Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO

Endoscopic ultrasound-guided therapies versus retrograde transvenous obliteration for gastric varices: Multicenter propensity matched analysis

Background and study aims

Retrograde transvenous obliteration (RTO) is an established technique for managing fundal varices. Endoscopic ultrasound (EUS)-guided glue injection with or without coil is an alternate approach. The present study compared outcomes of EUS-guided therapies with RTO for managing fundal varices.

Patients and methods

We retrospectively analyzed data from patients with fundal varices undergoing EUS-guided intervention or RTO at 10 tertiary centers in India and compared after propensity score matching. The primary outcome was variceal bleeding within 1 year. Secondary outcomes included procedure-related adverse events (AEs), variceal obliteration, reintervention, and mortality.

Results

A total of 167 patients (EUS 108, RTO 59) were included, with 59 in each group after propensity score matching. Incidence of variceal bleeding (15.3% vs. 13.6%, P = 0.793) within 1 year was comparable between the groups. Procedure-related AEs were higher in the RTO group (22% vs. 5.1%, P = 0.007), primarily new onset or worsening of ascites. Variceal obliteration at 4 weeks was similar between groups (83.1% vs. 91.5%, P = 0.167). Although reintervention within 1 year of the index procedure (30.5% vs. 22.0%, P = 0.296) was comparable, the EUS group required more frequent reintervention for GVs (28.8% vs. 5.1%, P = 0.001), and the RTO group required more frequent reintervention for EVs (16.9% vs. 1.7%, P = 0.008).

Conclusions

EUS-guided therapy offers a safe and effective alternative to RTO for managing fundal varices. Although reintervention rate for GVs were higher than for EUS, incidence of AEs and reintervention for EVs was higher with RTO.

Endoscopic clipping combined with cyanoacrylate injection vs. transjugular intrahepatic portosystemic shunt in the treatment of isolated gastric variceal bleeding: Randomized controlled trial

OBJECTIVES

Although the incidence of isolated gastric varices type 1 (IGV1) bleeding is low, the condition is highly dangerous and associated with high mortality, making its treatment challenging. We aimed to compare the safety and efficacy of endoscopic clipping combined with cyanoacrylate injection (EC-CYA) vs. transjugular intrahepatic portosystemic shunt (TIPS) in treating IGV1.

METHODS

In a single-center, randomized controlled trial, patients with IGV1 bleeding were randomly assigned to the EC-CYA group or TIPS group. The primary end-points were gastric variceal rebleeding rates and technical success. Secondary end-points included cumulative nonbleeding rates, mortality, and complications.

RESULTS

A total of 156 patients between January 2019 and April 2023 were selected and randomly assigned to the EC-CYA group (n = 76) and TIPS group (n = 80). The technical success rate was 100% for both groups. The rebleeding rates were 14.5% in the EC-CYA group and 8.8% in the TIPS group, showing no significant difference (P = 0.263). Kaplan-Meier analysis revealed that the cumulative nonbleeding rates at 6, 12, 24, and 36 months for the two groups lacked statistical significance (P = 0.344). Similarly, cumulative survival rates at 12, 24, and 36 months for the two groups were not statistically significant (P = 0.916). The bleeding rates from other causes were 13.2% and 6.3% for the respective groups, showing no significant difference (P = 0.144). No instances of ectopic embolism were observed in either group. The incidence of hepatic encephalopathy (HE) in the TIPS group was statistically higher than that in the EC-CYA group (P = 0.001).

CONCLUSION

Both groups are effective in controlling IGV1 bleeding. Notably, EC-CYA did not result in ectopic embolism, and the incidence of HE was lower than that observed with TIPS.

Splenic Duplication, a Rare Cause of Gastric Varices: A Case Report

Splenic duplication, also known as polysplenia syndrome, is a condition occasionally observed in which the spleen is divided into segments of similar size. However, gastric fundic varices arising from a duplicated spleen are exceedingly rare, and this medical anomaly has been infrequently reported in the literature. This case report presents a 40-year-old male with a rare instance of gastric fundic varices secondary to splenic duplication. Comprehensive imaging studies, including endoscopy, CT, Doppler US, and radioisotope splenic scans, were performed to confirm the diagnosis. This case contributes to valuable information in the medical literature, shedding light on a seldom-discussed condition.

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.

Pulmonary embolism: a complication of endoscopic variceal treatment

Gastric varices (GVs) are dilated veins in the stomach submucosa, typically caused by portal hypertension. A prompt diagnosis is needed, given the significant risk of bleeding and mortality. Endoscopic cyanoacrylate injections are widely adopted for treating GV due to their efficacy in preventing rebleeding with lower complication rates. Although rare, cyanoacrylate injections can lead to pulmonary embolism (PE) via the migration of glue through portosystemic shunts or other vascular pathways into the pulmonary circulation. Diagnosing cyanoacrylate glue pulmonary emboli can be challenging due to its radiopaque nature on imaging. We present a case of a male patient in his 50s, with liver cirrhosis who developed a PE following an endoscopic cyanoacrylate injection for an isolated gastric varix. The patient presented with pleuritic chest pain and haemoptysis, and CT chest revealed evidence of glue embolisation material within both lungs. Treatment with supportive care and close monitoring improved and resolved symptoms.

Evaluation of clinical outcome and predictors of mortality in patients undergoing antegrade transvenous variceal embolization in adjunct to salvage transjugular intrahepatic portosystemic shunt for active uncontrolled gastric variceal bleeding

OBJECTIVES

Salvage transjugular intrahepatic portosystemic shunt (TIPS) is indicated in patients with active endoscopically uncontrollable variceal bleeding. TIPS alone is not effective in the management of gastric varices, and balloon occluded transvenous obliteration (BRTO) requires favourable variceal anatomy. Concomitant placement of a TIPS stent with antegrade variceal embolization leads to control of gastric variceal bleeding with no significant increase in portal pressure.

METHODS

A single-centre retrospective observational study in which patients with active uncontrollable gastric variceal bleeding were included. Technical success of the procedure, 5-day rebleeding, 6-week, and 6-month survival, as well as other additional outcomes, were evaluated.

RESULTS

A total of 18 patients were included in the study. Technical success was 100% and significant non-target embolization was seen in 0% of patients. The 6-week and 6-month survival rates were 66.67%, with an overall survival of 108.786 days (censored at 180 days). The 5-day rebleed rate was 11.1%. A significant difference in Child-Turcotte-Pugh score (P = .03), model for end-stage liver disease-sodium (MELD-Na) score (P = .022), requirement of intubation (P = .038), haemoglobin (Hb) levels (P = .042), haematocrit value (P = .018), packed red blood cell infusion required prior to and after the procedure (P = .045, .044), and presence of refractory shock (P = .013) was observed between the survival and the mortality groups. Post-variceal bleeding Hb levels, mean arterial pressure, and MELD-Na scores were significant predictors of mortality.

CONCLUSION

TIPS in adjunct to antegrade transvenous embolization is a safe and effective modality for the management of active uncontrolled gastric variceal bleeding in patients with variceal anatomy unfavourable for performing retrograde obliteration.

ADVANCES IN KNOWLEDGE

(1) TIPS alone may not be effective in the management of gastric varices. BRTO requires favourable variceal anatomy and may lead to catastrophic oesophageal variceal haemorrhage. Concomitant placement of a TIPS stent with antegrade variceal embolization leads to control of gastric variceal bleeding with no significant increase in portal pressure. (2) TIPS, in conjunction with antegrade transvenous embolization, requires proper knowledge of variceal anatomy and the embolizing agent. Post-variceal bleeding Hb levels, mean arterial pressure, and MELD-Na scores were significant predictors of mortality.

Innovative Use of a Coaxial Double-Balloon Catheter System for Treating Gastric Varices

Herein, we present the case of a 52-year-old female with a history of hepatic surgery who developed gastric varices. Owing to the risk of rupture, a balloon-occluded retrograde transvenous obliteration (BRTO) procedure was performed using a coaxial double-balloon catheter system. Subsequently, the outer balloon catheter was advanced into the gastrorenal shunt. However, venography failed to visualize the varices. Attempts to advance the inner catheter into the varices have been unsuccessful. The inner catheter was advanced into the left gastric vein, establishing a closed circuit around the gastric varices using an outer balloon catheter. A sclerosing agent was subsequently injected through the gap between the outer and inner balloon catheters and via the outer balloon catheter, successfully embolizing the gastric varices. The coaxial double-balloon catheter system is a viable and effective method for treating gastric varices, particularly in cases where traditional BRTO techniques may be challenging owing to their complex vascular anatomy.

Endoscopic ultrasound-guided treatment of isolated gastric varices entwined with arteries: A case report

BACKGROUND

Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices (IGVs) owing to its precise visualization.

CASE SUMMARY

A 39-year-old man was diagnosed with a large IGV during a routine physical examination. Endoscopic ultrasonography showed gastric varices entwined with an artery, which greatly increased the difficulty of treatment. We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection.

CONCLUSION

Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.

New options for endoscopic treatment of gastric varices

BACKGROUND

Gastric venous bleeding is one of the most common adverse events in liver cirrhosis. The therapeutic effect of isolated gastric varices is relatively clear. However, there is no appropriate clinical and endoscopic treatment for extensive variceal bleeding in the gastric fundus and body.

METHODS

In this patient with non-isolated gastric varices, we decided to perform endoscopic multi-point ligation of the obvious varices in the gastric fundus and body.

RESULTS

In this patient, endoscopic treatment of gastric varices with bleeding after surgery achieved a significant therapeutic effect. Reexamination of gastroscopy at 3 months after operation showed that multiple scars were formed in the gastric fundus and fundus, and no obvious varices were found.

CONCLUSIONS

For patients with non-isolated gastric varices, endoscopic multi-point ligation is a safe and effective treatment option for the varices with obvious gastric fundus and body.

[Trends in endovascular treatment and prevention of portal bleeding]

Bleeding from esophageal and gastric varices is a major factor of mortality in patients with portal hypertension. The gold standard for diagnosis of portal hypertension is hepatic venous pressure gradient determining the treatment algorithms and risk of recurrent bleeding. Combination of endoscopic methods and therapy is limited by varix localization and not always effective. In these cases, endovascular bypass and decoupling techniques are preferred. Early endovascular treatment of portal bleeding is effective for hemostasis and higher transplantation-free survival of patients. Early transjugular intrahepatic portosystemic bypass should be associated with 8-mm covered stents of controlled dilation. Combination of endovascular techniques reduces the complications of each technique and potentiates their positive effect. Endovascular treatment and prevention of portal bleeding should be determined by anatomical features of portal venous system.

Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension

To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.

Balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic cyanoacrylate injection for treating gastric varices draining through gastrorenal shunts

BACKGROUND AND STUDY AIMS

Balloon-occluded retrograde transvenous obliteration-assisted endoscopic cyanoacrylate injection (E-BRTO) temporarily treats gastric fundic varices draining through gastrorenal shunts (GRS) occluding the GRS with a balloon, then endoscopically injecting cyanoacrylate. We retrospectively examined the safety, feasibility, and efficacy of E-BRTO.

PATIENTS AND METHODS

We enrolled 85 patients with hepatic cirrhosis plus gastric fundic varices with GRS; 34 underwent E-BRTO. The 51 patients who refused all secondary prophylactic treatments served as controls.

RESULTS

Finally, 33 of the 34 patients underwent successful E-BRTO without major adverse events. Gastric varices were eradicated from all 33 patients in the E-BRTO group; the average follow-up time was 161.0 (74.0) weeks (mean [SD]). Four end-point events (12%) were recorded during the follow-up period. In the control group, 33 patients (65%) suffered repeat variceal bleeding, resulting in seven deaths. The cumulative rebleeding rates of the E-BRTO group on the 6th, 24th, 48th, 96th, 144th, 192nd, 240th, and 288th week were 0%, 3%, 9%, 9%, 13%, 13%, 13%, and 13%, while the cumulative rebleeding rates of the control group in the same period were 10%, 20%, 35%, 46%, 55%, 65%, 76%, and 76%.

CONCLUSIONS

E-BRTO was safe, feasible, and well tolerated by patients with hepatic cirrhosis plus gastric fundic varices with GRS. Over the long-term follow-up period, the E-BRTO group demonstrated a lower rate of repeat bleeding than the control group.

Successful embolization of subcutaneous mesenteric varices within an ileal conduit in a patient with liver cirrhosis

Introduction

Venous hemorrhage from ectopic varices is potentially fatal. This report describes a rare case in which bleeding from mesenteric varices in an ileal conduit was treated successfully by embolization therapy.

Case presentation

The patient was an 82-year-old man who had previously undergone total pelvic exenteration for colon cancer with creation of an ileal conduit for urinary diversion. He subsequently developed liver cirrhosis and underwent partial hepatectomy for hepatocellular carcinoma. 9 years after his colon surgery, he was admitted with gross hematuria. Computed tomography revealed subcutaneous mesenteric varices in the ileal conduit and hemorrhage as a result of rupture of the varices. The bleeding continued despite repeated manual compression but was eventually stopped by embolization therapy.

Conclusion

Embolization therapy may be helpful for hemostasis in the event of intractable bleeding from mesenteric varices in an ileal conduit.

Gastric varices

PURPOSE OF REVIEW

Gastric varices are a rare cause of gastrointestinal bleeding in patients with portal hypertension. There have been significantly advances within endoscopic ultrasound for treatment of gastric varices over the past 5 years in addition to the conventional endoscopic and endovascular therapies. In this review, we will review the latest literature on gastric varices with emphasis on changes to the conventional classification systems and comparisons among the different treatment options for gastric varices in terms of efficacy and safety.

RECENT FINDINGS

There have been new guidelines proposed by the American Gastrointestinal Association on a simpler classification system compared to the conventional Sarin classification. In addition, endoscopic ultrasound guided coil embolization, a novel treatment pioneered over the past 5 years for gastric varices, has shown increased efficacy and reduced adverse event profile compared to cyanoacrylate glue, the more traditional therapy for gastric variceal bleeding. Options for endovascular therapy overall have not significantly changed over the recent years.

SUMMARY

Based on our literature review, we recommend a step-up approach with initial medical and endoscopic management with consideration of endovascular therapies when initial therapies fail.

Use of Balloon Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: A Narrative Review

Gastric Varices occur as a result of portal hypertension. Balloon Retrograde Transvenous Obliteration (BRTO) is a modality for managing gastric varices. The ultimate goal of this review is to promote the broader adoption of BRTO in managing gastric varices and to promote further research to improve patient outcomes. Before this study, an electronic literature search was undertaken based on identified concepts, keywords, and other pertinent descriptions. Search databases were developed and included "Gastric varices" AND "BRTO" OR "intervention" OR "treatment" OR "procedure" OR "glue" OR "adhesive".  The databases selected and thoroughly searched were PubMed, Cochrane Library and ScienceDirect. Following the first search, 274 articles were found in total. By applying inclusion criteria of full-text articles and a period of fewer than five years, the database was reduced to 37 articles, which was then further filtered to include only articles on adults over 19 years old, leaving a total count of 17 articles. BRTO is a relatively simple procedure to perform once the essential skill is attained and helpful in both emergency and elective management of gastric varices. Its use still needs to be improved by the unavailability and lack of skills. However, there are side effects associated with BRTO as it causes elevation of portal hypertension, recurrent bleeding, hemoglobinuria and pain post procedure. This review emphasizes the need for further research in this field, focusing on refining patient selection criteria, improving the technical aspect of the procedure and enhancing long-term outcomes.

EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices

Background and study aims  Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods  This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results  Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P  = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P  = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P  = 0.345). Conclusions  EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.

EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts

Background and Objective

Ectopic embolism caused by cyanoacrylate glue for the treatment of gastric varices with obvious spontaneous portosystemic shunts is a serious complication of endoscopic therapy. This study was performed to investigate the safety and therapeutic effect of EUS-guided coil placement and cyanoacrylate glue injection for gastric varices with obvious spontaneous portosystemic shunts.

Materials and Methods

Six patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts were included in this study. We evaluated the success rate of variceal occlusion after intraoperative embolization, the postoperative rebleeding rate at 48 h and 2 weeks posttreatment, and the incidence of ectopic embolism and other adverse events. Gastroscopy and computed tomography portal venography (CTPV) were performed 7 months later.

Results

All patients underwent successful coil placement and cyanoacrylate glue injection under EUS guidance. The blood flow was confirmed by Doppler examination, the target vessels were successfully blocked, and no rebleeding had occurred at 48 h or 2 weeks after endoscopic treatment. Gastroscopy was repeated 7 months after endoscopic treatment, revealing local ulcer formation. CTPV was also repeated 7 months after endoscopic treatment, showing that the coils were present in the target vessels with no displacement, the portosystemic shunt vessels were occluded, and no ectopic embolization had occurred.

Conclusion

The coil placement combined with cyanoacrylate glue embolism is a safe and effective method for patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Managing gastric varices

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.

Prognostic impact of worsening of esophageal varices after balloon-occluded retrograde transvenous obliteration

BACKGROUND AND AIM

Balloon-occluded retrograde transvenous obliteration (BRTO) is widely performed for treating gastric varices (GVs). However, worsening of esophageal varices (EVs) can be observed after BRTO. This study aimed to investigate the impact of EV worsening on prognosis after BRTO.

METHODS

Overall, 258 patients who underwent initial BRTO for GV treatment between January 2004 and May 2019 at 12 institutions were retrospectively registered.

RESULTS

Technical success was achieved in 235 patients (91.1%). Based on the exclusion criteria, 37 patients were excluded, and 198 were evaluated. The cumulative worsening rates of EVs at 1, 2, and 3 years were 39.0%, 59.4%, and 68.4%, respectively. In the univariate Cox proportional hazards model, sex, EV size, history of EV treatment, left gastric vein dilatation, platelet count, aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, albumin, albumin-bilirubin score, prothrombin time-international normalized ratio, fibrosis-4 index, AST to platelet ratio index, and spleen width were significantly associated with worsening of EV after BRTO. Multivariate analysis showed that sex (adjusted hazard ratio [aHR] 1.72; 95% confidence interval [CI] 1.03-2.86; P = 0.04), left gastric vein dilatation (aHR 1.90; 95% CI 1.17-3.10; P = 0.01), ALT (aHR 1.01; 95% CI 1.00-1.03; P = 0.02), albumin (aHR 0.61; 95% CI 0.43-0.87; P < 0.01), and spleen width (aHR 1.02; 95% CI 1.01-1.03; P < 0.01) were independent risk factors for worsening of EV after BRTO. Patients with EV worsening within 1 year after BRTO had a significantly worse prognosis than the other patients (P = 0.007).

CONCLUSIONS

Early worsening of EV after BRTO was associated with poor prognosis after BRTO.

Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments

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.

Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era

Background and study aims

This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy.

Patients and methods

Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups.

Results

94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased.

Conclusions

Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.

Accelerated balloon-retrograde transvenous obliteration (BRTO): an effective tool in the Arsenal against isolated gastric varices (IGV)

Gastric and oesophageal variceal bleeding poses high morbidity and mortality in cirrhosis. Amongst all types, isolated gastric varices (IGV) carry the highest propensity to bleed. Successful outcomes combine endoscopic and interventional radiology approaches using ligation, coils, glue or sclerosants. Transjugular intrahepatic portosystemic shunt success is only seen in a subset of patients, while balloon-retrograde transvenous obliteration (BRTO) has demonstrated high efficacy in preventing rebleeding and morbidity in patients with a myriad of anatomies and shunts. The American Association for the Study of Liver disease guidelines do not favour any particular modality; however, recent trials and meta-analyses support BRTO as the first-line therapy. Despite promising results, BRTO adoption is limited by procedural time, patient length-of-stay and equipment compatibilities hindering scalability in academic and community settings. To address these concerns, we present a successfully treated case of IGV with a revised technique called accelerated BRTO.

Transjugular intrahepatic portosystemic shunt (TIPS) as rescue therapy for endoscopic glue migration and bleeding gastric varices

Gastric variceal (GV) bleeding is an important and fatal complication for cirrhotic patients which has historically been controlled with sclerosants and band ligation. Cyanoacrylate glue therapy has emerged as a more favorable option with bleeding control of up to 90% and low complication rates; however, several reports show possible ectopic systemic glue migration, most commonly into the portomesenteric system and leading to portal hypertension. To decompress portal pressures and mitigate future complications, transjugular intrahepatic portosystemic shunt (TIPS) placement may be a viable rescue therapy. We present two cases of TIPS placement for an 18-year-old and 51-year-old male in the setting of endoscopic glue migration into the portomesenteric system that demonstrate feasibility and success in temporizing acute variceal bleeding. Both cases demonstrated decompressing portovenous pressures but may result in need for re-intervention.

Variceal Bleed and Portal Hypertensive Gastropathy in a Noncirrhotic Patient with Isolated Splenomegaly

Portal hypertension caused by cirrhosis is the most common etiology of esophageal varices. However, abnormalities of the splenoportal axis in the absence of liver disease may also cause portal hypertension resulting in varices. We report a rare case of esophageal variceal bleed in a noncirrhotic patient with isolated splenomegaly secondary to chronic granulocyte colony stimulating factor (G-CSF) therapy. The patient is a 26-year-old male with Cohen syndrome who required long-term G-CSF treatment for chronic neutropenia. He presented with large volume hematemesis and pancytopenia in the setting of known splenomegaly with no evidence of cirrhosis. An urgent EGD revealed active variceal bleeding and portal hypertensive gastropathy. The patient was appropriately resuscitated and underwent a successful transjugular intrahepatic portosystemic shunt and CT-guided coil placement for the bleeding varices. We are the first to report variceal bleed as a complication of long-term G-CSF use, a life-threatening consequence that requires urgent intervention.

Endoscopic Ultrasound-Guided Vascular Procedures: A Review

Since the 1980s, endoscopic ultrasound has advanced from being purely diagnostic to an interventional modality. The gastrointestinal tract offers an exceptional window for assessing the vascular structures in the mediastinum and in the abdomen. This has led to a rapidly growing interest in endoscopic ultrasound-controlled vascular interventions as a minimally invasive alternative to surgical and radiological procedures.

Bleeding Isolated Gastric Varices as a Rare Presentation of Pancreatic Neuroendocrine Tumor: Case Report and Literature Review

Isolated gastric varices (IGV) are gastric varices in the absence of esophageal varices. IGV is one of the rare causes of gastrointestinal bleeding and an uncommon complication of pancreatic neuroendocrine tumors (PNET). The gold standard diagnostic tool of varices is esophagogastroduodenoscopy (EGD). IGV tend to bleed with lesser portal pressure compared to esophageal varices. Initial treatment is similar to the gastroesophageal varices. The intervention options include endoscopic, radiological, and surgical approach.

Comparison of the Effects of TIPS versus BRTO on Bleeding Gastric Varices: A Meta-Analysis

Background and Aim. Upper gastrointestinal bleeding is a threat to patients with gastric varices (GVs). Previous studies have concluded that both transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) are effective treatments for patients with GV. We aimed to compare the efficiency and outcomes of these two procedures in GV patients through meta-analysis.

METHODS

The PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched using the keywords: GV, bleeding, TIPS, and BRTO to identify relevant randomized controlled trials and cohort studies. The overall survival (OS) rate, imminent haemostasis rate, rebleeding rate, technical success rate, procedure complication rate (hepatic encephalopathy and aggravated ascites), and Child-Pugh score were evaluated. Randomized clinical trials and cohort studies comparing TIPS and BRTO for GV due to portal hypertension were included in our meta-analysis. Two independent reviewers performed data extraction and assessed the study quality. A meta-analysis was performed to calculate risk ratios (RRs), mean differences (MDs), and 95% CIs using random effects models.

RESULTS

A total of nine studies fulfilled the inclusion criteria. There was a significant difference between TIPS and BRTO in the OS rate (RR, 0.81 (95% CI, 0.66 to 0.98); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90).

CONCLUSIONS

In this meta-analysis, BRTO brought more benefits to patients, with a higher OS rate and lower rebleeding rate. BRTO is a feasible method for GVB.

Biomaterials in Gastroenterology: A Critical Overview

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