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Poza Cordon J, Froilan Torres C, Burgos García A, Gea Rodriguez F, Suárez de Parga JM. Endoscopic management of esophageal varices. World J Gastrointest Endosc 2012; 4:312-22. [PMID: 22816012 PMCID: PMC3399010 DOI: 10.4253/wjge.v4.i7.312] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 05/10/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis
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Affiliation(s)
- Joaquin Poza Cordon
- Joaquin Poza Cordon, Consuelo Froilan Torres, Aurora Burgos García, Francisco Gea Rodriguez, Jose Manuel Suárez de Parga, Hospital Universitario la Paz, 28046 Madrid, Spain
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Suk KT, Baik SK, Yoon JH, Cheong JY, Paik YH, Lee CH, Kim YS, Lee JW, Kim DJ, Cho SW, Hwang SG, Sohn JH, Kim MY, Kim YB, Kim JG, Cho YK, Choi MS, Kim HJ, Lee HW, Kim SU, Kim JK, Choi JY, Jun DW, Tak WY, Lee BS, Jang BK, Chung WJ, Kim HS, Jang JY, Jeong SW, Kim SG, Kwon OS, Jung YK, Choe WH, Lee JS, Kim IH, Shim JJ, Cheon GJ, Bae SH, Seo YS, Choi DH, Jang SJ. Revision and update on clinical practice guideline for liver cirrhosis. THE KOREAN JOURNAL OF HEPATOLOGY 2012; 18:1-21. [PMID: 22511898 PMCID: PMC3326994 DOI: 10.3350/kjhep.2012.18.1.1] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/05/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Youn Cheong
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yong Han Paik
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jin Woo Lee
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Won Cho
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Seong Gyu Hwang
- Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Moon Young Kim
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Bae Kim
- Department of Pathology, Ajou University College of Medicine, Suwon, Korea
| | - Jae Geun Kim
- Department of Radiology, Ajou University College of Medicine, Suwon, Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Hyung Joon Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Woong Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Choi
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Won Young Tak
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Hong Soo Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Sang Kwon
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University College of Medicine, Seoul, Korea
| | - June Sung Lee
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University College of Medicine, Jeonju, Korea
| | - Jae Jun Shim
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Ulsan University College of Medicine, Gangneung, Korea
| | - Si Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Hee Choi
- Department of Internal Medicine, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Se Jin Jang
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Jung HS, Kim YS, Kwon OS, Ku YS, Kim YK, Choi DJ, Kim JH. [Usefulness of liver stiffness measurement for predicting the presence of esophageal varices in patients with liver cirrhosis]. THE KOREAN JOURNAL OF HEPATOLOGY 2008; 14:342-50. [PMID: 18815457 DOI: 10.3350/kjhep.2008.14.3.342] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIMS Bleeding from esophageal varices (EV) is a major cause of death in patients with liver cirrhosis. Endoscopic screening is recommended for diagnosing EV, but various noninvasive parameters can also be used to predict EV. The liver stiffness measurement (LSM), a noninvasive technique for estimating liver fibrosis, was recently reported to be strongly correlated with the hepatic venous pressure gradient. This study evaluated the usefulness of LSM for predicting the presence and size of EV in patients with cirrhosis. METHODS The relationships of LSM with the presence and size of EV were analyzed in 112 patients with liver cirrhosis. Liver cirrhosis was diagnosed histologically or clinically. The presence and size of EV were assessed by endoscopy, and LSM was determined by the Fibroscan technique. RESULTS LSM was strongly correlated with the presence of EV (P<0.0001): the LSM value was 42.7+/-21.9 kPa (mean+/-standard deviation) in patients with EV (n=82) and 19.1+/-12.6 kPa in patients without EV (n=30). The area under the receiver operating characteristic curve was 0.818 (95% CI, 0.732-0.904) for predicting the presence of EV, and an LSM value of 19.7 kPa was predictive of the presence of EV with a sensitivity of 87%, a specificity of 70%, a PPV of 89%, and a NPV of 66%. However, there was a weak correlation between LSM and the size of EV. CONCLUSIONS LSM is useful for predicting the presence of EV in patients with cirrhosis but not their size.
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Affiliation(s)
- Hyuk Sang Jung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Sanyal AJ, Fontana RJ, Di Bisceglie AM, Everhart JE, Doherty MC, Everson GT, Donovan JA, Malet PF, Mehta S, Sheikh MY, Reid AE, Ghany MG, Gretch DR. The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis. Gastrointest Endosc 2006; 64:855-64. [PMID: 17140886 DOI: 10.1016/j.gie.2006.03.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Accepted: 03/13/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND The factors predictive of the presence or the absence of esophageal varices in hepatitis C virus (HCV) and advanced fibrosis have not been defined. OBJECTIVES To define the prevalence of esophageal varices and the factors that are positively and negatively with such varices in hepatitis C and advanced fibrosis. DESIGN A prospective study of esophageal varices and associated risk factors in subjects with hepatitis C and advanced fibrosis. SETTING Prerandomization data from the HALT-C (hepatitis C long-term antiviral treatment against cirrhosis) clinical trial. PATIENTS AND INTERVENTION Subjects with bridging fibrosis or cirrhosis, who were virologic nonresponders to treatment with pegylated interferon alpha 2a and ribavirin, underwent endoscopy. RESULTS Sixteen percent of subjects with bridging fibrosis (95/598) and 39% of subjects with cirrhosis (164/418) had varices (P < .0001); 2% of subjects with bridging fibrosis (13/598) and 11% of those with cirrhosis (48/418) had medium or large varices. Subjects with bridging fibrosis and varices had a significantly lower platelet count and higher bilirubin and international normalized ratio (INR) compared with those without varices, suggesting that the biopsy may have underestimated the severity of fibrosis. A platelet count >150,000/mm(3) was associated with a negative predictive value of 99% for esophageal varices. By logistic regression modeling, African American race and female sex were protective, whereas a lower platelet count and higher bilirubin and INR predicted varices (c statistic, 0.758). CONCLUSIONS The risk of having varices increases with decreasing platelet counts, increasing bilirubin, and INR. The probability of having medium or large varices at platelet counts >150,000/mm(3) is negligible in this population.
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Affiliation(s)
- Arun J Sanyal
- Division of Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Abstract
Prevention of the first variceal haemorrhage should start when the patients have developed medium-sized to large varices. Non-selective beta-blockers and band ligation are equally effective in preventing the first bleeding episode. Rubber band ligation is the first choice for patients with contraindications or intolerance to beta-blockers. Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections. Combined endoscopic (band ligation or sclerotherapy) and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients. Antibiotic prophylaxis is an integral part of the treatment of acute variceal haemorrhage, and must be started as soon as possible. Emergency transjugular intrahepatic portosystemic stent shunt (TIPS) is the standard rescue therapy for patients failing combined endoscopic and pharmacological treatment. All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding. All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgical shunts. Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail.
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Affiliation(s)
- R de Franchis
- Gastroenterology and Gastrointestinal Endoscopy Service, Department of Internal Medicine, University of Milan, 20122 Milan, Italy.
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