EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis

Advances in the diagnosis and management of clinically significant portal hypertension in cirrhosis: A narrative review

Clinically significant Portal hypertension (PH), defined by a hepatic venous pressure gradient (HVPG) greater than 10 mmHg, is a key predictor of decompensation events in cirrhosis, leading to variceal hemorrhage, ascites, and hepatic encephalopathy. This narrative review explores the pathophysiology of PH in cirrhosis, evaluates diagnostic methods for identifying clinically significant PH (CSPH), and discusses guideline-driven strategies to prevent initial and further decompensation. While HVPG remains the gold standard for diagnosing CSPH, non-invasive tools such as liver stiffness measurement and spleen stiffness measurement are increasingly used for initial risk stratification. The combined use of these tools reduces the proportion of patients in the diagnostic "grey zone". Endoscopic ultrasound-guided portal pressure gradient is an emerging diagnostic tool that requires further validation. Non-selective beta-blockers are the cornerstone of primary prophylaxis for decompensation, and their combination with endoscopic variceal ligation is the first-line therapy for secondary prophylaxis of recurrent esophageal variceal bleeding. Statins show promise in reducing PH and preventing decompensation while further studies are still needed. This review also discusses the indications for preemptive transjugular intrahepatic portosystemic shunt and its role in managing refractory ascites and variceal bleeding.

Cyanoacrylate injection assisted by endosonographic mini-probe in the management of gastric varices: a single-center, retrospective cohort study

BACKGROUND

Gastric varices (GV) pose the potential risk of massive bleeding. Endoscopic ultrasound (EUS) guided real-time delivery of adhesives and devices has emerged as a promising therapeutic modality for GV but was limited in its generalizability due to the unavailability and lack of expertise of linear echoendoscopy. Therefore, we utilized the more readily available EUS mini-probe (EMP) in assisting cyanoacrylate (CYA) injection in the management of GV.

METHODS

This is a retrospective cohort study from a single tertiary medical center. One hundred and thirty-three eligible patients were divided into three groups based on the treatment modalities including EMP-guided CYA injection via a dual-channel gastroscope (EMP-D group), EMP-guided injection via a single-channel gastroscope (EMP-S group) and direct endoscopic injection (DEI group). The clinical characteristics, procedural parameters, outcomes, adverse events and follow-up data were analyzed.

RESULTS

An overall statistical significance was achieved in the number of puncture site (p < 0.001), the number of instant blood return upon puncture (p = 0.001), cyanoacrylate dose (p = 0.004), late rebleeding rate (p = 0.018), post-injection ulcer (p = 0.005), and non-rebleeding interval (p = 0.026) among the three groups. Patients in EMP-D group exhibited a lower rate of post-injection ulcer than those in DEI group (p = 0.009). Procedural time of EMP-D was shorter than that of EMP-S (p < 0.001). Less amount of cyanoacrylate was needed per reinjection session in EMP-D than in DEI (p = 0.002).

CONCLUSIONS

EMP-guided cyanoacrylate injection exhibited superior effectiveness and safety to DEI, while use of the dual-channel gastroscope further enhanced the precision and efficiency.

Endoscopic Ultrasound-Guided Variceal Therapy for Gastric Variceal Rupture After Failed Endoscopic Injection Sclerotherapy: A Case Report

Endoscopic ultrasound (EUS) has become an essential tool in vascular interventions due to its imaging potential in the proximity of various vascular structures in the mediastinum and abdominal cavity. EUS-guided variceal therapy (EUS-VT) has emerged as a promising approach for treating gastric varices (GV). Although still underused, EUS-VT offers such advantages as precise targeting and real-time variceal puncture visualization, making it a valuable alternative when conventional therapies fail. We report the case of a 63-year-old man with GVs secondary to fatty liver cirrhosis, who experienced repeated variceal ruptures despite multiple prior interventions (e.g., balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration, partial splenic embolization, and several endoscopic injection sclerotherapy (EIS) sessions). During his most recent variceal rupture episode, EUS-VT was performed. A 23-gauge sclerotherapy needle failed to reach the target varix under EUS guidance. However, successful puncture and obliteration could be achieved using a 22-gauge fine-needle aspiration needle and cyanoacrylate glue. Doppler imaging confirmed lipiodol distribution and the absence of blood flow, indicating successful embolization. No adverse events occurred or rebleeding was observed during the one-month follow-up. This case demonstrates the clinical utility of EUS-VT as a rescue therapy for gastric variceal bleeding in patients with anatomically complex lesions refractory to standard treatments. EUS-VT should be considered a viable option in selected cases when conventional EIS is unsuccessful due to anatomical limitations.

Advances in Endo-Hepatology: The Role of Endoscopic Ultrasound in the Management of Portal Hypertension

Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a "one-stop strategy", integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH.

Risk Factors for Glue Extrusion Bleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Retrospective Study of 269 Patients

BACKGROUND

Glue extrusion bleeding is a major complication of endoscopic cyanoacrylate glue injection for the treatment of gastric varices. However, its risk factors remain unclear.

AIMS

This retrospective study aimed to evaluate the risk factors for bleeding associated with glue extrusion.

METHODS

This study analyzed the medical data of cirrhotic patients who underwent endoscopic obliteration for gastric varices using cyanoacrylate glue between January 2016 and December 2022. The data within 1 year after therapy were carried out with logistic regression. A nomogram model was constructed based on the factors.

RESULTS

269 patients were enrolled. Risk factors associated with glue extrusion bleeding included the volume of the glue (≥ 4 mL)(OR 1.289, 95% CI 1.051-1.580; P = 0.015), massive ascites (OR 5.645, 95% CI 2.260-14.097; P = 0.000), active hemorrhage during endoscopy (OR 2.830, 95% CI 1.284-6.234; P = 0.010), and the use of β-blockers was a protective factor (OR 0.185, 95% CI 0.07-0.485; P = 0.001). The nomogram model had good prediction accuracy, with an area under the curve of 0.74 (95% CI 0.658-0.822; P < 0.001).

CONCLUSION

Massive ascites, active hemorrhage during endoscopy, glue volume ≥ 4 mL, and the use of β-blockers are associated with glue extrusion bleeding. At-risk patients may benefit from controlling the volume of the glue, undergoing endoscopic ultrasound and using β-blockers.

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Endoscopic ultrasound guided liver biopsy and portal pressure gradient: when, why and how? Can it become the standard of care in endo-hepatology?

INTRODUCTION

The armamentarium of 'Endo-hepatology' is proliferating with the advancements in techniques and availability of new devices in the field of endoscopic ultrasound (EUS). This has resulted in the merger of multitude of diagnostic and therapeutic interventions, such as EUS-liver biopsy (LB), EUS-angioembolization of gastric varices, EUS-portal pressure gradient (PPG) measurement, and others into a 'one-stop-shop' for efficient patient management. Lack of standardization of these techniques forms a major hinderance in their widespread adoption.

AREAS COVERED

A comprehensive literature search was undertaken across various databases on EUS-LB and EUS-PPG till November 2024 for reviews, observational studies, and randomized trials on EUS-LB and EUS-PPG, describing its indications, technique, and data of safety and efficacy, detailing its role in day-to-day clinical practice.

EXPERT OPINION

EUS-LB and EUS-PPG have shown promise in the ever-growing field of endo-hepatology. EUS-LB has exhibited excellent safety profile and comparable tissue yield compared to its percutaneous counterpart. On the other hand, EUS-PPG seems to be a viable alternative although it needs to be standardized further. From a patient and hospital perspective, they might prove to be convenient and cost-effective. Nevertheless, more evidence is warranted before they can be labeled as the new standard of care.

EUS-guided coiling plus glue injection compared with endoscopic glue injection alone in endoscopic treatment for gastric varices: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided coil plus glue injection has emerged as a safe and effective modality for gastric varices (GVs). Very few studies have compared EUS embolization with the direct endoscopic glue injection (EGI) technique for its safety and effectiveness. In this systematic review and meta-analysis, we compared the outcomes of EUS-guided coil plus glue injection versus EGI.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched for studies that compared EUS and EGI for GVs, and 1454 articles were screened following the Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol. Endpoints were pulmonary embolism, recurrent bleeding rate, reintervention rate, technical success, abdominal pain, and mortality rate. A restricted maximum likelihood random-effects model with odds ratios (ORs) and 95% confidence intervals (CIs) was used for binary endpoints. Heterogeneity was evaluated through Cochrane's Q statistic and Higgins and Thompson's I2 statistic. Significance was defined as P < .05.

RESULTS

We included 6 studies with 445 patients treated for GVs. Mean patient age was 49 years, and 43% were women. EUS was associated with a reduction in recurrent bleeding rate (OR, .22; 95% CI, .11-.45; P < .001; I2 = 0) and reintervention rate (OR, .29; 95% CI, .09-.89; P = .03; I2 = 49%) compared with EGI. There were no differences between groups in pulmonary embolism (OR, .34; 95% CI, .10-1.18; P = .09; I2 = 0%), mortality rate (OR, .78; 95% CI, .28-2.13; P = .63; I2 = 0%), technical success (OR, 3.50; 95% CI, .60-20.49; P = .16; I2 = 0%), fever (OR, 1.49; 95% CI, .42-5.21 days; P = .5; I2 = 0%), and abdominal pain (OR, .96; 95% CI, .31-2.95; P = .94; I2 = 32%).

CONCLUSIONS

In patients with GVs, EUS-guided coil plus glue injection is associated with lower recurrent bleeding and reintervention rates than EGI with no difference in pulmonary embolization rate, abdominal pain, technical success, and mortality rate.

Causes, management, and prognosis of severe gastrointestinal bleedings in critically ill patients with pancreatic cancer: A retrospective multicenter study

BACKGROUND

Gastrointestinal (GI) bleeding is a leading cause of intensive care unit (ICU) admission in pancreatic cancer patients.

AIMS

To analyze causes, ICU mortality and hemostatic treatment success rates of GI bleeding in pancreatic cancer patients requiring ICU admission.

METHODS

Retrospective multicenter cohort study between 2009 and 2021. Patients with a recent pancreatic resection surgery were excluded.

RESULTS

Ninety-five patients were included (62 % males, 67 years-old). Fifty-one percent presented hemorrhagic shock, 41 % required mechanical ventilation. Main GI bleeding causes were gastroduodenal tumor invasion (32 %), gastroesophageal varices (21 %) and arterial aneurysm (12 %). Arterial aneurysms were more frequent in patients with previous pancreatic resection (36 % vs 2 %, p < 0.001). Hemostatic procedures included gastroduodenal endoscopy in 81 % patients and arterial embolization in 28 % patients. ICU mortality was 19 %. Multivariate analysis identified four variables associated with mortality: performance status >2 (OR 9.34, p = 0.026), mechanical ventilation (OR 14.14, p = 0.003), treatment success (OR 0.09, p = 0.010), hemorrhagic shock (OR 11.24, p = 0.010). Treatment success was 46 % and was associated with aneurysmal bleeding (OR 29.89, p = 0.005), ongoing chemotherapy (OR 0.22, p = 0.016), and prothrombin time ratio (OR 1.05, p = 0.001).

CONCLUSION

In pancreatic cancer patients with severe GI bleeding, early identification of aneurysmal bleeding (particularly in case of previous resection surgery) and coagulopathy management may increase the treatment success and reduce mortality.

Therapeutic endoscopy: Recent updates and future directions

The landscape of therapeutic endoscopy has undergone a remarkable evolution over the past few decades, carving out a niche that merges innovative technology with advanced clinical practice. As we venture further into the 21st century, the horizon of this field continues to expand, driven by rapid advancements in technology and a deeper understanding of gastrointestinal pathology. This review article aims to shed light on the recent advances and future trajectories of therapeutic endoscopy, focusing on pivotal areas such as third space endoscopy, endoscopic resection techniques, artificial endoscopy, endoscopic ultrasound (EUS), the integration of artificial intelligence (AI), and endoscopic anti-reflux therapies.

Endoscopic ultrasound-guided vascular interventions: A review (with videos)

Endoscopic ultrasound (EUS) has evolved from a diagnostic to an interventional modality, allowing precise vascular access and therapy. EUS-guided vascular access of the portal vein has received increasing attention in recent years as a diagnostic and therapeutic tool. EUS-guided portal pressure gradient directly measures the hepatic vein portal pressure gradient and is crucial for understanding of liver function and prognostication of liver disease. EUS facilitates the sampling of portal venous blood to obtain circulating tumor cells (CTCs) in pancreatobiliary malignancies. This technique aids in the diagnosis and staging of cancers. EUS-guided interventions have a substantial potential for diagnosing portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma. EUS-guided coil and glue embolization have higher efficacy for the treatment of gastric varices than direct endoscopic glue. Pseudoaneurysm (PsA), a rare vascular complication of acute and chronic pancreatitis, is typically managed with interventional radiology (IR)-guided embolization and surgery. EUS is increasingly used in specialized centers for non-variceal gastrointestinal bleeding, particularly for pseudoaneurysm-related bleeding. There is limited data on EUS-guided intervention for bleeding ectopic varices, rectal varices and Dieulafoy lesions, but it is becoming more widely accepted. In this extensive review, we evaluated both current and potential future applications of EUS-guided vascular interventions, including EUS-guided gastric variceal bleed therapy, rectal and ectopic varices, pseudoaneurysmal bleeding, splenic artery embolization, portal pressure gradient measurement, portal vein sampling for CTCs, fine needle aspiration of PVTT, intrahepatic portosystemic shunt placement, liver tumor ablation and EUS-guided cardiac intervention.

Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy

Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.

EUS-Guided Vascular Interventions: Recent Advances

Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.

Advances in the endoscopic management of gastric varices

This review provides an overview of the treatment options available for gastric varices (GV) with a focus on endoscopic methods. Various minimally invasive techniques, including endoscopic band ligation, endoscopic cyanoacrylate injection, and transjugular intrahepatic portosystemic shunt, can be applied to the treatment of GV. Endoscopic cyanoacrylate injection is now recognized as a first-line treatment for GV. Endoscopic ultrasound-guided cyanoacrylate injection combined with coils has shown good security and effectiveness. Thrombin injection therapy is a promising treatment, with a similar hemostasis rate to cyanoacrylate injection but with fewer serious complications. With the deepening understanding of the hemodynamics of the GV system, various treatment methods and their combination are gradually evaluated to provide patients with safer and more effective treatment options.

Endoscopic ultrasound-guided pancreatic duct drainage: a comprehensive state of the art review

INTRODUCTION

Endoscopic retrograde pancreatography (ERP) has traditionally been the standard modality for pancreatic endotherapy. However, in certain situations, failure of retrograde ductal access may warrant an alternative modality of drainage. This can occur in various settings like difficult and/or surgically altered anatomy or duodenal obstruction. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a relatively newer addition to the armamentarium for endoscopic access to the PD.

AREAS COVERED

This comprehensive state-of-art review aims to give an overview of the indications, technical details, different approaches, and outcomes of EUS-PDD, with the latest evidence available in scientific literature.

EXPERT OPINION

Akin to its biliary drainage counterpart, EUS-PDD enables an EUS-assisted-ERP using rendezvous technique or EUS-guided drainage through transmural stenting. The technique has evolved over the ensuing years with multitude of accessories, approaches, and devices to optimize the outcomes. However, the technical success and adverse events rates need to be further improved. Additionally, it has a steep learning curve with requirements of advanced technical skill and optimum infrastructure back-up. Meticulous patient selection, precise knowledge of ductal anatomy, appropriate approach, and carefully chosen accessories can improve its clinical outcomes.

Role of endoscopy in hepatology

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?

Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.

Complications and management of interventional endoscopic ultrasound: A critical review

In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.

Endoscopic ultrasound-guided radiofrequency ablation of pancreatic insulinoma: a state of the art review

INTRODUCTION

Insulinomas are the most common functional pancreatic neuroendocrine tumors (PNETs) that lead to incapacitating hypoglycemia. Guidelines recommend surgical resection as the mainstay of management. However, surgery is fraught with complications, causing significant peri/post-operative morbidity. Since insulinomas are usually benign, solitary, small (<2 cm), and do not need lymphadenectomy, hence, in this regard, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is now being increasingly performed, to circumvent these adverse events and impairment of pancreatic function.

AREAS COVERED

A comprehensive literature search was undertaken across various databases (PubMed/MEDLINE, Embase, Scopus), with no language restriction, for relevant articles (case series, reviews, case reports) pertaining to EUS-RFA for insulinoma and PNETs, till October 2023. In this review, we have explicated the role of EUS-RFA for insulinoma management, detailing thoroughly its mechanism of action, EUS-RFA devices with data on its safety and efficacy, and an algorithmic approach for its management.

EXPERT OPINION

EUS-RFA is being advocated as a 'mini-invasive' option with the potential to replace surgery as a first-line approach for benign, sporadic, solitary, and small (<2 cm) insulinomas. Under real-time guidance, EUS-RFA has immense precision, is safe, predictable, with acceptable safety profile. Presently, it is being frequently performed for high-risk or inoperable candidates. Current need-of-the-hour is a randomized controlled trial to substantiate its role in the therapeutic algorithm for insulinoma management.