 Angers
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30
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Affiliation(s)
- A Albillos Martínez
- Servicio de Gastroenterología, Hospital Ramón y Cajal, Departamento de Medicina, Universidad de Alcalá, Madrid
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31
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Siringo S, Piscaglia F, Zironi G, Sofia S, Gaiani S, Zammataro M, Bolondi L. Influence of esophageal varices and spontaneous portal-systemic shunts on postprandial splanchnic hemodynamics. Am J Gastroenterol 2001; 96:550-6. [PMID: 11232705 DOI: 10.1111/j.1572-0241.2001.03558.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of the study was to assess postprandial splanchnic hemodynamic changes in cirrhosis in relation to variceal status. METHODS In 9 healthy controls and 56 patients with liver cirrhosis, stratified according to variceal status and presence of spontaneous portal-systemic shunts, the portal vein diameter and flow velocity, the congestion index of the portal vein, and the resistive index of the superior mesenteric artery (SMA-RI) were studied by Doppler ultrasound before and 30, 60, and 120 min after the intake of a standard meal. Comparison of postprandial parameters with basal ones was done within each group by paired t test and among groups by ANOVA and Duncan test. RESULTS Healthy controls and cirrhotic patients without varices showed similar significant splanchnic hemodynamic changes, namely a reduction of SMA-RI (-13% at 30 min) and a consequent increase in portal vein diameter (respectively, +32% and +17% in the two groups) and velocity (+66% and +51%). A significant reduction of SMA-RI was also found in patients with varices, irrespective of the variceal size (range, -7 to -11%), but the expected portal vein dilation and velocity increase were progressively blunted with the increase of variceal size (range, 0-5% for diameter and 5-19% for velocity). Patients with spontaneous portal-systemic shunts showed a response similar to that of patients with large varices. Significant modification of the congestion index of the portal vein did not occur in any group. CONCLUSIONS Our results show that the hemodynamic response to meal in patients with liver cirrhosis is influenced by the presence and size of esophageal varices and the presence of spontaneous portal-systemic shunts.
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Affiliation(s)
- S Siringo
- Dipartimento di Medicina Interna e Gastroenterologia, Universitá di Bologna, Italy
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32
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Les aspects endoscopiques de l’hypertension portale: diagnostic et classification. ACTA ACUST UNITED AC 2000. [DOI: 10.1007/bf03026171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Battaglia G, Morbin T, Patarnello E, Carta A, Coppa F, Ancona A. Diagnostic et traitement endoscopique des varices gastriques. ACTA ACUST UNITED AC 1999. [DOI: 10.1007/bf03020277] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Torres E, Barros P, Calmet F. Correlation between serum-ascites albumin concentration gradient and endoscopic parameters of portal hypertension. Am J Gastroenterol 1998; 93:2172-8. [PMID: 9820392 DOI: 10.1111/j.1572-0241.1998.00615.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We sought to determine the correlation between the level of serum-ascites albumin concentration gradient (SAAG) and the complications of portal hypertension (PHTN), manifested by the presence and grade of esophageal varices (EV). METHODS Our study included 31 patients with ascites, demonstrated by ultrasonography, who had measurement of the SAAG. All had upper gastrointestinal endoscopy with assessment of the presence and size of EV. High SAAG was considered to be present when the SAAG was > or = 1.1 g/dl and Low SAAG when it measured < 1.1 g/dl. RESULTS We found that 25 of 31 (80.6%) patients had High SAAG and six of 31 (19.4%) had Low SAAG. Esophageal varices were present in 17 of 25 (68%) patients with High SAAG and in none of six (0%) patients with Low SAAG (p = 0.028). In patients with alcoholic liver disease (ALD), 14 of 14 (100%) had EV. Otherwise, in patients with nonALD, only three of 11 (27.3%) had EV (p < 0.05). The presence of EV was associated with the Child-Pugh Score (p = 0.039). Among patients with High SAAG, EV were present in four of 10 (40%) with SAAG values of 1.10-1.49 g/dl; in four of 6 (66.7%) with SAAG values of 1.50-1.99 g/dl; and in nine of nine (100%) with SAAG values of > or =2.0 g/dl (p = 0.049). The size of the EV had no association with the level of SAAG in patients with High SAAG (p = 0.788), with a Pearson correlation coefficient of R = 0.54 (p = 0.005). Using the Receiver-Operating-Characteristic Curve a SAAG value of > or =1.435 +/- 0.015 g/dl was an accurate indicator of the presence of EV (cutoff point for the higher predictive value: positive = 87.5% and negative = 66.7%). CONCLUSIONS In patients with ascites the presence of EV is associated only with patients with High SAAG. The presence of EV in patients with ascites and High SAAG is directly related to the degree of SAAG. The size of the EV in patients with ascites and High SAAG is not associated with the degree of SAAG. A SAAG value of > or =1.435 +/- 0.015 g/dl is a useful means to predict the presence of EV in patients with ascites. Finally, in patients with ascites, EV were more prevalent in those with ALD.
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Affiliation(s)
- E Torres
- Department of Internal Medicine, Universidad Peruana Cayetano Heredia, School of Medicine, Hospital Nacional Cayetano Heredia, Lima, Peru
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35
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Abstract
BACKGROUND Colonic vascular ectasias and colorectal varices have been observed in patients with cirrhosis. However, the pathogenesis of these vascular lesions has not been established. METHODS We enrolled 35 cirrhotic patients and 20 normal controls in this study. All received colonoscopic examinations and measurements of plasma glucagon levels. Portal pressure measurements were performed in all the cirrhotic patients. RESULTS Colonic vascular ectasias occurred more commonly in cirrhotic patients than in controls (17 of 35 versus 0 of 20; p = 0.009) and more commonly in cirrhotic patients with ascites than in those without (15 of 24 versus 2 of 11; p = 0.038). However, the presence of colonic vascular ectasias was not related to the hepatic venous pressure gradient or plasma glucagon levels. Colorectal varices also occurred more commonly in cirrhotic patients than in controls (16 of 35 versus of 1 of 20; p = 0.034), but the hepatic venous pressure gradient, plasma glucagon levels, and severity of cirrhosis were not related to the presence of colorectal varices. CONCLUSIONS Portal hypertension per se and increased plasma glucagon levels may not play an important role in the pathogenesis of colonic vascular ectasias or colorectal varices in patients with cirrhosis.
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Affiliation(s)
- L S Chen
- Dept. of Medicine, Veterans General Hospital, Taipei, Taiwan
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