The value of EUS in the management of portal hypertension

Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy

PURPOSE

Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection.

METHODS

Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches.

RESULTS

Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery.

CONCLUSION

Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.

Endoscopic Color Doppler Ultrasonographic Evaluation of Gastric Varices Secondary to Left-Sided Portal Hypertension

Gastric varices that arise secondary to the splenic vein occlusion can result in gastrointestinal hemorrhaging. Endoscopic color Doppler ultrasonography (ECDUS) was performed in 16 patients with gastric varices secondary to splenic vein occlusion. This study retrospectively evaluated the role of ECDUS in the diagnosis of gastric varices secondary to splenic vein occlusion. Thirteen patients had co-existing pancreatic diseases: 8 with chronic pancreatitis, 4 with cancer of the pancreatic body or tail and 1 with severe acute pancreatitis. Of the remaining 3 patients, 1 had myeloproliferative disease, 1 had advanced gastric cancer, and the third had splenic vein occlusion due to an obscure cause. The endoscopic findings of gastric varices were: variceal form (F) classified as enlarged tortuous (F2) in 12 cases and large, coil-shaped (F3) in 4 cases, and positive for erosion or red color sign of the variceal surface in 4 cases and negative in 12 cases. ECDUS color flow images of gastric variceal flow clearly depicted a round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body in all 16 cases. The velocities of F3 type gastric varices were significantly higher than those of the F2 type. The wall thickness of varices positive for erosion or red color sign was significantly less than the negative cases. I conclude that ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion at the round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body.

Collateral pathways in portal hypertension

Presence of portosystemic collateral veins (PSCV) is common in portal hypertension due to cirrhosis. Physiologically, normal portosystemic anastomoses exist which exhibit hepatofugal flow. With the development of portal hypertension, transmission of backpressure leads to increased flow in these patent normal portosystemic anastomoses. In extrahepatic portal vein obstruction collateral circulation develops in a hepatopetal direction and portoportal pathways are frequently found. The objective of this review is to illustrate the various PSCV and portoportal collateral vein pathways pertinent to portal hypertension in liver cirrhosis and EHPVO.

Bleeding from gastric body varices effectively treated with endoscopic band ligation

A 55-year-old man with alcoholic liver cirrhosis was admitted to hospital with tarry stools. Videoendoscopy examination on admission revealed blood oozing from the greater curvature of the gastric body (ectopic varices). Endoscopic ultrasonography and computed tomography were used in making the diagnosis. Endoscopic band ligation (EBL) was performed for the bleeding site of these varices. The patient experienced no further episodes of bleeding during the 6 months following treatment with EBL. EBL was very effective in treating the bleeding from gastric body varices.

Correlation between Endosonographic and Doppler Ultrasound Features of Portal Hypertension in Patients with Cirrhosis

Purpose. Endoscopic ultrasound (EUS) permits the detailed visualization of clinically significant features of portal hypertension; however, it is an invasive procedure that is not widely available. The aim of this cross-sectional study was to determine whether a correlation exists between the features of portal hypertension detected using both Doppler ultrasound and EUS in subjects with liver cirrhosis. Materials and Methods. Analyzed cohort included 42 patients who underwent a detailed Doppler ultrasound focusing on the parameters of blood flow in the portal/splenic vein as well as an endoscopic/EUS procedure that included the assessment of the size and localization of “deep” varices. Results. The size of “deep” oesophageal varices detected with EUS exhibited no correlation with the parameters assessed by Doppler ultrasound. However, the size of the “deep” gastric varices detected using EUS correlated with the time averaged maximum velocity (T_max as well as V_min, V_max) for the portal vein using Doppler ultrasound and exhibited a correlation with the V_max and T_max for the splenic vein. No significant correlation was determined between the diameter of the azygous vein and the thickness of the gastric wall when seen on EUS versus the parameters measured with Doppler ultrasound. Conclusion. EUS provides important information regarding the features of portal hypertension, and in the case of “deep” oesophageal varices exhibits a limited correlation with the parameters detected by Doppler ultrasound. Thus, despite its invasiveness, EUS is a method that provides a reliable and unique assessment of the features of portal hypertension in patients with liver cirrhosis.

Does sclerotherapy of remnant little oesophageal varices after endoscopic ligation have impact on the reduction of recurrent varices? Prospective study

INTRODUCTION

Endoscopic band ligation (EBL) is superior to endoscopic injection sclerotherapy (EIS) of oesophageal varices, however, EBL is associated with a higher rate of variceal recurrences.

OBJECTIVE

To examine whether the reduction of recurrent varices can be achieved by additional sclerotherapy of remnant little varices after ligation.

METHODS

Forty-eight patients with liver cirrhosis who had previously bled from oesophageal varices were examined. Endoscopic therapy was performed in order to prevent recurrent variceal bleeding. I group: in 23 patients ligation of oesophageal varices with multi band ligation device was applied (EBL group). II group: in 25 patients sclerotherapy using polydocanol or absolute alcohol was applied after reducing the size of varices using ligation (EBL and EIS group).

RESULTS

There was no statistically significant difference between the examined groups of patients in relation to the number of sessions for variceal eradication, recurrence of variceal bleeding, deterioration of portal gastropathy and mortality in the observed period from 18.8 +/- 18.6 months (EBL group) and 22.2 +/- 26.2 months (EBL and EIS group). Variceal recurrence was verified in 21.7% of patients of the EBL group and 16% of the EBL and EIS group, but the difference was not statistically important. Several complications, such as dysphagia and chest pain, were statistically more frequent in the EBL and EIS group of patients.

CONCLUSION

The combined method of ligation and extra sclerosing of remnant small oesophageal varices after ligation does not have advantage in relation to the ligation alone.

Endoscopic ultrasonography for the evaluation of portal hypertension

Since the 1980s, endoscopic ultrasonography (EUS) has been useful in the evaluation of portal hypertension, either for the diagnostic aspects or for the evaluation of therapy and risk of bleeding. More recently, it has been described as a method for guiding interventions such as variceal injection, portal vein catheterization, or even for creating an intrahepatic portosystemic shunt in the animal laboratory. The new generation of radial electronic echoendoscopes is equipped with color Doppler capability, allowing for measurement of any hemodynamic parameter of the portal circulation. This article summarizes the current knowledge on the role of EUS for the evaluation of portal hypertension.

Gastric varices in patients with portal hypertension: evaluation with multidetector row CT

BACKGROUND

Gastric varices (GVs) are a major cause of gastrointestinal bleeding in patients with portal hypertension. Few studies have evaluated GVs with multidetector row computed tomography (MDCT).

GOALS

To assess the diagnostic performance of MDCT in detecting GVs and revealing variceal hemodynamic changes in patients with cirrhosis.

STUDY

A total of 127 consecutive cirrhotic patients who underwent both liver MDCT and esophagogastroduodenoscopy (EGD) were analyzed retrospectively. Two independent radiologists reviewed MDCT images for the detection of GVs. The variceal hemodynamic changes were assessed by the 2 radiologists in consensus on MDCT portography.

RESULTS

On the basis of EGD, of the 127 patients, 36 had GVs (28.4%), including small GVs in 15 patients and large GVs (>or=5 mm) in 21 patients. In detecting and grading GVs, there were moderate agreements (kappa value: 0.514 to 0.563) between MDCT and EGD, but in differentiating large varices requiring prophylactic therapy, a substantial agreement (kappa value: 0.804 for radiologist 1 and 0.796 for radiologist 2) was found. For radiologist 1, the sensitivity, specificity, accuracy, and positive and negative predictive values of MDCT for the identification of large GVs were 85.7%, 96.2%, 94.5%, 81.8%, and 97.1%, respectively; whereas for radiologist 2, they were 81.0%, 97.2%, 94.5%, 85.0%, and 96.3%, respectively. In evaluating the afferent and efferent veins of varices, the sensitivity, specificity, accuracy, and positive predictive value of MDCT portography were more than 80.0%.

CONCLUSIONS

MDCT is an effective screening tool for differentiating large GVs and revealing the afferent and efferent veins of varices in patients with cirrhosis.

Diagnosis of gastric varices and evaluation of the effectiveness of treatment using transabdominal color Doppler ultrasonography

OBJECTIVE

The aim of this study was to evaluate the hemodynamics of gastric varices using transabdominal color Doppler ultrasonography (CDUS).

METHODS

Using CDUS, we evaluated 41 consecutive patients with gastric varices. We examined color flow images and measured the velocity of gastric variceal blood flow using fast Fourier transform analysis. In addition, we compared detection rates of gastric varices and their outflow vessels using CDUS and computed tomography (CT).

RESULTS

Gastric varices were detected with CDUS in 41 of 41 patients (100%), and outflow vessels were detected in 34 (82.9%). Of these, 32 were gastrorenal shunts (GRSs), and 2 were GRSs and subphrenic veins. The velocity of the large and coil-shaped varices (mean +/- SD, 23.0 +/- 5.8 cm/s; n = 13) was significantly higher than that of the enlarged and tortuous varices (14.1 +/- 4.3 cm/s; n = 28; P < .001). With CT, gastric varices were detected in 41 of 41 patients (100%), and outflow vessels were detected in 38 (92.7%). Color Doppler ultrasonographic and CT findings were in complete agreement in 35 of 41 patients (85.4%). A total of 11 patients with a high risk of variceal rupture underwent balloon-occluded retrograde transvenous obliteration, and CDUS and CT findings after treatments were consistent.

CONCLUSIONS

Transabdominal CDUS is a useful noninvasive modality for the diagnosis of gastric variceal hemodynamics and for evaluation of the therapeutic effects of gastric variceal treatment.

Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion

AIM

This study provides a retrospective evaluation of cases with gastric varices secondary to splenic vein occlusion.

METHODS

Our study group consisted of 14 patients. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively.

RESULTS

Eleven patients had co-existing pancreatic diseases: seven with chronic pancreatitis, three with cancer of the pancreatic body or tail and one with severe acute pancreatitis. Among the three remaining patients, one had advanced left renal cancer, one had myeloproliferative disease and the third had splenic vein occlusion due to an obscure cause. A diagnosis of gastric varices was made following endoscope gastroduodenoscopy or endoscopic color Doppler ultrasonography (ECDUS), and splenic vein occlusions were diagnosed from enhanced computed tomography in all cases. Specific findings of gastric varices secondary to splenic vein occlusion were based on ECDUS color flow images of gastric variceal flow that clearly depicted round cardiac and fundal regions at the center, with varices expanding to the curvatura ventriculi major of the gastric body. For three cases with gastric variceal bleeding, endoscopic injection sclerotherapy using a mixture of histoacryl and lipiodol (70% histoacryl solution) was performed, after which no further bleeding from gastric varices was detected. Due to a high risk of gastric variceal rupture, splenectomy was performed in two cases and splenic arterial embolization in another two cases.

CONCLUSION

ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion. Treatment should take into account the diseases underlying these conditions.

Observation of gastric variceal flow characteristics by endoscopic ultrasonography using color Doppler

OBJECTIVES

The aim of this study was to investigate the endoscopic color Doppler ultrasonography (ECDUS) findings of gastric varices and to determine the role of ECDUS in the diagnosis of gastric varices.

METHODS

Using ECDUS, we evaluated 114 patients with gastric varices found consecutively by routine upper endoscopy. We monitored the color flow images of gastric varices and perigastric collateral veins. We measured the blood flow velocity of gastric varices and the thickness of the gastric wall to submucosal gastric varices with this technique, and investigated the usefulness of ECDUS in evaluating the hemodynamics of gastric varices. Endoscopic findings of gastric varices were evaluated according to the grading system of the Japanese Research Committee on Portal Hypertension.

RESULTS

Color flow images of gastric varices and perigastric veins were delineated in all 114 patients with ECDUS. Evaluation of blood flow velocity in the 114 gastric varices revealed velocities of 7.7-35.7 cm/s (mean 18.2 +/- 5.9 cm/s). The velocities (23.7 +/- 6.4 cm/s, N = 21) of large, coil-shaped (F3)-type gastric varices were significantly higher than those (16.7 +/- 4.9 cm/s, N = 93) of enlarged tortuous (F2)-type varices (P < 0.0001). The 114 gastric varices were at 1.0-2.2 mm (1.6 +/- 0.3 mm) of gastric wall thickness. The thickness (1.2 +/- 0.1 mm, N = 22) for red color sign (RC)- or erosion-positive varices was significantly less than that (1.7 +/- 0.2 mm, N = 92) for the negative cases (P < 0.0001). The mean velocity was 28.0 +/- 6.1 cm/s in bleeding cases (N = 4) and 17.6 +/- 5.5 cm/s in nonbleeding cases (N = 110), and the velocities of the bleeding cases were significantly higher than those of the nonbleeding cases (P < 0.001). The mean thickness of the gastric wall was 1.2 +/- 0.2 mm for bleeding cases and 1.6 +/- 0.3 mm for nonbleeding cases, and the mean wall thickness in the bleeding cases was significantly less than in the nonbleeding cases (P < 0.001).

CONCLUSIONS

ECDUS is a useful modality for diagnosis of the hemodynamics of gastric varices and may allow the prediction of a high risk for hemorrhage.

Detection of submucosal gastric fundal varices with multi-detector row CT angiography

BACKGROUND AND AIM

The diagnosis of submucosal fundal varices is challenging. Currently, endoscopy and endoscopic ultrasound (EUS) are considered most useful for this purpose. The aim of this study was to evaluate if multi-detector row CT (MDCT) angiography contributes to the diagnosis of submucosal fundal varices.

PATIENTS AND METHODS

Twenty two patients with endoscopically suspected fundal varices were prospectively included in the study. All patients underwent EUS and MDCT angiography. Levels of agreement between EUS and MDCT angiography for the detection of submucosal and perigastric fundal varices were evaluated by three blinded independent readers. In addition, variceal size and location, as well as afferent and efferent vessels of the submucosal varices, were determined.

RESULTS

Good or excellent image quality of MDCT angiography was obtained in 21/22 patients (95%). Based on EUS, submucosal varices were detected in 16 of 22 patients (73%) and perigastric varices in 22/22 patients (100%). Using MDCT angiography, the presence of submucosal varices was confirmed in all of these 16 patients by all three readers. Perigastric varices were also confirmed in all 22 patients by all three readers. In addition, all three readers noted the presence of a submucosal varix in an additional patient which was not detected on initial EUS. MDCT angiography showed an excellent interobserver reliability with regard to variceal diameter (kappa=0.90) and variceal location (kappa=0.94). Based on MDCT angiography, afferent and efferent vessels of submucosal varices included the left gastric vein in 11 (65%), the posterior/short gastric veins in 15 (88%), gastrorenal shunts in 10 (59%), the left inferior phrenic vein in six (35%), and the left pericardiophrenic vein in six (35%) of 17 patients.

CONCLUSIONS

MDCT angiography is equivalent to EUS in terms of detection and characterisation of fundal varices, in particular with regard to the distinction between submucosal and perigastric fundal varices.

Portal hypertension

Many advances in the management of portal hypertension and variceal hemorrhage have occurred during the last 10 years. Effective therapy for primary prevention of variceal hemorrhage is now available in the form of nonselective beta-blockers. Active bleeding should be managed with terlipressin, somatostatin or its analogues, and endoscopic therapy; TIPS and surgery are reserved as salvage therapy for patients who fail endoscopic treatment. Survivors of a variceal hemorrhage should be evaluated for liver transplantation. Specific treatment may be provided with EVL while these patients await transplantation. Patients who fail endoscopic treatment may be treated by TIPS or surgery.