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Daneti D, Senthamizhselvan K, Chandra MR, Mohan P, Kate V. Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study. J Clin Exp Hepatol 2024; 14:101315. [PMID: 38283706 PMCID: PMC10821593 DOI: 10.1016/j.jceh.2023.101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/06/2023] [Indexed: 01/30/2024] Open
Abstract
Background and aims Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding. Methods This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied. Results A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding. Conclusion In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.
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Affiliation(s)
- Dharanesh Daneti
- Department of Medical Gastroenterology, JIPMER, Puducherry, India
| | | | | | - Pazhanivel Mohan
- Department of Medical Gastroenterology, JIPMER, Puducherry, India
| | - Vikram Kate
- Department of Surgery, JIPMER, Puducherry, India
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2
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Charif F, Peretti L, Kacimi D, Bindler M, Bugnet AS. [Suspected pulmonary nodule in a male heavy smoker: Is biopsy really necessary?]. Rev Mal Respir 2024; 41:89-92. [PMID: 38042756 DOI: 10.1016/j.rmr.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 10/28/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Sclerotherapy is a widely used as a lifesaving therapeutic option in cases of upper gastrointestinal bleeding (UGB) due to ruptured gastro-esophageal varices (GOV) in cirrhotic patients, especially when there exists a portosystemic shunt. This endoscopic technique can entail many complications, including systemic and non-thrombotic pulmonary embolism (PE). While multiple pulmonary parenchymal manifestations have been described following sclerotherapy of GOV, to our knowledge no solitary suspicious pulmonary nodule has been described. CASE PRESENTATION We report the case of 55-year-old man with heavy smoking history who was referred to our pulmonary clinic for work-up of a solitary pulmonary nodule. He was known to have liver cirrhosis with history of massive UGB due to rupture of GOV two months before. He was treated with sclerotherapy by injecting a 3 cc of Histoacryl/lipiodole solution. The post- endoscopic phase was unremarkable. An enhanced CT scan of chest and abdomen performed two months later showed a right upper lobe nodule, even though at that point, the patient was completely asymptomatic. This was ascribed to non-thrombotic PE secondary to sclerotherapy due to complete resolution of the nodule on a CT scan carried out at 2-month follow-up. At that point, his condition did not require any further treatment. CONCLUSION Solitary pulmonary nodule is one of the radiologic manifestations of PE subsequent to sclerotherapy of GOV. Awareness and radiologic follow-up of this unusual radiologic presentation may prevent unnecessary biopsies.
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Affiliation(s)
- F Charif
- Service de pneumologie, hôpitaux du Léman, 3, avenue de la Dame, Thonon-lès-Bains, France.
| | - L Peretti
- Service de pneumologie, hôpitaux du Léman, 3, avenue de la Dame, Thonon-lès-Bains, France
| | - D Kacimi
- Service de pneumologie, hôpitaux du Léman, 3, avenue de la Dame, Thonon-lès-Bains, France
| | - M Bindler
- Service de pneumologie, hôpitaux du Léman, 3, avenue de la Dame, Thonon-lès-Bains, France
| | - A S Bugnet
- Service de pneumologie, hôpitaux du Léman, 3, avenue de la Dame, Thonon-lès-Bains, France
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Khan MA, Anis A, Nayyer A, Bhatti JM. Glue embolization to the lung vasculature following histoacryl injection sclerotherapy: A neglected etiology of pulmonary embolism. Am J Med Sci 2023; 366:383-386. [PMID: 37659469 DOI: 10.1016/j.amjms.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 02/03/2023] [Accepted: 07/13/2023] [Indexed: 09/04/2023]
Abstract
Pulmonary embolism is a significant complication of N-butyl-2-cyanoacrylate, commonly known as histoacryl, used to sclerose bleeding gastroesophageal varices. We present a 50-year-old female with seronegative chronic liver disease who was managed with endoscopic histoacryl injection sclerotherapy for bleeding gastric fundal varices. Following treatment, the patient developed sudden respiratory distress due to multiple pulmonary glue emboli, requiring inpatient supportive care along with close monitoring for a week. The patient slowly recovered with conservative management. On subsequent outpatient follow-up, the patient showed no signs of any long-term consequences. Our aim is to alert physicians regarding the uncommon occurrence of acute respiratory distress secondary to pulmonary embolism following histoacryl injection sclerotherapy, as well as to describe its clinical and radiological manifestations.
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Affiliation(s)
- Misha Aftab Khan
- Department of Medicine, Dr. Ziauddin University Hospital, Karachi, Pakistan.
| | - Armeena Anis
- Department of Medicine, Dr. Ziauddin University Hospital, Karachi, Pakistan
| | - Areeba Nayyer
- Department of Medicine, Dr. Ziauddin University Hospital, Karachi, Pakistan
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Todd A, Shekhar C, O'Rourke J, Forde C, Pallan A, Wadhwani SS, Tripathi D, Mahon BS. Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices. BMJ Open Gastroenterol 2023; 10:e000819. [PMID: 37562855 PMCID: PMC10423785 DOI: 10.1136/bmjgast-2021-000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND AND AIMS Bleeding from parastomal varices causes significant morbidity and mortality. Treatment options are limited, particularly in high-risk patients with significant underlying liver disease and other comorbidities. The use of EUS-guided embolisation coils combined with thrombin injection in gastric varices has been shown to be safe and effective. Our institution has applied the same technique to the treatment of parastomal varices. METHODS A retrospective review was performed of 37 procedures on 24 patients to assess efficacy and safety of EUS-guided injection of thrombin, with or without embolisation coils for treatment of bleeding parastomal varices. All patients had been discussed in a multidisciplinary team meeting, and correction of portal hypertension was deemed to be contraindicated. Rebleeding was defined as stomal bleeding that required hospital admission or transfusion. RESULTS All patients had significant parastomal bleeding at the time of referral. 100% technical success rate was achieved. 70.8% of patients had no further significant bleeding in the follow-up period (median 26.2 months) following one procedure. 1-year rebleed-free survival was 80.8% following first procedure. 7 patients (29.1%) had repeat procedures. There was no significant difference in rebleed-free survival following repeat procedures. Higher age was associated with higher risk of rebleeding. No major procedure-related complications were identified. CONCLUSIONS EUS-guided thrombin injection, with or without embolisation coils, is a safe and effective technique for the treatment of bleeding parastomal varices, particularly for patients for whom correction of portal venous hypertension is contraindicated.
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Affiliation(s)
- Andrew Todd
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chander Shekhar
- Department of Gastroenterology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Joanne O'Rourke
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colm Forde
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Arvind Pallan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunulogy and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Brinder Singh Mahon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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5
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Çil E, Şahin KE. Pulmonary embolism due to an indefinite plug: 5-year follow-up. Interact Cardiovasc Thorac Surg 2022; 35:6650651. [PMID: 35894799 PMCID: PMC9338705 DOI: 10.1093/icvts/ivac202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/06/2022] [Accepted: 07/25/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Thoracic computed tomography angiography revealed a filling defect with an internal air density in the lower lobar branch of the left pulmonary artery accompanied by pleural fluid, in a patient who applied with sudden onset chest pain and dyspnoea. The filling defect remained stable after anticoagulant treatment. No progression or complications were observed in 5-year follow-up. In pulmonary embolism that does not resolve despite adequate treatment, non-thrombotic sources, particularly foreign body, should be considered.
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Affiliation(s)
- E Çil
- Department of Chest Diseases, Adiyaman University Education and Research Hospital , Adiyaman, Turkey
| | - K E Şahin
- Department of Cardiology, Adiyaman University Education and Research Hospital , Adiyaman, Turkey
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Sallout D, Tatro E, Adler DG. Managing gastric varices. Frontline Gastroenterol 2022; 13:535-542. [PMID: 36250174 PMCID: PMC9559633 DOI: 10.1136/flgastro-2021-101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.
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Affiliation(s)
- Deema Sallout
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Eric Tatro
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Endoscopy, Center for Advanced Therapeutic Endoscopy, Denver, Colorado, USA
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Safety and Efficacy of Thrombin for Bleeding Gastric Varices: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:953-963. [PMID: 33728506 DOI: 10.1007/s10620-021-06915-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/22/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The optimal therapy for bleeding-related gastric varices is still a controversial topic. There is a paucity of literature that comprehensively summarizes the available literature regarding safety and efficacy of thrombin in bleeding gastric varices. METHODS Four independent reviewers performed a comprehensive review of all original articles published from inception to October 2020, describing the use of thrombin for management of bleeding gastric varices. Primary outcomes were (1) pooled early and late rebleeding rate, (2) pooled gastric variceal related mortality rate, (3) pooled rescue therapy rate, and (4) pooled adverse event rate with the use of thrombin in bleeding gastric varices. The meta-analysis was performed and the statistics were two-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test. RESULTS Eleven studies were included in the analysis after comprehensive search. This yielded a pooled early rebleeding rate of 9.3% (95% CI 4.9-17) and late rebleeding rate 13.8% (95% CI 9-20.4). Pooled rescue therapy rate after injecting thrombin in bleeding gastric varices was 10.1% (95% CI 6.1-16.3). The pooled 6-week gastric variceal-related mortality rate after injecting thrombin in bleeding gastric varices was 7.6% (95% CI 4.5-12.5). There were a total of four adverse events out of a total of 222 patients with pooled adverse event rate after injecting thrombin in bleeding gastric varices was 5.6% (95% CI 2.9-10.6). CONCLUSION In summary, the systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest low rates of rebleeding and minimal rates of adverse events. While, early and late rebleeding rate and rescue therapy rate are similar to cyanoacrylate-based therapy, the minimal rates of adverse events are perhaps the most important benefit of thrombin. Thus, the current data suggest that thrombin is a very promising therapeutic alternative with low risk of adverse events for bleeding gastric varices.
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8
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Han C, Ling X, Liu J, Lin R, Ding Z. Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments. Therap Adv Gastroenterol 2022; 15:17562848211056148. [PMID: 35126666 PMCID: PMC8808014 DOI: 10.1177/17562848211056148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/08/2021] [Indexed: 02/04/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)-guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy's lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.
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Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, China
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 PMCID: PMC8567466 DOI: 10.3748/wjg.v27.i40.6874] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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Khera PS, Garg PK, Tiwari S, Bhargava N, Yadav T, Sureka B, Ghosh T, Babu S, Dadhich S, Singh S. Retrograde Transvenous Obliteration of Gastric Varices using Sodium Tetradecyl Sulphate: Technical Considerations and Results from a Single Institution Retrospective Study. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1728998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Retrograde transvenous obliteration (RTO) with the assistance of a balloon (BRTO) or a vascular plug (PARTO) is an established method for treating gastric varices (GVs) secondary to portal hypertension. Most of the available studies on RTO have used lipiodol along with sclerosing agents like ethanolamine oleate or sodium tetradecyl sulfate (STS). We evaluated the safety and efficacy of RTO for treating GVs using STS as a sclerosant without lipiodol.
Materials and Methods Sixteen patients (nine men, age range 16–74 years) were included in this retrospective study. Twelve patients presented with acute bleeding, two with chronic bleeding, one with large varices without bleeding, and one with refractory hepatic encephalopathy (HE). BRTO was attempted in 14 patients and PARTO in 2 patients. The technical and clinical success and complications of RTO were studied.
Results The RTO procedure was technically successful in 14 (14/16, 87.5%) patients, with 13 (13/14, 93%) obtaining clinical success. One patient died due to the early recurrence of bleeding. Three patients had minor intraprocedural complications.
Conclusion Retrograde gastric variceal obliteration using STS is safe and technically feasible with high technical and clinical success and low complication rate.
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Affiliation(s)
- Pushpinder S. Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan K. Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Narendra Bhargava
- Department of Gastroenterology, Dr S N Medical College, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Binit Sureka
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Tushar Ghosh
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Santhosh Babu
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sunil Dadhich
- Department of Gastroenterology, Dr S N Medical College, Jodhpur, Rajasthan, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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11
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Choi SI, Yoon EL. Two Cases of Fungemia after Endoscopic Variceal Obturation for Gastric Variceal Bleeding. Yonsei Med J 2021; 62:182-186. [PMID: 33527799 PMCID: PMC7859686 DOI: 10.3349/ymj.2021.62.2.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Soo In Choi
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.
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12
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Endoscopic ultrasound-guided coil deployment with sclerotherapy for gastric varices. Clin J Gastroenterol 2020; 14:76-83. [PMID: 33040299 DOI: 10.1007/s12328-020-01259-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
We present a case of gastric varices (GV) in the fundus treated by endoscopic ultrasound (EUS)-guided coil deployment with sclerotherapy. A 46-year-old man with a previous history of fatty liver and obesity presented to the emergency department with abdominal pain. Contrast computed tomography (CT) showed chronic liver disease, splenomegaly, and GV. Esophagogastroduodenoscopy (EGD) showed GV in the fundus. Follow-up EGD 6 months later revealed an increase in GV diameter to over 20 mm. Balloon-occluded retrograde transvenous obliteration appeared difficult due to the small caliber of the gastrorenal shunt observed on contrast CT. We performed EUS-guided coil deployment with sclerotherapy. The coil was deployed using a 19-gauge needle under EUS and fluoroscopic guidance. Next, 5% ethanolamine oleate with contrast medium was injected into GV using a 22-gauge needle. GV was reduced without complications, and no GV growth or hemorrhage was observed during 8 months of follow-up.
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Skripkina E, Alessandri C, Assaraf J, Meffert A, Ly A, Merle JC, Vitellius M, Langeron O, Mongardon N. Stardust lung and liver after gastric variceal haemorrhage. Anaesth Crit Care Pain Med 2020; 40:100736. [PMID: 32956839 DOI: 10.1016/j.accpm.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Elena Skripkina
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Claire Alessandri
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Julie Assaraf
- Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Arnaud Meffert
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - André Ly
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Jean-Claude Merle
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Manuel Vitellius
- Service de radiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Olivier Langeron
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, Univ Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), F-94700 Maisons-Alfort, France.
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14
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Acute pericarditis: A rare complication of gastric variceal obturation with cyanoacrylate glue. Clin Res Hepatol Gastroenterol 2020; 44:e25-e28. [PMID: 31401042 DOI: 10.1016/j.clinre.2019.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/07/2019] [Accepted: 06/27/2019] [Indexed: 02/04/2023]
Abstract
Endoscopic obturation by cyanoacrylate glue is currently the treatment of reference of gastric varices bleeding in patients with portal hypertension with a good efficacy for bleeding control and secondary prophylaxis. However, several adverse events related to this treatment have been described including immediate rebleeding and glue embolism. Here we present a case of gastric variceal obturation by cyanoacrylate inducing an acute pericarditis due to glue embolism in mediastinal, pericardial and phrenic veins that was managed conservatively. We also discussed pathophysiological explanations and surveillance modality.
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15
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Oleas R, Robles-Medranda C. Insights into the role of endoscopic ultrasound-guided vascular therapy. Ther Adv Gastrointest Endosc 2019; 12:2631774519878282. [PMID: 31633107 PMCID: PMC6769219 DOI: 10.1177/2631774519878282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/04/2019] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal variceal bleeding is a life-threatening complication in patients with liver cirrhosis and portal hypertension. The endoscopic injection of cyanoacrylate is considered as the first-line alternative for gastric varices treatment; however, the incidence of adverse events supports the endoscopic ultrasound–guided approach. Endoscopic ultrasound–guided interventions are a safe and feasible technique for the injection of sclerosants, cyanoacrylate, thrombin, and the deployment of coils into targeted vessels. This review article aims to offer an overview of the role of endoscopic ultrasound–guided vascular therapy and present the available data regarding endoscopic ultrasound–guided management of gastrointestinal bleeding and other vascular therapies. The available data have shown the superiority of endoscopic ultrasound–guided endovascular therapy over the endoscopic technique, which supports the implementation of endoscopic ultrasound–guided therapy in therapeutical algorithms and guidelines. Regarding whether injecting cyanoacrylate, the deployment of coils, or combined therapy, we recommend the endoscopic ultrasound–guided combined therapy in patients with gastric varices due to the high eradication rate with lower rebleeding and reintervention rates. Multicenter worldwide studies are required to confirm the actual clinical applicability of endoscopic ultrasound–guided endovascular therapy and establish treatment algorithms. Endoscopic ultrasound offered a safe and effective alternative in the management of variceal and nonvariceal gastrointestinal bleeding, with the implementation of new diagnostic and treatment options for various gastrointestinal conditions, representing a new territory for research and development.
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Affiliation(s)
- Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Av. Abel Romeo Castillo y Av. Juan Tanca Marengo, Torre Vitalis, Mezanine 3, Guayaquil 090505, Ecuador
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16
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Robles-Medranda C, Valero M, Nebel JA, de Britto Junior SR, Puga-Tejada M, Ospina J, Muñoz-Jurado G, Pitanga-Lukashok H. Endoscopic-ultrasound-guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting. Dig Endosc 2019; 31:283-290. [PMID: 30449033 DOI: 10.1111/den.13305] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To report the results of endoscopic ultrasound-guided injection of coils with cyanoacrylate (CYA) using a less-expensive coil with an emphasis on the roles of Doppler and endosonographic varicealography (EV) in identifying the feeder vessel in gastric varix treatment. METHODS An observational, descriptive study with prospectively collected data. Patients with gastric varices (GV) were included and were treated by endoscopic ultrasound-guided injection of CYA and a less-expensive coil. Technical success, complete and immediate variceal obliteration, rebleeding, complication and survival rates were evaluated. RESULTS Thirty patients with GV with a mean age of 62 years (range: 44-76 years) were treated. Median number of coils used was 2 (range: 1-3), and median volume of CYA was 1.8 mL (1.2-2.4 mL). Technical success rate was 100%. EV technical success was observed in 26/30 patients. Complete variceal obliteration was observed in 96.6% of patients, and immediate disappearance of the varix was observed in 24 (80%) patients. The complication rate was 6.7%. CONCLUSIONS Endoscopic-ultrasound guidance for gastric varix treatment with the addition of EV and the use of a less-expensive coil is a safe and effective technique that results in the immediate disappearance of GV after targeting the feeding vessel.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | - Manuel Valero
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | | | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | - Jesenia Ospina
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | - Guillermo Muñoz-Jurado
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Ecuador
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17
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Tangcheewinsirikul N, Suankratay C. Acute pulmonary embolism following endoscopic sclerotherapy for gastroesophageal variceal hemorrhage: A case report and literature review. SAGE Open Med Case Rep 2019; 7:2050313X19838946. [PMID: 30967953 PMCID: PMC6444781 DOI: 10.1177/2050313x19838946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/25/2019] [Indexed: 11/21/2022] Open
Abstract
Gastroesophageal variceal hemorrhage is a substantial cause of death in patients
with portal hypertension. Cyanoacrylate injection is a widely used endoscopic
treatment for variceal hemorrhage. We report herein the case of a 49-year-old
male with decompensated alcoholic cirrhosis, who received endoscopic
sclerotherapy to stop gastroesophageal variceal hemorrhage during
hospitalization. The following day, he developed acute progressive dyspnea, and
computed tomogram of pulmonary artery revealed acute pulmonary embolism at the
right lower pulmonary artery. A final diagnosis of sclerotherapy-associated
pulmonary embolism was made, and he gradually improved conservatively without
anticoagulant treatment 2 weeks after hospitalization.
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Affiliation(s)
| | - Chusana Suankratay
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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18
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Mazzawi T, Markhus CE, Havre RF, Do-Cong Pham K. EUS-guided coil placement for acute gastric variceal bleeding induced by non-EUS-guided variceal glue injection (with video). Endosc Int Open 2019; 7:E380-E383. [PMID: 30834298 PMCID: PMC6395176 DOI: 10.1055/a-0826-4253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/22/2018] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided coil placement is a new emerging technique for management of gastric varices. In this video case report, we describe an EUS-guided coil placement for managing acute bleeding of gastric varices, following an unsuccessful glue injection to achieve hemostasis.
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Affiliation(s)
- Tarek Mazzawi
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.,Corresponding author Tarek Mazzawi, MD, PhD Section of GastroenterologyDepartment of MedicineHaukeland University HospitalJonas Lies vei 655020 BergenNorway+4755974785
| | - Carl Erik Markhus
- Department of Radiology, Haukeland University Hospital, Bergen, Norway,
| | - Roald F. Havre
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.
| | - Khanh Do-Cong Pham
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.
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19
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Schultheiß M, Giesler M, Maruschke L, Schmidt A, Sturm L, Thimme R, Rössle M, Bettinger D. Adjuvant Transjugular Variceal Occlusion at Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS): Efficacy and Risks of Bucrylate Embolization. Cardiovasc Intervent Radiol 2019; 42:729-736. [PMID: 30788517 DOI: 10.1007/s00270-019-02176-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/31/2019] [Indexed: 02/06/2023]
Abstract
Adjuvant embolization of varices may reduce rebleeding in patients with a transjugular intrahepatic portosystemic shunt (TIPS). The aim of this study was to investigate the efficacy and the risks of adjuvant variceal embolization at TIPS implantation using bucrylate. PATIENTS AND METHODS The retrospective study evaluated 104 of 237 cirrhotic patients with TIPS for variceal bleeding who received adjuvant bucrylate embolization. For TIPS creation, bare stents were used in 35 patients (33.7%) and covered stents in 69 patients (66.3%) patients. Isolated gastric varices were seen in 10 patients (9.6%). RESULTS Six patients (5.8%) rebled during a median follow-up time of 26 months (1-57 months). Rebleeding occurred in 14% (5/35) of patients with a bare stent but only in 1.4% (1/69) of patients with a covered stent. The 1- and 2-year rebleeding rates of all patients were 0.9 and 2.9% and of patients receiving a bare stent were 2.9 and 8.6%, respectively. Bucrylate migration was seen in 13 patients (12.5%). In 9 of these patients (8.7%), asymptomatic lung embolization occurred. This was rare in patients with esophageal varices (3.1%) but frequent (60%) in patients with isolated gastric varices and a spontaneous splenorenal shunt. CONCLUSIONS Our results suggest that adjuvant embolization using bucrylate is effective and delays variceal rebleeding. The general use of covered stents, however, alleviates the utility of adjuvant bucrylate embolization which may be restricted to patients with a high risk of rebleeding indicated by large varices, active, acute or recent variceal bleeding and advanced cirrhosis. Bucrylate should not be used in isolated gastric varices because it bears a high risk of migration into the lungs.
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Affiliation(s)
- Michael Schultheiß
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Max Giesler
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Lars Maruschke
- Department of Radiology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Lukas Sturm
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Robert Thimme
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Martin Rössle
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Dominik Bettinger
- Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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20
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Endoscopic Sclerotherapy with a Large Volume of High Concentration of Cyanoacrylate for Jejunal Variceal Bleeding bys Single-Balloon Enteroscopy. ACTA ACUST UNITED AC 2018; 54:medicina54050068. [PMID: 30344299 PMCID: PMC6262278 DOI: 10.3390/medicina54050068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022]
Abstract
Jejunal varices are a rare manifestation of portal hypertension, and they are associated with a high mortality and poor prognosis when bleeding occurs. A bleeding jejunal varix is much more challenging to diagnose and manage because of its anatomic location. Herein, we describe the case of a 62-year-old man with active jejunal variceal bleeding who presented with massive hematochezia and hypovolemic shock. He was treated successfully with a high volume and concentration of a glue mixture as endoscopic sclerotherapy using single-balloon enteroscopy in the intensive care unit. Enteroscopic sclerotherapy is an effective option for jejunal variceal bleeding.
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21
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Michael PG, Antoniades G, Staicu A, Seedat S. Pulmonary Glue Embolism: An unusual complication following endoscopic sclerotherapy for gastric varices. Sultan Qaboos Univ Med J 2018; 18:e231-e235. [PMID: 30210858 DOI: 10.18295/squmj.2018.18.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/29/2018] [Accepted: 02/18/2018] [Indexed: 12/31/2022] Open
Abstract
A pulmonary glue embolism is an unusual but potentially life-threatening complication following the treatment of variceal bleeding, especially in patients with large varices requiring large volumes of sclerosant. Other contributory factors include the rate of injection and ratio of the constituent components of the sclerosant (i.e. n-butyl-cyanoacrylate and lipiodol). This condition may be associated with a delayed onset of respiratory compromise. Therefore, a high degree of clinical suspicion is essential in patients with unexplained cardiorespiratory decline during or following endoscopic sclerotherapy. We report a 65-year-old man who was admitted to the Hull Royal Infirmary, Hull, UK, in 2017 with haematemesis and melaena. He subsequently developed acute respiratory distress syndrome secondary to a glue embolism following emergency sclerotherapy for bleeding gastric varices. The aetiology of the embolism was likely a combination of the large size of the gastric varices and the large volume of cyanoacrylate needed. After an endoscopy, the patient underwent transjugular intrahepatic portosystemic shunting twice to control the bleeding, after which he recovered satisfactorily.
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Affiliation(s)
| | | | - Anca Staicu
- Department of Gastroenterology, Hull & East Yorkshire Hospitals National Health Service Trust, Hull, UK
| | - Shahid Seedat
- Department of Radiology, Hull Royal Infirmary, Hull, UK
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22
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Kimura G, Hashimoto Y, Ikeda M. Successful obliteration of bleeding duodenal varices by EUS-guided injection of N-butyl-2-cyanoacrylate. VideoGIE 2017; 2:317-319. [PMID: 30027135 PMCID: PMC6031286 DOI: 10.1016/j.vgie.2017.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Gen Kimura
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yusuke Hashimoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
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23
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Khera PS, Myungsu L, Joonsung C. Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows. Indian J Radiol Imaging 2017; 27:100-104. [PMID: 28515596 PMCID: PMC5385763 DOI: 10.4103/0971-3026.202952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.
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Affiliation(s)
- Pushpinder S Khera
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Lee Myungsu
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Choi Joonsung
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
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24
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Calvert AD, Dyer AW, Montgomery VA. Embolization of prostatic brachytherapy seeds to pulmonary arteries: a case study. Radiol Case Rep 2017; 12:34-38. [PMID: 28228874 PMCID: PMC5310242 DOI: 10.1016/j.radcr.2016.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/21/2016] [Accepted: 10/03/2016] [Indexed: 11/30/2022] Open
Abstract
Pulmonary seed embolization is a complication of prostatic brachytherapy with varying incidence rates. Key factors that reportedly influence the incidence of seed embolization include planning volume, quantity of seeds, seed placement, and type of seeds (stranded vs free). The clinical implications of seed migration are unclear because sequelae were not demonstrated in multiple short-term studies yet there have been several reports of long-term complications. We report a case of a 56-year-old patient who presented with dyspnea approximately 6 years after brachytherapy treatment for a very low-risk prostate cancer. Chest radiograph showed multiple linear densities overlying the right suprahilar lung. Computed tomography confirmed the location of the densities within the pulmonary arteries in the right upper lobe.
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Affiliation(s)
- Alexander D Calvert
- Department of Radiology, Methodist University Hospital, 1265 Union Ave, Memphis, TN, USA
| | - Andrew W Dyer
- Department of Radiology, Methodist University Hospital, 1265 Union Ave, Memphis, TN, USA
| | - Van A Montgomery
- Department of Radiology, Methodist University Hospital, 1265 Union Ave, Memphis, TN, USA
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25
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Burke MP, O'Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection. Forensic Sci Med Pathol 2017; 13:82-85. [PMID: 28091982 DOI: 10.1007/s12024-016-9835-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 01/27/2023]
Abstract
We present the case of a 25 year old woman with a complex past medical history including Crigler-Najjar syndrome (Type 1) with a liver transplant in 1993 and subsequent development of cirrhosis with portal hypertension in the transplanted liver. The deceased presented to hospital with hematemesis and investigations showed a large gastric varix. The varix was injected with cyanoacrylate glue. Within 30 min of injection the patient became acutely hypoxic. Urgent chest X-ray demonstrated radio opaque glue within the pulmonary arteries. It was evident that future treatment was futile and supportive treatment was withdrawn. The deceased was referred for medico legal post mortem examination. The post mortem CT scan performed prior to autopsy showed widespread radio-opaque material within the pulmonary arteries. At autopsy, rubbery grey/tan "clot" occluded the major proximal and segmental pulmonary arteries. Microscopic examination of the "clot" showed clumps of erythrocytes surrounded by foreign material. We discuss this relatively uncommon but well recognized complication of variceal injection with cyanoacrylate glue.
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Affiliation(s)
- Michael Philip Burke
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia. .,Department of Forensic Medicine, Monash University, Melbourne, Australia.
| | - Chris O'Donnell
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Yeliena Baber
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Australia
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26
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Lin H, Xu Y, Tian F, Chen QF, Chen XT. Clinical effects of a modified sandwich method for Lg f type gastric varices. Shijie Huaren Xiaohua Zazhi 2016; 24:3910-3914. [DOI: 10.11569/wcjd.v24.i27.3910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the efficacy and safety of a modified sandwich method (endoscopic injection of tissue adhesive and lauromacrogol) for Lgf type gastric varices.
METHODS A retrospective study was performed to review the clinical and follow-up data of 30 patients with Lgf type gastric varices, who were treated by the modified sandwich method (lauromacrogol-tissue adhesive-lauromacrogol). Then we analysed the endoscopic variceal manifestations, hemostatic rate, improvement of gastric varices, rebleeding rate and complications.
RESULTS The average follow-up time was 6.43 mo ± 2.82 mo. Varices disappeared in 20 (66.67%) patients, were reduced in 7 (23.33%), and showed no change in 2 (10.00%). Intraoperative bleeding occurred in 1 case and rebleeding occurred in another case within 24 h. Abdominal pain occurred in 8 (26.7%) patients, low-grade fever and transient bacteremia in 2 (8.7%), all of which recovered after symptomatic treatment for 1-2 d. No patients had ectopic embolism.
CONCLUSION The modified sandwich method is effective and safe for Lgf type gastric varices.
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27
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Mansoor E, Singh A, Nizialek G, Veloso HM, Katz J, Cooper GS, Isenberg G. Massive Gastrointestinal Bleeding Due to Isolated Jejunal Varices in a Patient With Extrahepatic Portal Hypertension: A Case Report. Am J Gastroenterol 2016; 111:1209-11. [PMID: 27481431 DOI: 10.1038/ajg.2016.191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Emad Mansoor
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Ajaypal Singh
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gregory Nizialek
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Hazel Marie Veloso
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Jeffry Katz
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gregory S Cooper
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Gerard Isenberg
- Division of Gastroenterology and Liver Disease, Department of Medicine-Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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28
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Singh V, Singh R, Bhalla A, Sharma N. Cyanoacrylate therapy for the treatment of gastric varices: a new method. J Dig Dis 2016; 17:392-8. [PMID: 27107396 DOI: 10.1111/1751-2980.12351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 02/11/2016] [Accepted: 04/18/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cyanoacrylate (CYA) injection is recommended for bleeding gastric varices (GV) but with significant adverse effects. Transesophageal endoscopic ultrasound-guided therapy of large GV with a combined coil and CYA injection has shown promising results. However, it is expensive and requires technical expertise. In this study, we aimed to compare the safety and efficacy of a new method with UCYA [undiluated CYA (UCYA) followed by lipiodol-diluated CYA (DCYA)] in the management of large bleeding GV. METHODS Fifteen consecutive patients with bleeding from large GV (>1 cm) were prospectively treated with DCYA and another 15 patients treated with UCYA retrospectively. All patients in the DCYA group underwent thoracic computed tomography scan to identify glue embolism. RESULTS Baseline characteristics were similar between the two groups. Rates of GV obliteration and rebleeding were 100% vs 93.3% (P = 0.309) and 6.7% vs 33.3% (P = 0.06) in the DCYA and UCYA groups, respectively. One patient in the UCYA group had needle fixation which led to fatal bleeding after forceful needle extraction. In DCYA group none had glue embolism. CONCLUSIONS Both UCYA and DCYA are effective in treating bleeding from large GV. DCYA has lower rebleeding rates and tends to have fewer adverse events than UCYA injection, although the differences are not statistically significant. Large-sample-sized prospective randomized trials are required.
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Affiliation(s)
- Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjan Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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29
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Abstract
The continued need to develop minimally invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. EUS has now stepped into the therapeutic arena. EUS provides the unique advantage of both real-time imaging and access to structures within and adjacent to the gastrointestinal (GI) tract. Hence, EUS-guided therapeutic techniques continue to evolve in several directions enabling a variety of minimally invasive therapies for pancreatic and biliary pathologies. Furthermore, the close proximity of the GI tract to vascular structures in the mediastinum and abdomen permits EUS-guided vascular access and therapy. Studies have demonstrated several EUS-guided vascular interventions by using standard endoscopic accessories and available tools from the interventional radiology armamentarium. This article provides an overview of the literature including clinical and nonclinical studies for the management of nonvariceal and variceal GI bleeding, formation of intrahepatic portosystemic shunts (IPSS), and EUS-guided cardiac access and therapy.
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Affiliation(s)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Endoscopic ultrasound (EUS)-guided coil injection therapy of esophagogastric and ectopic varices. Surg Endosc 2015; 30:1396-404. [PMID: 26139494 DOI: 10.1007/s00464-015-4342-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/17/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic band ligation and glue injection are established techniques for variceal bleeding. As EUS may enhance variceal detection and improve therapeutic targeting, we aim to report our experience on EUS-guided coil embolization, with and without concomitant glue injection, of varices. METHODS A prospectively maintained EUS database was retrospectively reviewed to identify consecutive patients who underwent EUS-guided variceal angiotherapy. All patients had failed or were poor candidates for standard endoscopic, surgical, or interventional radiologic therapies. The main outcome measurements were rates of rebleeding and adverse events. RESULTS Fourteen patients [mean age 58 (SD 12) years, 50% male] underwent EUS-guided coil injection with (n = 4) or without (n = 10) concomitant glue injection to treat esophagogastric (n = 1), gastric (n = 5), duodenal (n = 3), or choledochal (n = 5) varices. Prior endoscopic and cross-sectional imaging detected only 57 and 64% of the varices seen. A mean of 5.1 (SD 1.9) coils and a median of 3.25 (range 2-3.5) mL of cyanoacrylate were injected during the initial procedure. During median follow-up of 12 (range 1-104) months, three patients died from unrelated causes and eight patients did not have further bleeding episodes. In the remaining three patients who had choledochal varices, the frequency and intensity of rebleeding decreased significantly. Only one asymptomatic adverse event occurred with coil migration to the liver. CONCLUSIONS EUS-guided angiotherapy of varices is safe and feasible in selected patients who failed conventional therapy, and should be considered in the clinical management of these patients.
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Fujii-Lau LL, Wong Kee Song LM, Levy MJ. New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:553-67. [PMID: 26142038 DOI: 10.1016/j.giec.2015.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic treatment of gastrointestinal (GI) bleeding is considered the first line of therapy. Although standard techniques, such as epinephrine injection, through-the-scope hemoclips, bipolar coagulation, argon plasma coagulation, and band ligation are routinely used, some GI bleeds are refractory to these therapies. Newer technologies have emerged to assist with the treatment of GI bleeding. This article highlights endoscopic and endoscopic ultrasound-guided therapies that may be used by experienced endoscopists for the primary control of GI bleeding or for cases refractory to standard hemostatic techniques.
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Affiliation(s)
- Larissa L Fujii-Lau
- Division of Gastroenterology and Hepatology, Washington University, 660 S. Euclid Ave Campus, Box 8124, St Louis, MO 63110, USA
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Crisan D, Tantau M, Tantau A. Endoscopic management of bleeding gastric varices--an updated overview. Curr Gastroenterol Rep 2015; 16:413. [PMID: 25189661 DOI: 10.1007/s11894-014-0413-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastric varices (GVs) are known to bleed massively and often difficult to manage with conventional techniques. This article aims to overview the endoscopic methods for the management of acute gastric variceal bleeding, especially the advantages and limits of GV obliteration with tissue adhesives, by comparison with band ligation and other direct endoscopic techniques of approach. The results of indirect radiological and surgical techniques of GV treatment are shortly discussed. A special attention is payed to the emerging role of endoscopic ultrasound in the therapy of bleeding GV, in the confirmation of its eradication and in follow-up strategies.
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Affiliation(s)
- Dana Crisan
- 3rd Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania,
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Fujii-Lau LL, Law R, Wong Kee Song LM, Levy MJ. Novel techniques for gastric variceal obliteration. Dig Endosc 2015; 27:189-96. [PMID: 25079248 DOI: 10.1111/den.12337] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 07/28/2014] [Indexed: 12/29/2022]
Abstract
Acute hemorrhage related to gastric varices (GV) is more severe and often more difficult to immediately treat upon detection, leading to a poorer patient prognosis, as compared to esophageal variceal bleeding. Currently, the recommended treatment of bleeding GV is endoscopic cyanoacrylate injection and transjugular intrahepatic portosystemic shunt placement for endoscopic failures. Newer endoscopic (e.g. hemospray) and endosonographic (e.g. coil injection, glue obliteration, or combined coil and glue injection) techniques have been developed to offer an alternative treatment and improve patient outcome. The present article serves to review the endoscopic, endosonographic, and interventional radiological techniques used to treat GV and their clinical applications.
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Abstract
Gastric varices (GV) are present in one in 5 patients with portal hypertension and variceal bleeding. GV bleeds tend to be more severe with higher mortality. High index of suspicion, early detection and proper locational diagnosis are important. An algorithmic approach to the management of GV bleeding prevents rebleeds and improves survival. Vasoactive drugs should be started with in 30 minutes (door to needle time) and early endotherapy be done. Cyanoacrylate injection in experienced hands achieves hemostasis in >90% patients. A repeat session is sometimes needed for complete obturation of GV. Transjugular intrahepatic portosystemic shunt and balloon retrograde transvenous obliteration are effective rescue options. Secondary prophylaxis of GV bleeding is done with beta-blocker and endotherapy.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1, Vasant Kunj, New Delhi 110010, India.
| | - Awinash Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, D1, Vasant Kunj, New Delhi 110010, India
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Chew JRY, Balan A, Griffiths W, Herre J. Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage. BMJ Case Rep 2014; 2014:bcr-2014-206461. [PMID: 25320260 DOI: 10.1136/bcr-2014-206461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A non-contrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications.
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Affiliation(s)
- Joyce Ruo Yi Chew
- Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Anu Balan
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jurgen Herre
- Department of Respiratory Medicine, Addenbrooke's Hospital, Cambridge, UK
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Affiliation(s)
- Richard Conway
- From the Department of Intensive Care Medicine, St. James Hospital, Dublin, Ireland
| | - Ahmed Aglan
- From the Department of Intensive Care Medicine, St. James Hospital, Dublin, Ireland
| | - Enda O'Connor
- From the Department of Intensive Care Medicine, St. James Hospital, Dublin, Ireland
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EUS-guided angiotherapy for gastric varices: coil, glue, and sticky issues. Gastrointest Endosc 2013; 78:722-5. [PMID: 24120335 DOI: 10.1016/j.gie.2013.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 07/03/2013] [Indexed: 12/14/2022]
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Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, Subtil-Inigo JC, Junquera-Florez F, Gornals JB, Repiso-Ortega A, Vila-Costas J, Marcos-Sanchez F, Muñoz-Navas M, Romero-Gomez M, Brullet-Benedi E, Romero-Vazquez J, Caunedo-Alvarez A, Pellicer-Bautista F, Herrerias-Gutierrez JM, Fritscher-Ravens A. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 2013; 78:711-21. [PMID: 23891417 DOI: 10.1016/j.gie.2013.05.009] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 05/08/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative. OBJECTIVES To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability. DESIGN Retrospective analysis of a prospectively maintained database. SETTING Multicenter study, tertiary referral centers. PATIENTS AND INTERVENTIONS Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment. RESULTS There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding. LIMITATIONS Nonrandomized; EUS expertise necessary. CONCLUSIONS EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.
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Affiliation(s)
- Rafael Romero-Castro
- Service of Gastroenterology, University Hospital Virgen Macarena, Sevilla, Spain
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Choi MH, Kim YS, Kim SG, Lee YN, Seo YR, Kim MJ, Lee SH, Jeong SW, Jang JY, Kim HS, Kim BS. The secondary prophylactic efficacy of beta-blocker after endoscopic gastric variceal obturation for first acute episode of gastric variceal bleeding. Clin Mol Hepatol 2013; 19:280-7. [PMID: 24133666 PMCID: PMC3796678 DOI: 10.3350/cmh.2013.19.3.280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The most appropriate treatment for acute gastric variceal bleeding (GVB) is currently endoscopic gastric variceal obturation (GVO) using Histoacryl®. However, the secondary prophylactic efficacy of beta-blocker (BB) after GVO for the first acute episode of GVB has not yet been established. The secondary prophylactic efficacy of BB after GVO for the first acute episode of GVB was evaluated in this study. METHODS Ninety-three patients at Soonchunhyang University Hospital with acute GVB who received GVO using Histoacryl® were enrolled between June 2001 and March 2010. Among these, 42 patients underwent GVO alone (GVO group) and 51 patients underwent GVO with adjuvant BB therapy (GVO+BB group). This study was intended for patients in whom a desired heart rate was reached. The rates of rebleeding-free survival and overall survival were calculated for the two study groups using Kaplan-Meyer analysis and Cox's proportional-hazards model. RESULTS The follow-up period after the initial eradication of gastric varices was 18.14±25.22 months (mean±SD). During the follow-up period, rebleeding occurred in 10 (23.8%) and 21 (41.2%) GVO and GVO+BB patients, respectively, and 39 patients died [23 (54.8%) in the GVO group and 16 (31.4%) in the GVO+BB group]. The mean rebleeding-free survival time did not differ significantly between the GVO and GVO+BB groups (65.40 and 37.40 months, respectively; P=0.774), whereas the mean overall survival time did differ (52.54 and 72.65 months, respectively; P=0.036). CONCLUSIONS Adjuvant BB therapy after GVO using Histoacryl® for the first acute episode of GVB could decrease the mortality rate relative to GVO alone. However, adjuvant BB therapy afforded no benefit for the secondary prevention of rebleeding in GV.
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Affiliation(s)
- Moon Han Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Korea
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40
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices. World J Gastroenterol 2013; 19:5125-5130. [PMID: 23964147 PMCID: PMC3746385 DOI: 10.3748/wjg.v19.i31.5125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/14/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.
METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.
RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.
CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.
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Elrazek AEMAA, Yoko N, Hiroki M, Afify M, Asar M, Ismael B, Salah M. Endoscopic management of Dieulafoy’s lesion using Isoamyl-2-cyanoacrylate. World J Gastrointest Endosc 2013; 5:417-419. [PMID: 23951399 PMCID: PMC3742709 DOI: 10.4253/wjge.v5.i8.417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 07/01/2013] [Indexed: 02/05/2023] Open
Abstract
Dieulafoy’s lesion (DL) is a rare but important cause of obscure gastrointestinal bleeding that may be overlooked during diagnostic endoscopy. Mortality rates are similar to those of other causes for gastrointestinal bleeding. Diagnosis by upper endoscopy is the modality of choice during acute bleeding. In the absence of active bleeding, the lesion resembles a raised nipple or visible vessel. There are no guidelines regarding effective selective therapy for DL, when diagnosed, endoscopist experience is the major determinant of the treatment strategy. Following our strategy, an expert endoscopist with a skilled assistant should have a high rate of successful DL diagnosis when an obscured gastrointestinal lesion is suspected. Cyanoacryltes compounds have been used successfully in management of Gastric varices and DLs. To our knowledge, there have been no previous reports regarding use of isoamyl-2-cyanoacrylate (AMCRYLATE®; Concord Drugs Ltd., Hyderabad, India) as an effective therapy for gastric DL without serious complications. In our case study, Isoamyl-2-cyanoacrylate (AMCRYLATE®) was effective and safe for treating DL. Surgical wedge resection of the lesion should be considered as a therapeutic option if endoscopic therapy fails.
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Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Rodriguez SA. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013; 78:209-15. [PMID: 23867370 DOI: 10.1016/j.gie.2013.04.166] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/11/2022]
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Narváez-Rivera RM, Cortez-Hernández CA, González-González JA, Tamayo-de la Cuesta JL, Zamarripa-Dorsey F, Torre-Delgadillo A, Rivera-Ramos JFJ, Vinageras-Barroso JI, Muneta-Kishigami JE, Blancas-Valencia JM, Antonio-Manrique M, Valdovinos-Andraca F, Brito-Lugo P, Hernández-Guerrero A, Bernal-Reyes R, Sobrino-Cossío S, Aceves-Tavares GR, Huerta-Guerrero HM, Moreno-Gómez N, Bosques-Padilla FJ. [Mexican consensus on portal hypertension]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:92-113. [PMID: 23664429 DOI: 10.1016/j.rgmx.2013.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 11/30/2012] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.
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Affiliation(s)
- R M Narváez-Rivera
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario «Dr. José Eleuterio González», Monterrey, N.L., México
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Smith GH, McEachan JE, McLean A, Huntley JS. Prevention of knot slippage with the use of cyanoacrylate glue: a mechanical study. J Orthop Surg (Hong Kong) 2013; 21:65-7. [PMID: 23629991 DOI: 10.1177/230949901302100117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the effect of cyanoacrylate glue on knot slippage and strength in vitro. METHODS Ethibond 3/0 was tested using a tensile tester. A single drop of cyanoacrylate glue was applied to the knots. Seven knot configurations (10 samples each) were tested: (1) a surgeon's knot (S) plus 4 square throws (+4) without glue (control group), (2) S plus one square throw (+1) without glue, (3) S+1 with glue, (4) S with glue, (5) S+1 wet posttie without glue, (6) S+1 wet pre-tie without glue, and (7) S+1 wet pre-tie with glue. Wet sutures were immersed in normal saline for 24 hours prior to knot tying. Wet pre- and post-tie sutures were immersed for one minute prior to knot tying and tensile testing, respectively. Outcome measures were the mode of failure (knot slippage or suture snapping) and the ultimate tensile strength. RESULTS All knots without glue failed owing to knot slippage, except for the controls, whereas all knots with glue failed owing to suture snapping. The ultimate tensile strength was significantly higher in knots with glue and controls than in knots without glue. The ultimate tensile strength did not differ significantly between S+4 without glue and S with glue (p=0.48), indicating that glue could reinforce knots and reduce the number of throws needed. Wet suture is protective against failure (p<0.01). CONCLUSION Cyanocrylate glue may have clinical applications for flexor tendon repairs for which a reduced knot size is advantageous.
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Affiliation(s)
- George H Smith
- South East Scotland Rotation, Royal Infirmary, Edinburgh, United Kingdom.
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Tantau M, Crisan D, Popa D, Vesa S, Tantau A. Band ligation vs. N-Butyl-2-cyanoacrylate injection in acute gastric variceal bleeding: a prospective follow-up study. Ann Hepatol 2013. [PMID: 24378269 DOI: 10.1016/s1665-2681(19)30907-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND. Treatment of gastric varices (GV) implies a number of several difficulties and sometimes entails complications. The best endoscopic success rate was attributed until now to the use of tissue adhesives(N-Butyl-2-Cyanoacrylate) and band ligation. AIM. To assess the therapeutic efficacy and safety of cyanoacrylate injection compared to band ligation in patients with acute GV hemorrhage. MATERIAL AND METHODS. Thirty-seven patients with upper gastrointestinal bleeding from GV were included in the study, treated with cyanoacrylate injection (GVO)-19 patients or band ligations (GVL)-18 patients. They were followed up for overall results, complications and survival rate. RESULTS. The mean age of the study group was 60.22 ± 9.34 years, with a male/female ratio of 21:16. The mean follow-up period was 427.26 ± 214.16 days in the GVO group and 406.21 ± 213.23 days in the GVL group (p = 0.76). Initial hemostasis was achieved in all patients treated with cyanoacrylate and in 88.88% from the GVL group (p = 0.43). Rebleeding occurred in 72.22% of the GVL group and in 31.57% of the GVO patients (p = 0.03). Patients in the GVO group had a significantly larger rebleeding-free period(p = 0.006). No difference was found in survival rates(p = 0.75). The Child Class (p = 0.003 for Class C) and treatment method (p = 0.01) were independently associated with the rate of rebleeding. No differences were found regarding the rate of complications. CONCLUSION. The use of cyanoacrylate in acute GV bleeding had better results when compared with band ligation in terms of controlling the hemorrhage and recurrence of bleeding. The overall survival rate was not influenced by the method used for the treatment of complicated GV.
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Affiliation(s)
- Marcel Tantau
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor"; 3rd. Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana Crisan
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor"; 3rd. Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Stefan Vesa
- Department of Pharmacology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alina Tantau
- 4th. Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices. World J Gastroenterol 2012; 18:1373-8. [PMID: 22493551 PMCID: PMC3319964 DOI: 10.3748/wjg.v18.i12.1373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices.
METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.
RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient.
CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.
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Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012; 2:55-69. [PMID: 25755406 PMCID: PMC3940364 DOI: 10.1016/s0973-6883(12)60088-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/22/2011] [Indexed: 02/06/2023] Open
Abstract
Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10-20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3-30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15-30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0-10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5-4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.
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Affiliation(s)
- Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Address for correspondence: Vivek A Saraswat, Professor, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Percutaneous transhepatic obliteration for massive variceal rectal bleeding. Emerg Radiol 2012; 19:355-8. [PMID: 22370695 DOI: 10.1007/s10140-012-1032-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/16/2012] [Indexed: 12/22/2022]
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Singer AD, Fananapazir G, Maufa F, Narra S, Ascher S. Pulmonary embolism following 2-octyl-cyanoacrylate/lipiodol injection for obliteration of gastric varices: an imaging perspective. J Radiol Case Rep 2012; 6:17-22. [PMID: 22690282 DOI: 10.3941/jrcr.v6i2.845] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bleeding from esophageal and gastric varices remains a significant cause of morbidity and mortality for patients with liver cirrhosis. Currently, therapeutic strategies for gastric variceal bleeding include transjugular intrahepatic portosystemic shunt, cyanoacrylate sclerotherapy and hepatic transplantation. Though relatively safe and efficacious, endoscopic sclerotherapy using cyanoacrylate has known complications including infection, bleeding, and distal embolization. This case report describes a patient who became febrile and tachycardic following sclerotherapy and subsequently had an abnormal chest radiograph that prompted further evaluation for pulmonary embolization of the sclerosant. The focuses of this report are the computed tomographic and radiographic findings associated with 2-octyl-cyanoacrylate/lipiodol pulmonary embolization.
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Affiliation(s)
- Adam Daniel Singer
- Department of Internal Medicine, Georgetown University Hospital, Washington, D.C., USA.
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