Esophageal variceal ligation plus sclerotherapy vs. ligation alone for the treatment of esophageal varices

Usefulness of double-balloon endoscopy-assisted injection sclerotherapy for hemorrhagic varices in the jejunum reconstructed for liver transplantation in a pediatric case

A 10-year-old girl was admitted to our hospital for treatment of recurrent melena and severe anemia. Her treatment history comprised Kasai's portoenterostomy for biliary atresia as an infant, followed by liver transplantation and partial splenectomy for portal hypertension at 1 year old. Her medications comprised steroids, immunosuppressive agents, a β-blocker, and a potassium-competitive acid blocker. Since the age of 5 years, she had repeatedly visited a local hospital for melena, but the bleeding source had not been identified. She was referred to our hospital, and laboratory data revealed severe anemia. An enhanced computed tomography showed post-liver transplantation status, splenomegaly, and gastric varices, without extravasation. Esophagogastroduodenoscopy and colonoscopy did not identify the bleeding source. Double-balloon endoscopy (DBE) revealed variceal bleeding and serosanguinous fluid accumulated at the choledochojejunostomy site in the jejunum. After obtaining informed consent, our team and the radiologists cooperatively performed DBE-assisted endoscopic injection sclerotherapy with 75% n-butyl-2-cyanoacrylate through a 23- gage needle according to high-resolution varicerography in a hybrid emergency room. Subsequently, the patient was discharged and regularly monitored without any complications. We demonstrated the first pediatric case of successful DBE-assisted endoscopic injection for hemorrhagic jejunal varices after liver transplantation for biliary atresia and partial splenectomy.

A case report of gastric antral vascular ectasia treated by endoscopic band ligation combined with lauromacrogol injection

RATIONALE

Gastric antral vascular ectasia (GAVE) is a rare acquired lesion characterized by vascular dilation in the gastric antrum, frequently results in occult or overt gastrointestinal bleeding. Endoscopic intervention remains the cornerstone of therapy. Argon plasma coagulation was previously considered a first treatment option. But recently, endoscopic band ligation (EBL) has emerged as an alternative, increasingly favored for its safety and efficacy. Nonetheless, a consensus on the most effective treatment approach has yet to be established.

PATIENT CONCERNS

A 74-year-old female was hospitalized for persistent chest tightness and dyspnea for 1 year. Physical examination showed an anemic appearance with normal blood pressure. Upon admission to the hospital, the blood routine examination revealed severe anemia and the fecal occult blood test was persistently positive.

DIAGNOSES

The endoscopic observations and histological evidence led to a diagnosis of GAVE for the patient.

INTERVENTIONS

Considering the poor response to prior pharmacotherapy, endoscopic intervention was selected for this hospitalization. The initial EBL alone did not yield particularly satisfactory results. Combining EBL with lauromacrogol injection as a subsequent treatment resulted in encouraging outcomes.

OUTCOMES

At the 6-week follow-up, the patient exhibited a negative fecal occult blood test, normalization of hemoglobin level, and endoscopic images demonstrated near complete resolution of vascular ectasias.

LESSONS

The combination of EBL with lauromacrogol injection has shown a satisfactory short-term outcome, providing a new option for the endoscopic management of GAVE. However, its long-term efficacy still requires further observation.

Application of a virtual ruler in predicting postoperative rebleeding from esophageal varices in patients with liver cirrhosis

BACKGROUND

Esophageal variceal diameter (EVD) is one of the most important predictors of variceal bleeding, as well as an important predictor of the effectiveness of endoscopic esophageal varices (EV) treatments. EVD is currently determined using visual inspection by endoscopic operators, meaning that results can vary widely between operators. This approach also means that cases unsuitable for endoscopic variceal ligation (EVL) can be complicated by postoperative hemorrhage. Thus, the purpose of this study was to explore the value of a virtual ruler (VR) in predicting rebleeding after the endoscopic treatment of EV in patients with cirrhosis.

METHODS

We enrolled 588 patients with cirrhosis and EV (with and without gastric varices), who were treated with EVL or endoscopic injection sclerotherapy across 3 hospitals. We categorized participants into 2 groups, a nonbleeding group and a rebleeding group, according to whether they bled again after surgery. We compared basic demographic and clinical data, laboratory tests, EVD, and treatment modalities between the 2 groups. Potential risk factors for rebleeding after EV operations were analyzed using univariate and multivariable regression analyses. Correlations between esophageal variceal rebleeding and EVD were also analyzed, as was the consistency between visual EVD estimates and EVD measured using a VR.

RESULTS

Child-Pugh class, albumin (ALB) levels, prothrombin time (PT), EVD (visual value), EVD (VR value), red sign, and the number of laps used for EVL showed statistically significant differences between the rebleeding and nonbleeding groups. Univariate regression analysis showed that Child-Pugh classification, ALB levels, PT, EVD (VR value), and red sign were strongly associated with rebleeding after endoscopic treatment of EV, whereas multivariable regression analysis showed that Child-Pugh classification, ALB levels, and EVD (VR value) were predictive factors for rebleeding after endoscopic treatment of EV. Differences between visual EVD estimates and VR EVD measurements were large. (Kappa value: 0.391, P < .001). However, the 2 methods showed high agreement for EVD >1 cm (87/95) CONCLUSION: EVD (VR value) can more accurately predict rebleeding rates. It can also provide a basis for selecting appropriate endoscopic treatment modalities for EV and effectively circumvent postoperative EV rebleeding.

Managing a Prospective Liver Transplant Recipient on the Waiting List

The management of a patient in the peri-transplantation period is highly challenging, and it is even more difficult while the patient is on the transplantation waitlist. Keeping the patient alive during this period involves managing the complications of liver disease and preventing the disease's progression. Based on the pre-transplantation etiology and type of liver failure, there is a difference in the management protocol. The current review is divided into different sections, which include: the management of underlying cirrhosis and complications of portal hypertension, treatment and identification of infections, portal vein thrombosis management, and particular emphasis on the management of patients of hepatocellular carcinoma and acute liver failure in the transplantation waitlist. The review highlights special concerns in the management of patients in the Asian subcontinent also. The review also addresses the issue of delisting from the transplant waitlist to see that futility does not overtake the utility of organs. The treatment modalities are primarily expressed in tabular format for quick reference. The following review integrates the vast issues in this period concisely so that the management during this crucial period is taken care of in the best possible way.