N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy

Endoscopic ultrasonography-guided coil embolization and cyanoacrylate injection versus cyanoacrylate injection alone for gastric varices: a randomized comparative study

BACKGROUND

Bleeding from gastric varices is life-threatening, with significant rebleeding risk despite standard cyanoacrylate glue injection therapy. Our aim was to evaluate the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization with cyanoacrylate injection (Coil+CYA) compared with EUS-guided cyanoacrylate injection alone (CYA) for the treatment of gastric varices.

METHODS

The study was conducted at a tertiary referral center in India, using a single-blinded, prospective, and parallel-group randomized design. A total of 50 patients were randomly assigned (1 : 1) to Coil+CYA or CYA. The primary outcome was clinical success (i.e. variceal obliteration). Secondary outcomes involved technical success, gastric variceal recurrence during follow-up, rebleeding episodes, reintervention, and survival.

RESULTS

Post-intervention, gastric variceal obliteration assessed by EUS was higher in the Coil+CYA group (100% vs. 92.3%; P = 0.49), with both groups achieving 100% technical success. Rebleeding episodes during 0-12 and 12-24 weeks were comparable in the two groups. At 12 weeks, on EUS, variceal reappearance was less common in the Coil+CYA group (12.5% vs. 19.2%; P = 0.70). Significantly fewer reinterventions were needed in the Coil+CYA group (20.8% vs. 53.8%; P = 0.03). The time to reintervention was significantly longer in the Coil+CYA group (P = 0.01), and the survival time was also longer (P = 0.04).

CONCLUSIONS

EUS-guided coil embolization with cyanoacrylate injection achieved superior clinical success, reducing the need for reintervention and resulting in improved survival compared with cyanoacrylate injection alone.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding

OBJECTIVES

Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function.

METHODS

From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups.

RESULTS

Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups.

CONCLUSION

EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice

Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.

Impact of COVID-19 on endoscopic follow-up of gastroesophageal varices

BACKGROUND

Portal hypertension is considered as a major complication of liver cirrhosis. Endoscopy plays a main role in managing of gastrointestinal complications of portal hypertension. Endoscopists are at increased risk for COVID-19 infection because upper gastrointestinal (GI) endoscopy is a high-risk aerosol-generating procedure and may be a potential route for COVID-19.

OBJECTIVES

To compare the outcome between cirrhotic patients who underwent classic regular endoscopic variceal ligation after primary bleeding episode every 2-4 weeks, and those presented during the era of COVID-19 and their follow-up were postponed 2 months later.

METHODS

This retrospective study included cross-matched 238 cirrhotic patients with portal hypertension presented with upper GI bleeding, 112 cirrhotic patients presented during the era of COVID19 (group A) underwent endoscopic variceal ligation, another session after 2 weeks and their subsequent follow-up was postponed 2 months later, and 126 cirrhotic patients as control (group B) underwent regular endoscopic variceal band ligation after primary bleeding episode every 2-4 weeks.

RESULTS

Eradication of varices was achieved in 32% of cases in group A, and 46% in group was not any statistically significant (p > 0.05); also, there was no any statistical significant difference between both groups regarding occurrence of rebleeding, post endoscopic symptoms, and mortality rate (p > 0.05).

CONCLUSION

Band ligation and injection of esophageal and gastric vary every 2 months were as effective and safe as doing it every 2 to 4 weeks after primary bleeding episode for further studies and validation.

Prophylactic cyanoacrylate injection for gastric extension of esophageal varices: a randomized controlled trial

Aim of the study

Gastric variceal bleeding is more severe and fatal than esophageal bleeding. Injection of cyanoacrylate into bleeding gastric varices is recommended, but prophylactic injection is debatable. Aim of this study is to evaluate prophylactic cyanoacrylate injection into gastric extension of esophageal varices type 2 (GOV2).

Material and methods

This randomized controlled trial included 75 patients (3 groups) with risky or bleeding esophageal varices and non-bleeding GOV2. Group A received a cyanoacrylate GOV2 injection, esophageal variceal band ligation (EBL), and β-blocker (BB); group B received EBL and BB; and group C received EBL. Follow-up for ≥ 24 weeks to check for bleeding or death was performed.

Results

Baseline variables were comparable among the 3 groups. During follow-up (median, 37.5 weeks), increasing gastric extension and or bleeding risk signs were significantly lower in group A (0%) than B (12%) and C (32%) (p < 0.001). Bleeding occurred more in groups B (24%) and C (24%) than in A (8%) (p = 0.2). Gastric extension size was an independent predictor of bleeding (p = 0.03). Portal hypertensive gastropathy (PHG) decreased in groups A (24%) and B (24%) more than in C (8%) (p = 0.5). Mortality rates were 0.0% in group A, 8% in B, and 4% in C (p = 0.2).

Conclusions

Prophylactic cyanoacrylate injection into GOV2 before EBL significantly decreased the varix size and risk signs for bleeding with a statistically insignificant tendency to decrease the bleeding rate. A large gastric extension was an independent predictor of bleeding. Adding β-blockers can potentially decrease PHG and bleeding risk. An independent study with a larger sample size is recommended to confirm the rate of bleeding and test the mortality difference.

Safety and efficacy of endoscopic ultrasound-guided combination therapy for treatment of gastric varices: a systematic review and meta-analysis

BACKGROUND

EUS-guided combination therapy (coil and hemostatic glue) for bleeding and non-bleeding gastric varices has recently attracted considerable attention after promising results were published in multiple small studies. We performed a meta-analysis to investigate the safety and efficacy of EUS-guided combination therapy in the treatment of GVs.

METHODS

Publications investigating the safety and efficacy of EUS-guided combination therapy in patients with gastric varices were searched in Medline, Ovid Journals, Medline non-indexed citations and Cochrane Central Register of Controlled Trials. Pooling was conducted by both fixed and random effects model.

RESULTS

In pooled analysis of 10 studies (N = 323), the technical success of EUS-guided combination therapy was 98.66% (95% CI 97.14-99.62). The pooled variceal obliteration rate after first session of treatment was 78.31% (95% CI 73.05-83.14). In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.79% (95% CI 94.28-98.60). The pooled rate of hemorrhage from treated gastric varices was 4.92% (95% CI 2.85-7.52). After EUS-guided combination therapy, the pooled percentage of patients developing abdominal pain was 9.79% (95% CI 6.82-13.24), pulmonary embolism was 2.20% (95% CI 0.89-4.06), febrile episodes was 1.17% (95% CI 0.30-2.61), and procedure-related bleeding was noted in 2.62% (95% CI 1.18-4.63) of the patients. Subgroup analysis of studies using coil embolization and cyanoacrylate injection showed pooled variceal obliteration rate of 77.92% (95% CI 72.35-83.01) after first session of treatment. In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.76% (95% CI 94.11-98.65). The pooled rate of re-bleeding from treated gastric varices was 5.09% (95% CI 2.90-7.83).

CONCLUSIONS

This meta-analysis suggests that EUS-guided combination therapy is safe and effective for patients with gastric varices and should be considered in the clinical management of these patients.

Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis

BACKGROUND AND AIM

Bleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta-analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices.

METHODS

We conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial-specific risk ratios (RRs) were estimated and pooled using random-effect model meta-analysis.

RESULTS

We included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N-butyl-2-cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all-cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36-0.98; I2 = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35-0.68, I2 = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs.

CONCLUSION

The use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all-cause mortality and better hemostasis compared with other therapies.

Two Cases of Fungemia after Endoscopic Variceal Obturation for Gastric Variceal Bleeding

Fever is a common complication of endoscopic variceal obturation (EVO) therapy for gastric variceal bleeding. However, fungemia related to EVO therapy has not yet been reported. Herein, we report two cases of post-EVO fungemia in cirrhotic patients who underwent therapeutic EVO for gastric variceal bleeding. Both patients developed sustained high fever after repeated EVO procedures while on prophylactic antibiotic use. In both patients, blood cultures revealed yeast, and they were finally diagnosed with Candida infection. Candida is a common member of the intestinal flora; however, it can cause invasive infection with consequent poor prognosis in cirrhotic patients. The route of Candida invasion is unclear; however, repeated EVO may predispose patients to Candida infection, particularly those who are in the end stage of liver disease and receiving prophylactic antibiotics. Our cases highlight that repeated invasive procedures can increase the risk of fungal infections, and fungemia should be considered in the differential diagnosis of post-EVO fever.

Biomaterials in Gastroenterology: A Critical Overview

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

Update on the management of gastrointestinal varices

Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.

SAFETY AND EFFICACY OF EUS-GUIDED COIL PLUS CYANOACRYLATE VERSUS CONVENTIONAL CYANOACRYLATE TECHNIQUE IN THE TREATMENT OF GASTRIC VARICES: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques.

OBJECTIVE

This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone.

DESIGN

A pilot randomized controlled trial.

METHODS

Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure.

RESULTS

A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed.

CONCLUSION

There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding

BACKGROUND

Endoscopic injection of cyanoacrylate into gastric varices may be performed by EUS-guided fine needle injection (EUS-FNI) or direct endoscopic injection (DEI). The aim of this study is to compare the rate of recurrent GV bleeding and adverse events between DEI and EUS-FNI for treatment of GV.

METHODS

In a single-center study, a retrospective cohort of patients with actively/recently bleeding or high-risk GV treated with DEI were compared with a prospective cohort of similar patients treated with EUS-FNI. Repeat endoscopy after index treatment was performed 3 months later or earlier if rebleeding occurred. The main outcomes assessed were rates of GV or overall rebleeding and adverse events.

RESULTS

Forty patients (mean age 57.2 ± 9.1 years, 73% male) and 64 patients (mean age 58.0 ± 12.5 years, 52% male) underwent DEI and EUS-FNI, respectively. Compared to the DEI group, the frequency of isolated gastric varices type 1 (IGV1) were higher (p < 0.001) but MELD scores were lower (p = 0.004) in the EUS-FNI group. At index endoscopy, EUS-FNI utilized a lower mean volume of cyanoacrylate (2.0 ± 0.8 mL vs. 3.3 ± 1.3 mL; p < 0.001) and injected a greater number of varices (1.6 ± 0.7 vs. 1.1 ± 0.4; p < 0.001) compared to DEI. Overall, GV rebleeding [5/57 (8.8%) vs. 9/38 (23.7%); p = 0.045] and non-GV-related gastrointestinal bleeding [7/64 (10.9%) vs. 11/40 (27.5%); p = 0.030] were less frequent in the EUS-FNI group compared to the DEI group, respectively. Adverse event rates were similar (20.3% vs. 17.5%, p = 0.723).

CONCLUSIONS

EUS-guided CYA injection of active or recently bleeding GV in patients with portal hypertension appears to decrease the rate of GV rebleeding despite injection of more varices and less CYA volume during the initial endoscopic procedure. Adverse events are similar between the two groups. EUS-FNI appears to be the preferred strategy for treatment of these patients.

Biocompatible alkyl cyanoacrylates and their derivatives as bio-adhesives

Cyanoacrylate adhesives and their homologues have elicited interest over the past few decades owing to their applications in the biomedical sector, extending from tissue adhesives to scaffolds to implants to dental material and adhesives, because of their inherent biocompatibility and ability to polymerize solely with moisture, thanks to which they adhere to any substrate containing moisture such as the skin.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

Management of different types of gastric varices with band ligation: a 3-year experience

BACKGROUND AND AIM

Gastric varices (GVs) occur with an incidence of 20% in patients with portal hypertension. The aim of this study was to evaluate the efficacy of endoscopic band ligation (BL) as an option in the management of small-to-moderate nonbleeding GVs in cirrhotic patients.

PATIENTS AND METHODS

A total of 50 patients (GOV2; n=6, IGV1; n=34, IGV2; n=10) with nonbleeding small-to-moderate-sized GVs without local risk signs of bleeding, such as large size, red-colored elevated areas or red wales, and systemic factors of bleeding risk such as an international normalized ratio of at least 2 and a platelet count of 80 000/µl or less were subjected to endoscopic BL. The patients were followed up every 2 weeks for 1 month and then every 1.5 months for 6 months. The primary outcome was GV eradication, detection of complications such as postprocedural bleeding ulceration and mortality.

RESULTS

The mean number of BL sessions was 2.2±0.8; post-BL ulceration occurred in two (4%) patients (n=2 in IGV1, P=0.61), bleeding occurred in one (2%) patient (n=1 in IGV1, P=0.79), and epigastric pain occurred in six (12%, n=4 in GOV2, n=2 in IGV1) patients. There was no mortality reported among patients treated with BL.

CONCLUSION

Endoscopic BL resulted in better outcome and a lower incidence of complications when used to treat small-to-medium-sized nonbleeding GVs. Further, early eradication can save effort and cost, thus avoiding the future risk of treatment of large or risky GVs with sclerotherapy.

Gastric Varices in Cirrhosis vs. Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-butyl-2-cyanoacrylate Injection

BACKGROUND

Gastric varices (GV) are found in patients with portal hypertension. Incidence of bleeding from GV is relatively low, but is severe, and associated with higher mortality.

AIMS AND OBJECTIVES

To compare the types of GV in cirrhosis vs. extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection.

METHODS

Four hundred and fifty-four patients undergone glue injection of GV for primary prophylaxis or control of bleeding for first episode of bleeding from GV between August 2010 and August 2015 were analyzed.

RESULTS

Of 454 patients, 64% (n = 292) were cirrhotics and 36% (n = 162) had EHPVO. Types of GV were GOV1 in 16.4% (n = 48) of cirrhotics vs. 7.4% (n = 12) of EHPVO, GOV2 in 76.7% (n = 224) of cirrhotics vs. 53.1% (n = 86) of EHPVO, Isolated gastric Varices (IGV1) in 39.5% (n = 64) of patients with EHPVO vs. 6.8% (n = 20) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 2.89 ± 1.59 ml over a median of 1 session (range: 1-7). The total volume of glue required was lower in cirrhotics (2.44 ± 1.17 ml vs. 3.69 ± 1.91 ml, P < 0.05) than in EHPVO patients. One hundred and seventeen (40.1%) of cirrhotics required >1 sessions of glue injection as compared to 102 (63%) of EHPVO patients. Over mean follow up of 14.7 ± 6.46 months, rebleeding (10% vs. 13%) was similar in patients with cirrhosis and EHPVO and mortality (15.4% vs. 2.5%) was higher in cirrhotics than EHPVO.

CONCLUSION

In patients with bleeding from GV, GOV2 are more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for GV obturation.

Management of rectal varices in portal hypertension

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.

U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.

Echo-endoscopic analysis of variceal hemodynamics in patient with isolated gastric varices

Background:

It is considered that gastric varices (GVs) which have the large form in endoscopic view should be treated because they are regarded as having high blood flow volume and the risky varices of hemorrhage. However, there is no data of the correlation among the endoscopic view, diameter of GV, and blood flow volume in GV. The aim of this study was to investigate whether GV diameter correlates to blood flow volume or not. In addition, the correlation between the endoscopic findings of GVs, patient status, and blood flow volume was assessed.

Materials and Methods:

In this study, 24 patients were enrolled. Variceal form and its location were observed using flexible GI endoscopes. Assessment of variceal form and location was according to Japanese society of portal hypertension. Then, the GV diameter (the maximum short axis), the GV flow velocity, and the GV flow volume were measured by echo-endoscope with curved linear array or with electronic radial array.

Results:

Nineteen of 24 enrolled patients were analyzed. There was strong correlation between the GV diameter and the GV flow volume (rs = 0.85, P < 0.01). No significant difference in the GV diameter and the GV flow volume was found between each location. However, there was no significant difference in the GV diameter between each variceal form. In addition, no significant difference was found among Child–Pugh classifications, and in cases associated with or without hepatocelluer carcinoma.

Conclusions:

Strong correlation was found between GV diameter and flow volume of GV, regardless of the location. However, since there was no significant difference in the GV diameter between each variceal form in endoscopic view, measuring GV diameter is important to understand its hemodynamics for further treatment.

Endoscopic Diagnosis and Therapy in Gastroesophageal Variceal Bleeding

Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It requires attention to technique and the appropriate choice of therapy for a given patient at a given point in time. Subjects must be monitored continuously after initiation of therapy for control of bleeding, and second-line definitive therapies must be introduced quickly if endoscopic and pharmacologic treatment fails.

N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices

AIM: To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices.

METHODS: Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I (n-butyl-2-cyanoacrylate; Histoacryl^®), Group II (iso-amyl-2-cyanoacrylate; Amcrylate^®) and Group III (mixture of 72% chromated glycerin; Scleremo^® with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo.

RESULTS: 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference, (P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference, (P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments.

CONCLUSION: All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.

Proton pump inhibitor administration delays rebleeding after endoscopic gastric variceal obturation

AIM: To clarify the efficacy of proton pump inhibitors (PPIs) after endoscopic variceal obturation (EVO) with N-butyl-2-cyanoacrylate.

METHODS: A retrospective study was performed on 16 liver cirrhosis patients with gastric variceal bleeding that received EVO with injections of N-butyl-2-cyanoacrylate at a single center (Kyung Hee University Hospital at Gangdong) from January 2008 to December 2012. Medical records including patient characteristics and endoscopic findings were reviewed. Treatment results, liver function, serum biochemistry and cirrhosis etiology were compared between patients receiving PPIs and those that did not. Furthermore, the rebleeding interval was compared between patients that received PPI treatment after EVO and those who did not.

RESULTS: The patient group included nine males and seven females with a mean age of 61.8 ± 11.7 years. Following the EVO procedure, eight of the 12 patients that received PPIs and three of the four non-PPI patients experienced rebleeding. There were no differences between the groups in serum biochemistry or patient characteristics. The rebleeding rate was not significantly different between the groups, however, patients receiving PPIs had a significantly longer rebleeding interval compared to non-PPI patients (22.2 ± 11.2 mo vs 8.5 ± 5.5 mo; P = 0.008). The duration of PPI use was not related to the rebleeding interval. A total of six patients, who had ulcers at the injection site, exhibited a shorter rebleeding interval (16.8 ± 5.9 mo) than patients without ulcers (19.9 ± 3.2 mo), though this difference was not statistically significant.

CONCLUSION: PPI therapy can extend the rebleeding interval, and should therefore be considered after EVO treatment for gastric varices.

Endoscopic management of gastric variceal bleeding

Expert knowledge of endoscopic management of gastric varices is essential, as these occur in 20% of patients with portal hypertension. Bleeding is relatively uncommon, but carries significant mortality when this occurs. Inability to directly target intravascular injections and the potential complication related to glue embolization has resulted in the development of novel techniques. Direct visualization of the varix lumen using endoscopic ultrasound (EUS) allows targeted therapy of feeder vessels with real-time imaging. EUS-guided combination therapy with endovascular coiling and cyanoacrylate injections promise to provide reduced complication rates, increased obliteration of varices, and reduced long-term rebleeding rates.

Balloon-occluded retrograde transvenous obliteration versus endoscopic injection sclerotherapy for isolated gastric varices: a comparative study

Isolated gastric varices (IGV) have a lower risk of bleeding than esophageal varices, however IGV bleeding is associated with a higher mortality than bleeding of esophageal varices. In recent years, two widely used treatments for IGV have been balloon-occluded retrograde transvenous obliteration (B-RTO) and endoscopic injection sclerotherapy (EIS) using cyanoacrylate or ethanolamine oleate (EO). This study compared these two treatment methods for IGV. The subjects were 112 patients who were treated at our hospital for IGV bleeding between October 1990 and December 2003. Forty-nine (49) patients were treated with B-RTO and 63 patients with EIS. These two patient groups were compared as regards content of treatment, post-treatment incidence of variceal bleeding, incidence of IGV rebleeding, survival rate, cause of death, and complications. Multivariate analysis was performed on post-treatment variceal bleeding and survival. Although EO was used in higher amounts in the B-RTO group than in the EIS group, the B-RTO group had a significantly lower number of treatment sessions and a significantly shorter treatment period (p<0.05). The EIS group had significantly more patients with IGV rebleeding after treatment than the B-RTO group. Treatment method was the only independent prognostic factor of IGV bleeding after treatment (p=0.024). The two groups did not differ significantly in the percentage of patients with aggravated esophageal varices after treatment. Bleeding from ectopic varices was not observed in any patient. There was no significant difference in survival by treatment method. The presence of hepatocellular carcinoma was the only independent prognostic factor for survival (p=0.003). It is concluded that B-RTO was more effective than EIS in the eradication of IGV and prevention of IGV recurrence and rebleeding.

A miniature ultrasound probe is useful in reducing rebleeding after endoscopic cyanoacrylate injection for hemorrhagic gastric varices

OBJECTIVE

To better assess the usefulness of miniature ultrasound probe (MUP) sonography in the evaluation of the adequacy of gastric variceal injection with cyanoacrylate to decrease the risk of post injection rebleeding.

MATERIAL AND METHODS

Sixty-nine patients with bleeding gastric varices were included in this study. Endoscopic cyanoacrylate injection was performed in the acute phase for variceal hemostasis. After injection, patients (n = 34) included in the MUP group prospectively received endoscopic ultrasonography (EUS) with MUP during each scheduled endoscopic follow-up session. Patients (n = 35) in the control group who were included historically were followed up with the same interval with endoscopy only.

RESULTS

Four (11.4%) patients in the control group received reinjection, and there were 10 episodes of rebleeding in 7 (20.0%) patients. Nine (26.5%) patients received reinjection due to inadequate obturation as judged by EUS. There were six episodes of rebleeding in three (8.8%) patients in the MUP group. The free-of-rebleeding rate for the MUP group was significantly higher than that for the control group (p < 0.05). The cumulative survival for the MUP group was slightly better than that for the control group but was not statistically significant. The patients' compliance in both groups was similar. The endosonographers considered the performance of MUP sonography to be convenient.

CONCLUSIONS

MUP sonography is useful for the evaluation of the adequacy of tissue adhesive obturation of gastric varices that may reduce the probability of rebleeding.

Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience

BACKGROUND

Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding.

PATIENTS AND METHODS

Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol(TM). Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A-12.1 %; B-53.8 %; C-34.1 % and median MELD score at admission was 13 (3-26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5-126).

RESULTS

A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p < 0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p < 0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure.

CONCLUSION

N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death.

Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

BACKGROUND

Gastric varices are found in patients with portal hypertension. Incidence of bleeding from gastric varices is relatively low, but tends to be more severe, and is associated with higher mortality than esophageal variceal bleeding.

AIMS AND OBJECTIVES

To compare the prevalence and types of gastric varices in cirrhosis versus extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection.

METHODS

Eighty six patients presenting with bleeding from gastric varices between August 2010 and August 2011 were retrospectively analyzed.

RESULTS

Of 86 patients, 65% (n = 56) were cirrhotics and 35% (n = 30) had EHPVO. Distribution of types of gastric varices showed GOV1 in 14% (n = 8) of cirrhotics vs. 7% (n = 2) of EHPVO, GOV2 in 80% (n = 45) of cirrhotics vs. 53% (n = 16) of EHPVO, IGV1 in 40% (n = 12) of patients with EHPVO vs. 4% (n = 2) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 3.7 ± 2.58 ml over a median of 1 session (range: 1-8). The total volume of glue required was lower in cirrhotics (3.2 ± 2 ml vs. 4.7 ± 3.1 ml, p < 0.05) than in EHPVO patients. Twenty (36%) of cirrhotics required >1 sessions of glue injection as compared to 17 (57%) of EHPVO patients. Over mean follow up of 12 months, rebleeding (9% vs. 10%) and mortality (11% vs. 3%) were similar in patients with cirrhosis and EHPVO.

CONCLUSIONS

In patients with bleeding from gastric varices, GOV2 is more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for gastric varix obturation.

Endoscopic color Doppler ultrasonography for esophagogastric varices

Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Endoscopic ultrasonography not only visualizes the surface of the varices but also provides detailed information about their internal structure. The direction of blood flow can be determined and its velocity measured only via endoscopic color Doppler ultrasonography (ECDUS). This can show graphically esophageal varices, paraesophageal veins, and passageways in esophageal variceal patients and gastric varices, perigastric collateral veins in gastric variceal patients. It is important to evaluate the hemodynamics of the portal venous system when treating the esophago-gastric varices. ECDUS is a useful modality for the evaluation of the detailed hemodynamics and the therapeutic effects of esophago-gastric varices.

Medical and endoscopic management of gastric varices

In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed.

Delivery of large molecules via poly(butyl cyanoacrylate) nanoparticles into the injured rat brain

Poly(n-butyl-2-cyanoacrylate) (PBCA) nanoparticles have been successfully applied to deliver small-molecule drugs to the central nervous system (CNS). However, it is unclear whether PBCA nanoparticles can be used as the delivery system for large molecules to potentially treat traumatic brain injury (TBI). In this study, we tested the capacity of PBCA nanoparticles in passing through the blood-brain barrier (BBB) and transporting large molecules into normal and injured brains in the rat. We first synthesized PBCA nanoparticles by dispersion polymerization and then loaded the particles with either horseradish peroxidase (HRP, 44 kDa) or enhanced green fluorescent protein (EGFP, 29 kDa), which were further coated with polysorbate 80. Next, the polysorbate 80-coated HRP or EGFP-loaded PBCA nanoparticles were intravenously injected into the normal and brain-injured rats. We found that, at 45 min after injection, PBCA nanoparticle-delivered HRP or EGFP was hardly detected in the normal brains of the rats, but a small amount of EGFP carried by PBCA nanoparticles was noted in the normal brains 48 h after administration, which was further confirmed by immunolocalization with anti-EGFP antibodies. In contrast, at 4 h after TBI with a circulation time of 45 min, although the penetration of HRP or EGFP alone was hampered by the BBB, the PBCA nanoparticle-delivered HRP or EGFP was widely distributed near injured sites. Together, our findings provide histological evidence that PBCA nanoparticles can be used as an efficient delivery system for large molecules to overcome the barrier in the brain with TBI.

Long-term result of endoscopic Histoacryl® (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices

AIM: To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl^® for treatment of gastric variceal bleeding and prophylaxis.

METHODS: Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl^® injections endoscopically. One hundred patients underwent endoscopic Histoacryl^® injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure.

RESULTS: According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl^® per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl^® injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%.

CONCLUSION: Histoacryl^® injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.

Portale Hypertension

Während die Pathologie, die zur portalen Hypertension führt, im prähepatischen, hepatischen und posthepatischen venösen Gefäßbett liegen kann, machen die intrahepatischen Erkrankungen mit Abstand den Großteil aus. In unseren Breitengraden ist es die durch Alkoholabusus bedingte ethyltoxische Leberzirrhose, weltweit die durch Infektionen (HCV, HBV) bedingten Zirrhosen. Die chronische Hepatitis C mit ihren Komplikationen (Leberzellversagen, portale Hypertension und hepatozelluläres Karzinom) wird in den kommenden Jahren trotz moderner Therapieverfahren noch an Bedeutung gewinnen.

Endoscopic treatment of esophageal varices in advanced liver disease patients: band ligation versus cyanoacrylate injection

BACKGROUND

The results of variceal band ligation (VBL) in patients with advanced liver disease are unknown. Cyanoacrylate injection (CI) might have a better outcome than VBL in the treatment of esophageal varices (EV) in these patients.

AIM

To compare VBL and CI in the treatment of EV in patients with advanced liver disease.

PATIENTS AND METHODS

Thirty-eight patients with medium or large EV and Child-Pugh index of at least eight were randomized into two groups: VBL (n=20) and CI (n=18). The patients were followed-up for at least 6 months after the end of treatment. Main outcomes were eradication, bleeding, mortality, complication, and recurrence rates.

RESULTS

Variceal eradication rates were similar in the VBL and CI groups (90 vs. 72%, P=0.39). Mean number of sessions until eradication was 3.17 and 3, respectively. Bleeding episodes until eradication were equally observed in both groups (P=0.17). Mortality (55 vs. 56%, P=0.52) and major complication rates (5 and 17%, P=0.32) were similar. Chest pain with dysphagia was more frequent in the CI group (55.6 vs. 10%, P=0.004). A higher risk of variceal recurrence was observed in the CI group (33 vs. 57%, P=0.04).

CONCLUSION

No significant differences between the VBL and CI groups were observed in the treatment of EV in patients with advanced liver disease regarding mortality, variceal eradication, and major complications rates. However, minor complications and variceal recurrence were significantly more common in the CI group. In addition, there was a clear trend toward more bleeding episodes in patients included in the CI group.

Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate

BACKGROUND & AIMS

Endoscopic variceal obturation with tissue adhesive is used to control gastric variceal bleeding. We investigated the prevalence of serious complications from this therapy.

METHODS

We performed a retrospective analysis of complications that occurred in 753 patients with gastric variceal hemorrhages who were hospitalized in 2 tertiary referral hospitals. All patients received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation.

RESULTS

Complications occurred in 51 patients. Thirty-three patients experienced rebleeding because of early-onset (within 3 months) extrusion of the N-butyl-2-cyanoacrylate glue cast (4.4%), 10 patients developed sepsis (1.3%), and 5 patients developed distant embolisms (0.7%; 1 pulmonary, 1 brain, and 3 splenic). One patient had major gastric variceal bleeding after endoscopic variceal obturation (0.1%), 1 developed a large gastric ulcer (0.1%), and 1 had mesentery hematoma, hemoperitoneum, and infection in the abdominal cavity (0.1%). The complication-related mortality was 0.53% (3 deaths from sepsis and 1 death from rebleeding after early-onset glue cast extrusion).

CONCLUSIONS

The occurrence of complications after endoscopic variceal obturation with N-butyl-2-cyanoacrylate in gastric varices treatment is rare.

Long-term outcomes of prophylactic endoscopic histoacryl injection for gastric varices with a high risk of bleeding

PURPOSE

Endoscopic histoacryl injection (EHI) is reported to be an effective treatment modality for bleeding gastric varices (GVs) but controversial as a prophylactic treatment for non-bleeding GVs because efficacy and safety have yet to be determined. The aim of this study was to evaluate safety and long-term outcomes of prophylactic EHI for non-bleeding GVs with a high risk of bleeding.

METHODS

Thirty-three patients (23 males/10 females, mean age 56.6 years old) with a high risk of gastric variceal bleeding (large tumorous (27), red color sign (14) or rapidly growing in size (1)) underwent EHI. According to the grade of GVs, 25 patients belonged to F3, seven to F2, and one to F1. In terms of the locations of GVs, four patients belonged to type IGV1, 21 to type GOV2, and eight to type GOV1.

RESULTS

Obliteration of GVs was achieved in all of the treated patients. Twenty-three patients required one session and ten needed more than two sessions to obliterate their GVs. A mean volume of histoacryl used per session was 2.0 ml. Complications related to the procedure included immediate bleeding in two patients and bacteremia in one patient. The mean duration of follow-up was 12.2 months and eradication of GVs was achieved in 21 (95%) of 22 patients who were followed-up more than 3 months. Index GVs recurred in three of 21 patients (14%) and re-bleeding in index GVs after EHI occurred in two of 26 patients (8%).

CONCLUSIONS

Prophylactic EHI can be a promising procedure for eradication of non-bleeding GVs in case with a high risk of bleeding.

Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration

BACKGROUND AND AIM

Our study aimed to evaluate the therapeutic results of endoscopic N-butyl-2-cyanoacrylate injection (EBC) and balloon-occluded retrograde transvenous obliteration (BRTO) in patients with gastric variceal hemorrhage (GVH) and/or high-risk gastric varices (GV).

METHODS

Twenty-seven patients with GVH and/or high-risk GV (>or= 5 mm in diameter, those with red spots, and a Child-Pugh grading of B or C liver cirrhosis) who were treated with either EBC or BRTO from April 2005 to December 2007 were included in our study.

RESULTS

EBC or BRTO was initially used for the treatment of GVH in 14 and 13 patients, respectively. Technical success was achieved in all 14 patients (100%) initially treated with EBC, and 10 of 13 patients (76.9%) initially treated with BRTO. Significant rebleeding occurred in 10 patients (71.4%) of the EBC group, and two patients (15.4%) of BRTO group (P < 0.01). Five of six patients (83.3%) treated with rescue BRTO due to rebleeding after initial EBC achieved technical success, and all six patients who were treated with rescue BRTO had no rebleeding during the median follow up of 17 (range: 2-37) months. The cumulative survival rate of the EBC with the BRTO rescue group/BRTO group was significantly higher than the EBC group.

CONCLUSION

The therapeutic efficacies of EBC and BRTO for the treatment of active GVH and/or high-risk GV appeared to be similar. However, EBC might be associated with a higher rebleeding rate than BRTO. BRTO could be an effective rescue treatment for patients with GVH after initial treatment of EBC.

Endoscopic haemostasis

Endoscopic haemostasis should be attempted as the initial approach in most cases of gastrointestinal (GI) bleeding, although cross-disciplinary collaboration is a prerequisite. For variceal bleeding, band ligation is the method of choice in the elective setting, although injection therapy still has a role in acute bleeding. Histoacryl remains preferable for fundic varices in most parts of the world. For peptic ulcer bleeds, injection therapy should be combined with at least one 'mechanical' modality, thermal treatment or clipping. In rebleeding, a single endoscopic retreatment can be attempted, but alternative approaches must be considered. Acute lower GI bleeding is primarily a diagnostic challenge but, if the focus is found, the regular techniques for haemostasis can usually be applied. If small bowel haemorrhage is suspected after upper and lower endoscopy, capsule endoscopy and balloon enteroscopy offer make it possible to address even small bowel foci.

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Two patients with liver cirrhosis and portal hypertension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography (CTPA) has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.

Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices

AIM

Because the procedure of balloon-occluded retrograde transvenous obliteration (B-RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long-term outcome of B-RTO, including changes in esophageal varices.

METHODS

B-RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices (n = 7), F(1) varices (n = 11), and F(2) varices (n = 4). The outcome measures included the development/worsening of esophageal varices after B-RTO and survival rates.

RESULTS

The cumulative bleeding-free probability for all 22 patients at 3 years after B-RTO was 100%. The overall 3-year survival was 94.4%. Seven patients who had no esophageal varices prior to B-RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F(1) esophageal varices prior to B-RTO showed no changes in the varices after B-RTO, while two patients progressed to F(2) varices and two developed F(3) varices. The cumulative treatment-free probability of the esophageal varices at 24 months after B-RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre-existing F(1) varices, and 75% for those with pre-existing F(2) varices.

CONCLUSION

Although the B-RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.

Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate

BACKGROUND

Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices.

METHODS

Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary.

RESULTS

Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27).

CONCLUSIONS

This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.