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Verma A, Meshram R, Phulware RH, Parate S, Vaibhav V. Sudden Death Caused by Gastroesophageal Varices Rupture: Insights From an Autopsy-Based Case Series Unraveling the Pathological Events. Cureus 2023; 15:e46166. [PMID: 37905260 PMCID: PMC10613317 DOI: 10.7759/cureus.46166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/02/2023] Open
Abstract
Sudden death is characterized by natural yet unexpected death, typically occurring within 24 hours from the onset of the patient's symptoms. While the majority of sudden deaths stem from cardiac issues/causes, there are instances where non-cardiac factors are at play. One such scenario involves hemorrhage from ruptured esophageal varices, a complication that stems from portal hypertension. Portal hypertension can manifest due to a range of pre-hepatic, hepatic, and post-hepatic conditions, with liver cirrhosis being the primary culprit. Although sudden death cases linked to the gastrointestinal system are relatively rare, the rupture of gastroesophageal varices, precipitating severe morbidity and a high mortality rate, represents a life-threatening condition. In this context, we present a case series encompassing five instances of sudden natural deaths arising from the rupture of gastroesophageal varices.
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Affiliation(s)
- Arushi Verma
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Raviprakash Meshram
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Ravi H Phulware
- Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Rishikesh, IND
| | - Shailesh Parate
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Vikas Vaibhav
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
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Samanta J, Nabi Z, Facciorusso A, Dhar J, Akbar W, Das A, Birda CL, Mangiavillano B, Auriemma F, Crino SF, Kochhar R, Lakhtakia S, Reddy DN. EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis. Liver Int 2023; 43:1783-1792. [PMID: 37269164 DOI: 10.1111/liv.15630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/28/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques. METHODOLOGY This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted. RESULTS Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention. CONCLUSION Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Asian Institute of Gastroenterology (AIG), Hyderabad, India
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Wahid Akbar
- Asian Institute of Gastroenterology (AIG), Hyderabad, India
| | | | - Chhagan Lal Birda
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Zhang X, Yan JQ, Gao YY, Song DZ, Lou C. Non-cirrhotic portal hypertension secondary to cholangiointestinal anastomotic stricture after choledochal cyst excision: a case report. Front Med (Lausanne) 2023; 10:1149484. [PMID: 37287745 PMCID: PMC10242113 DOI: 10.3389/fmed.2023.1149484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/04/2023] [Indexed: 06/09/2023] Open
Abstract
Background Cystectomy accompanied by biliary system reconstruction is an important treatment option for choledochal cysts, but the risk of post-operative complications is high. The most famous long-term complication is anastomotic stricture, whereas non-cirrhotic portal hypertension secondary to cholangiointestinal anastomotic stricture is rare. Case summary Here we report the case of a 33-year-old female patient with a type I choledochal cyst who underwent choledochal cyst excision with Roux-en-Y hepaticojejunostomy. Thirteen years later, the patient presented with severe esophageal and gastric variceal bleeding, splenomegaly, and hypersplenism. Furthermore, cholangiointestinal anastomotic stricture with cholangiectasis was identified on imaging. A pathological examination of the liver suggested intrahepatic cholestasis, but the fibrosis was mild and inconsistent with severe portal hypertension. Therefore, the final diagnosis was portal hypertension secondary to a cholangiointestinal anastomotic stricture after choledochal cyst surgery. Fortunately, the patient recovered well after endoscopic treatment and dilated cholangiointestinal anastomotic stricture. Conclusion Choledochal cyst excision with Roux-en-Y hepaticojejunostomy is the recommended standard of care for type I choledochal cysts; however, the long-term risk of cholangiointestinal anastomotic stricture requires consideration. Moreover, cholangiointestinal anastomotic stricture can lead to portal hypertension, and the degree of elevated portal pressure may be inconsistent with the degree of intrahepatic fibrosis.
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Affiliation(s)
- Xu Zhang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jun Qing Yan
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Yan Ying Gao
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - De Zhao Song
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Department of Interventional Radiology, The Third Central Hospital of Tianjin, Tianjin, China
| | - Cheng Lou
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China
- Artificial Cell Engineering Technology Research Center, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, Tianjin, China
- Hepatobiliary Surgery, The Third Central Hospital of Tianjin, Tianjin, China
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Kumar V, Kansal D, Chaudhary SC, Gupta KK, Usman K, Atam V, Sawlani KK, Lamba M, Kumar A, Reddy H. Serum Ammonia Levels as a Non-invasive Predictor of the Presence and Severity of Esophageal Varices in Chronic Liver Disease Patients. Cureus 2023; 15:e39792. [PMID: 37398752 PMCID: PMC10313239 DOI: 10.7759/cureus.39792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Background Portal hypertension leads to the formation of portosystemic collateral veins, of which esophageal varices (EV) are the most severe complications and have the greatest clinical impact. The possibility of identifying cirrhotic patients with varices by non-invasive tests is appealing, as they can lead to reduced healthcare costs and can be done in resource-limited settings. In this study, we investigated ammonia as a potential non-invasive predictor of EV. Methods This was a single-center cross-sectional observational study that was done at a tertiary health care hospital in north India. It included 97 chronic liver disease patients irrespective of etiology after excluding patients with portal vein thrombosis and hepatocellular carcinoma to participate in endoscopic screening for the presence of EV and correlate it with various non-invasive markers like serum ammonia levels, thrombocytopenia and aspartate aminotransferase to platelet ratio index (APRI ). On the basis of endoscopy, enrolled patients were divided into two groups, i.e., group A consisting of large varices (grade III and grade IV) and group B consisting of patients with low-grade varices and no varices (grade II, grade I, and no varices). Results This study included 97 patients, out of which 81 patients have varices on endoscopy, and mean serum ammonia levels were found to be significantly higher in cases with varices (135 ±69.70 ) vs. those without varices (94±43) (p value=0.026). Further, on comparing serum ammonia values between patients with large varices (Grade III/IV) (Group A) with a mean value of 176 ± 83 vs. Grade I/II/No varices (Group B) with a mean value of 107±47, which were significantly higher in Group A patients (<0.001). In our study, we also found a correlation between blood urea level as a non-invasive predictor of varices, but no statistically significant relation was found between thrombocytopenia and APRI. Conclusion This study found that serum ammonia can be used as a useful marker for the prediction of EV and can also be used to determine the severity of varices. Apart from ammonia, serum urea levels can also prove to be a good non-invasive marker for the prediction of varices although further multicentric studies are warranted to reach this conclusion.
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Affiliation(s)
- Vivek Kumar
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Divyam Kansal
- Internal Medicine, King George's Medical University, Lucknow, IND
| | | | - K K Gupta
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Kauser Usman
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Virendra Atam
- Internal Medicine, King George's Medical University, Lucknow, India., Lucknow, IND
| | - K K Sawlani
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Mahak Lamba
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Ajay Kumar
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Himanshu Reddy
- Internal Medicine, King George's Medical University, Lucknow, IND
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Wu L, Fang QQ, Huang XQ, Xue CY, Rao CY, Luo JJ, Xu PJ, Chen Y, Chen S, Li F. Risk factors associated with failure of endoscopic combined treatment to prevent varices rebleeding in patients with liver cirrhosis. Expert Rev Gastroenterol Hepatol 2023; 17:301-308. [PMID: 36795329 DOI: 10.1080/17474124.2023.2181787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND The aim of this study is to investigate risk factors associated with gastroesophageal variceal rebleeding after endoscopic combined treatment. RESEARCH DESIGN AND METHODS Patients who had liver cirrhosis and underwent endoscopic treatment to prevent variceal rebleeding were retrospectively recruited. Hepatic venous pressure gradient (HVPG) measurement and CT examination of portal vein system were performed before endoscopic treatment. Endoscopic obturation for gastric varices and ligation for esophageal varices were performed simultaneously at the first treatment. RESULTS One hundred and sixty-five patients were enrolled, and after the first endoscopic treatment, recurrent hemorrhage occurred in 39 patients (23.6%) during 1-year follow-up. Compared to the non-rebleeding group, HVPG was significantly higher (18 mmHg vs.14 mmHg, P = 0.024) and more patients had HVPG exceeding 18 mmHg (51.3% vs.31.0%, P = 0.021) in the rebleeding group. No significant difference was found in other clinical and laboratory data between two groups (P > 0.05 for all). By a logistic regression analysis, high HVPG was the only risk factor associated with failure of endoscopic combined therapy (OR = 1.071, 95%CI, 1.005-1.141, P = 0.035). CONCLUSIONS The poor efficacy of endoscopic treatment to prevent variceal rebleeding was associated with high HVPG. Therefore, other therapeutic options should be considered for the rebleeding patients with high HVPG.
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Affiliation(s)
- Ling Wu
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Qing-Qing Fang
- Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Xiao-Quan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Center of Evidence-Based Medicine, Fudan University, Shanghai, P.R. China
| | - Chun-Yan Xue
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Chen-Yi Rao
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Jian-Jun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Peng-Ju Xu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Ying Chen
- Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China.,Center of Evidence-Based Medicine, Fudan University, Shanghai, P.R. China.,Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Feng Li
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R. China.,Department of Gastroenterology, Minhang Hospital, Fudan University, Shanghai, P.R. China
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Zhang Q, Niu S, Yang L, Zhu B, Shi K, Zhang X, Zhang Y, Bi Y, Mu Y, Wang X. A novel prognostic model for predicting the risk of first variceal hemorrhage in patients with HBV-related cirrhosis. Front Cell Infect Microbiol 2023; 13:1062172. [PMID: 36733609 PMCID: PMC9886685 DOI: 10.3389/fcimb.2023.1062172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Background Variceal hemorrhage (VH) is a life-threatening complication of cirrhosis. An accurate VH risk evaluation is critical to determine appropriate prevention strategies. We aimed to develop an individualized prediction model to predict the risk of first VH in hepatitis B virus (HBV)-related cirrhotic patients. Methods A nomogram was developed based on a retrospective analysis of 527 consecutive HBV-related cirrhotic patients with gastroesophageal varices (GEVs). The nomogram evaluation was performed using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), calibration plot, and decision curve analysis (DCA). The results were verified using an external cohort (n = 187). Results We developed a nomogram based on clinical and endoscopic features, including the size of varices, red wale marks, ascites, spleen thickness, γ-glutamyltransferase, and hematocrit. The C-index of the nomogram in the derivation and validation cohort was 0.806 and 0.820, respectively, and the calibration plot fitted well. Compared with those of the North Italian Endoscopic Club (NIEC) and revised NIEC indexes, the AUC (derivation cohort: 0.822 vs. 0.653 vs. 0.713; validation cohort: 0.846 vs. 0.685 vs. 0.747) and DCA curves of this nomogram were better. Further, based on the risk scores, patients were classified into low-, medium-, and high-risk groups, and significant differences were noted in VH incidence among the three risk groups (P <0.001 for each cohort). Conclusions An effective individualized nomogram to predict the risk of first VH in HBV-related GEV patients was established, which can assist clinicians in developing more appropriate prevention strategies.
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Affiliation(s)
- Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuaishuai Niu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Bingbing Zhu
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ke Shi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yi Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yufei Bi
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yongping Mu
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China,*Correspondence: Xianbo Wang, ; Yongping Mu,
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Muacevic A, Adler JR, Awan SA, Shaikh AJ, Abbasi AA. Effectiveness of Proton Pump Inhibitor Therapy in the Prevention of Bleeding After Prophylactic Endoscopic Variceal Band Ligation. Cureus 2023; 15:e33932. [PMID: 36819375 PMCID: PMC9937675 DOI: 10.7759/cureus.33932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
Background Endoscopic variceal ligation (EVL) is a surgical intervention that can work well to curb variceal bleeding in people with liver cirrhosis. However, it could make ulcer bleeding worse and be fatal in some cases. The widespread use of proton pump inhibitors (PPI) in cirrhotic individuals with variceal bleeding is empirical rather than based on scientific data. According to many studies, PPIs reduce the size of post-EVL ulcers. This study aimed to see if PPI use could reduce rebleeding after endoscopy therapy in cirrhotic patients with variceal bleeding. Methodology A retrospective cross-sectional study was conducted at a tertiary care hospital from August 2019 to September 2021. Cirrhotic patients with bleeding gastroesophageal varices (GEVs) who had undergone EVL at the same hospital were enrolled in the study. Medical records were organized, and the sample was divided into two groups based on whether or not PPI was given. Both PPI and non-PPI patients had their endoscopic findings, initial hemostasis outcomes, rebleeding rates, bleeding-related mortality rates, and treatment-related comorbidities compared. Results A total of 46 patients were selected for the study and divided into two groups (PPI group n=28 and non-PPI group n=18). The majority of the patients were males. The PPI group had a mean age of 58.6 ±7.8 years, whereas the non-PPI group had a mean age of 53.6 ±4.4 years. Hepatitis B virus (HBV) infection was the most prevalent cause of cirrhosis in both groups. After endoscopic treatment, three patients (16%) in the non-PPI group suffered a variceal hemorrhage. Bleeding-related fatalities and the time it took for the bleeding to stop varied significantly between the two groups. History of variceal bleeding (relative risk (RR)=1.45; 95% confidence interval (CI), 1.60-7.67; p=0.02), presence of gastric varices (RR=2.23; 95% CI, 2.56-9.832; p=0.035), and not administering PPIs (RR =7.542; 95% CI, 3.98-29.13; p=0.008) were linked with rebleeding. The presence of red concurrent esophageal varices (RR=6.37; 95% CI, 0.562-15.342; p=0.002) and failure to provide PPIs (RR=2.3; 95% CI, 1.621-25.64; p=0.04) were linked with post-EVL bleeding in a multivariate analysis. Conclusions Proton pump inhibitors reduce the occurrence of early bleeding and adverse events after EVL in cirrhotic patients. Not prescribing PPIs and the presence of GEVs were substantially related to a higher risk of bleeding during preventative EVL. Not initiating PPI medication immediately was the sole predictor of bleeding complications in patients who had undergone EVL without gastric varix treatment. To lower the risk of post-EVL ulcer bleeding, we recommend PPI use in patients undergoing EVL.
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Toyodome A, Tamai T, Sasaki F, Hashiguchi M, Taniyama O, Ijuin S, Sakae H, Tabu K, Oda K, Kumagai K, Mawatari S, Ido A. Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report. Intern Med 2022. [PMID: 36328577 DOI: 10.2169/internalmedicine.0666-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We treated a case of gastroesophageal varices due to decompensated liver cirrhosis associated with Wilson's disease. The varicose veins penetrated the paraesophageal vein. We performed endoscopic variceal ligation (EVL) on the perforating vein and endoscopic injection sclerotherapy (EIS) distally. However, 5 days after treatment, the patient vomited blood. Esophagogastroduodenoscopy showed bleeding from the ulcer after EVL at the perforating vein. We performed EVL and stopped the bleeding. However, the next day, she vomited blood again and developed hemorrhagic shock. We were able to achieve hemostasis and save the patient's life with combination therapy consisting of percutaneous transhepatic obliteration and Sengstaken-Blakemore tube placement.
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Affiliation(s)
- Ai Toyodome
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Tsutomu Tamai
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
- Department of Gastroenterology, Kagoshima City Hospital, Japan
| | - Fumisato Sasaki
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | | | - Ohki Taniyama
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Sho Ijuin
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Haruka Sakae
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Kazuaki Tabu
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Kohei Oda
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Kotaro Kumagai
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Seiichi Mawatari
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Akio Ido
- Department of Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
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Huang X, Zhang M, Ai Y, Jiang S, Xiao M, Wang L, Jian Y, Zhuge Y, Zhang C, Chen S. Characteristics of myeloproliferative neoplasm-associated portal hypertension and endoscopic management of variceal bleeding. Ther Adv Chronic Dis 2022; 13:20406223221125691. [PMID: 36172080 PMCID: PMC9511301 DOI: 10.1177/20406223221125691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Myeloproliferative neoplasms (MPNs) are a rare yet important clinical cause of portal hypertension, which may cause recurrent gastroesophageal variceal bleeding (GVB). MPN-associated variceal bleeding lacks specific guidelines and clinical consensus and desiderates cohort studies. We performed a multicenter retrospective study to investigate the efficacy of endoscopic management of bleeding in MPNs. Methods: We included consecutive MPN patients with gastroesophageal varices in eight tertiary university hospitals between January 2007 and March 2020. The clinical characteristics of participants were summarized. MPN patients with a history of GVB were followed up for the rebleeding and death, compared with controls suffering from schistosomiasis-associated portal hypertension who received endoscopic treatment for variceal bleeding at the same period. Results: A total of 62 MPN patients with gastroesophageal varices were identified, and 37 had a history of GVB. Of these, 24 patients received endoscopic variceal ligation and endoscopic injection of cyanoacrylate for the prophylaxis of variceal rebleeding. Endoscopic treatment significantly reduced the rebleeding rate in MPN patients with a history of GVB (28.2% versus 68.3%, p = 0.0269). Multivariable Cox regression indicated that endoscopic treatment (HR = 0.10, 95% CI: 0.02–0.54, p = 0.008) was the independent protective factor for decreasing the 3-year rebleeding rate, while the use of non-selective beta-blockers (NSBB) (HR = 13.41, 95% CI: 2.15–83.42, p = 0.005) was the risk factor for increasing the 3-year rebleeding rate. As for the efficacy of endoscopic management, 3-year rebleeding rate was significantly lower in MPN patients in contrast to 46 controls with schistosomiasis-associated variceal bleeding (32.9% versus 59.0%, p = 0.0346). Conclusion: Endoscopic treatment might be a feasible and potent approach in the management of gastroesophageal variceal rebleeding in MPNs, while NSBB might be ineffective.
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Affiliation(s)
- Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Yingjie Ai
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyu Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei Xiao
- Department of Gastroenterology, Anhui Provincial Hospital, Hefei, China
| | - Lifen Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yourong Jian
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China.,Center of Evidence-based Medicine, Fudan University, Shanghai, China.,Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, China
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10
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Wu Y, Chen M, Huang M, Liao G, Tang S, Zheng H, Li Y, Peng B, Zheng X, Pan S, Hou J, Chen B. [Value of purple sign for predicting rebleeding events in cirrhotic patients following endoscopic selective varices devascularization]. Nan Fang Yi Ke Da Xue Xue Bao 2021; 41:1822-1827. [PMID: 35012914 PMCID: PMC8752418 DOI: 10.12122/j.issn.1673-4254.2021.12.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the value of the purple sign for predicting long-term rebleeding events in cirrhotic patients following endoscopic selective varices devascularization. METHODS We retrospectively analyzed the clinical data of 97 patients with liver cirrhosis, who had a history of gastroesophageal variceal bleeding and underwent endoscopic selective varices devascularization. Thirty-two of the patients showed purple sign after endoscopic treatment. We used propensity score matching (PSM) to minimize the selection bias of the patients (purple sign vs no purple sign) and reduce the intergroup differences of clinical characteristics. The primary outcome measure of this study was cumulative rebleeding events after endoscopic selective varices devascularization. RESULTS The 1-year rebleeding rate (27.0% vs 36.7%) or 6-month rebleeding rate (10.9% vs 26.9%) following endoscopic treatment was not significantly different between the purple sign group and no purple sign group before PSM (P=0.2385). But after PSM, the 1-year rebleeding rate (28.2% vs 56.4%) and 6-month rebleeding rate (5.0% vs 37.0%) were significantly lower in the purple sign group than in the no purple sign group (P=0.0304). CONCLUSIONS The presence of purple sign indicates a lower risk of rebleeding after endoscopic treatment of cirrhotic gastroesophageal varices and a potentially favorable treatment response after endoscopic therapy, thus providing a clinical indicator for stratification of the patients for sequential endoscopic sessions.
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Affiliation(s)
- Y Wu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - M Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - M Huang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - G Liao
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - S Tang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - H Zheng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - Y Li
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - B Peng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - X Zheng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - S Pan
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - J Hou
- Department of Gastroenterology and Hepatology of First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
| | - B Chen
- Department of Gastroenterology and Hepatology of First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510000, China
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11
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Takata K, Nagata T, Uchida Y, Kitaguchi T, Higashi T, Fukuda H, Yamauchi R, Tsuchiya N, Tanaka T, Yokoyama K, Morihara D, Takeyama Y, Shakado S, Hamada Y, Yoshimitsu K, Sakisaka S, Hirai F. Gastroesophageal Varices and Hyperplastic Nodules of the Liver in a Patient with Anorexia Nervosa. Intern Med 2021; 60:3107-3112. [PMID: 33867388 PMCID: PMC8545646 DOI: 10.2169/internalmedicine.6855-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We report a case of anorexia nervosa (AN) with gastroesophageal varices (GEV) in a 36-year-old woman. The patient presented to our hospital with progressive bloating due to severe ascites. She had no history of alcohol intake. Esophagogastroduodenoscopy and enhanced computed tomography revealed GEV and multiple hepatic nodules, respectively. The histological examination of a liver biopsy specimen revealed similar features to nonalcoholic fatty liver disease and showed hyperplastic nodules that were suspected to be related to the uneven distribution of portal blood flow in the liver. In conclusion, patients with long-term AN should undergo abdominal imaging to detect signs of portal hypertension.
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Affiliation(s)
- Kazuhide Takata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takahiro Nagata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Yotaro Uchida
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takanori Kitaguchi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Tomotaka Higashi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Naoaki Tsuchiya
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Daisuke Morihara
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Yasuaki Takeyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Yoshihiro Hamada
- Department of Pathology, Fukuoka University Faculty of Medicine, Japan
| | - Kengo Yoshimitsu
- Department of Radiology, Fukuoka University Faculty of Medicine, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
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12
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Kawaguchi K, Sakai Y, Terashima T, Shimode T, Seki A, Orita N, Takeshita Y, Shimakami T, Takatori H, Arai K, Kitamura K, Yamashita T, Yamashita T, Takamura M, Mizukoshi E, Takamura T, Honda M, Wada T, Kaneko S. Decline in serum albumin concentration is a predictor of serious events in nonalcoholic fatty liver disease. Medicine (Baltimore) 2021; 100:e26835. [PMID: 34397849 PMCID: PMC8341320 DOI: 10.1097/md.0000000000026835] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 06/20/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023] Open
Abstract
ABSTRACT Nonalcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome, which includes diabetes mellitus and hyperlipidemia. A fraction of NAFLD patients develop nonalcoholic steatohepatitis, leading to cirrhosis associated with various serious complications, including hepatocellular carcinoma, gastroesophageal varices, cardiovascular events, and other organ malignancy. Although the incidence of chronic viral hepatitis with associated complications has gradually decreased as highly effective antiviral therapies have been established, the number of patients with steatohepatitis has been increasing.This retrospective study examined data of 229 patients from 22 hospitals in our region. We examined 155 cases of chronological data and assessed the development of liver fibrosis and evaluated hepatic reserve-related markers such as platelet count, FIB-4 index, prothrombin time, and serum albumin concentration. We analyzed the relationship of these chronological changes and the incidence of NAFLD related serious complications.Data related to liver fibrosis progression, albumin, and prothrombin time were significantly associated with the occurrence of serious complications associated with cirrhosis. We compared 22 event and 133 nonevent cases of chronological changes in the data per year and found that serum albumin concentration was significantly lower in the group that developed serious complications (event cases: -0.21 g/dL/year, nonevent cases: -0.04 g/dL/year (P < .001)). This albumin decline was only the associated factor with the event incidence by multivariate analysis (P < .01).Annual decline in serum albumin concentration in patients with NAFLD is associated with serious events from the outcome of multicenter retrospective study. This highlights its potential utility as a surrogate marker to assess the efficacy of prediction of NAFLD related serious events.
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Affiliation(s)
- Kazunori Kawaguchi
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Yoshio Sakai
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
- Department of Laboratory Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Takeshi Terashima
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Tetsuhiro Shimode
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Akihiro Seki
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Noriaki Orita
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Yumie Takeshita
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences
| | - Tetsuro Shimakami
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Hajime Takatori
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Kuniaki Arai
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Kazuya Kitamura
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Tatsuya Yamashita
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Graduate School of Medical Sciences
| | - Eishiro Mizukoshi
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences
| | - Masao Honda
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
| | - Takashi Wada
- Department of Laboratory Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Shuichi Kaneko
- Department of Gastroenterology, Kanazawa University Graduate School of Medical Sciences
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13
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Miyamoto Y, Enomoto H, Nishikawa H, Nishimura T, Iwata Y, Nishiguchi S, Iijima H. Association of the Modified ALBI Grade With Endoscopic Findings of Gastroesophageal Varices. In Vivo 2021; 35:1163-1168. [PMID: 33622916 DOI: 10.21873/invivo.12364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM This study aimed to assess the association of the modified albumin-bilirubin (mALBI) grade with the endoscopic findings of gastroesophageal varices (GEVs). PATIENTS AND METHODS A total of 141 patients with histologically proven cirrhosis who underwent a liver biopsy and esophagogastroduodenoscopy were enrolled. The relationships between the mALBI grade and endoscopic findings were evaluated. RESULTS The incidence of GEVs and high-risk GEVs differed among mALBI grades. Patients with mALBI grades of 2b-3 had higher rates of GEVs and high-risk GEVs in comparison to those with mALBI grades of 1-2a (p<0.0001). In addition, patients with mALBI grade 2b or grade 3, but not those with mALBI grade 2a, had significantly higher rates of complicated GEVs and high-risk GEVs in comparison to those with mALBI grade 1. CONCLUSION The mALBI grade may be useful in predicting the presence of GEVs and for stratifying their bleeding risk.
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Affiliation(s)
- Yuho Miyamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Gastroenterology, Takarazuka City Hospital, Hyogo, Japan
| | - Hirayuki Enomoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan;
| | - Hiroki Nishikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Nishimura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinori Iwata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Hiroko Iijima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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14
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Huang Y, Huang F, Yang L, Hu W, Liu Y, Lin Z, Meng X, Zeng M, He C, Xu Q, Xie G, Liu C, Liang M, Li X, Kang N, Xu D, Wang J, Zhang L, Mao X, Yang C, Xu M, Qi X, Mao H. Development and validation of a radiomics signature as a non-invasive complementary predictor of gastroesophageal varices and high-risk varices in compensated advanced chronic liver disease: A multicenter study. J Gastroenterol Hepatol 2021; 36:1562-1570. [PMID: 33074566 DOI: 10.1111/jgh.15306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/12/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Gastroesophageal varices (GEV) present in compensated advanced chronic liver disease (cACLD) and can develop into high-risk varices (HRV). The gold standard for diagnosing GEV is esophagogastroduodenoscopy (EGD). However, EGD is invasive and less tolerant. This study aimed to develop and validate radiomics signatures based on noncontrast-enhanced computed tomography (CT) images for non-invasive diagnosis of GEV and HRV in patients with cACLD. METHODS The multicenter trial enrolled 161 patients with cACLD from six university hospitals in China between January 2015 and September 2019, who underwent both EGD and noncontrast-enhanced CT examination within 14 days prior to the endoscopy. Two radiomics signatures, termed rGEV and rHRV, respectively, were built based on CT images in a training cohort of 129 patients and validated in a prospective validation cohort of 32 patients (ClinicalTrials. gov identifier: NCT03749954). RESULTS In the training cohort, both rGEV and rHRV exhibited high discriminative abilities on determining the existence of GEV and HRV with the area under receiver operating characteristic curve (AUC) of 0.941 (95% confidence interval [CI] 0.904-0.978) and 0.836 (95% CI 0.766-0.905), respectively. In validation cohort, rGEV and rHRV showed high discriminative abilities with AUCs of 0.871 (95% CI 0.739-1.000) and 0.831 (95% CI 0.685-0.978), respectively. CONCLUSIONS This study demonstrated that rGEV and rHRV could serve as the satisfying auxiliary parameters for detection of GEV and HRV with good diagnostic performance.
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Affiliation(s)
- Yifei Huang
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Fangze Huang
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Li Yang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Weiling Hu
- Department of Gastroenterology, Sir Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yanna Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zihuai Lin
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xiangpan Meng
- Jiangsu Key Laboratory of Molecular and Functional Imaging, Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Manling Zeng
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Chaohui He
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Qing Xu
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guanghang Xie
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Chuan Liu
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Mingkai Liang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoguo Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Ning Kang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Dan Xu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jitao Wang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Liting Zhang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaorong Mao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Changqing Yang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ming Xu
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Hua Mao
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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15
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Namikawa T, Iwabu J, Munekage M, Uemura S, Maeda H, Kitagawa H, Nakayama T, Fukuhara H, Inoue K, Al-Sheikh M, Jaiswal N, Kobayashi M, Hanazaki K. Laparoscopic-endoscopic cooperative surgery for early gastric cancer with gastroesophageal varices. Asian J Endosc Surg 2020; 13:539-543. [PMID: 32066204 DOI: 10.1111/ases.12791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/30/2019] [Accepted: 02/02/2020] [Indexed: 02/05/2023]
Abstract
This report describes a patient with early gastric cancer with gastroesophageal varices who underwent laparoscopic-endoscopic cooperative surgery. The patient, a 75-year-old woman, was referred to our hospital for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed a superficial spreading-type tumor on the posterior wall of the upper third of the stomach that was very close to the gastric varices. Biopsy specimens showed a moderately differentiated tubular adenocarcinoma. Abdominal contrast-enhanced CT showed an enhanced submucosal area with noticeably dilated veins around the perigastric region and no masses in the liver. The patient underwent local resection of the stomach using laparoscopic-endoscopic cooperative surgery; this procedure was chosen because of the patient's risk of bleeding from the gastric varices in the area adjacent to the cancer during endoscopic submucosal dissection. Macroscopic examination of the resected specimen showed a superficial spreading lesion measuring 55 × 50 mm. The pathological diagnosis was moderately differentiated tubular adenocarcinoma invading the gastric submucosal layer without lymphovascular invasion.
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Affiliation(s)
- Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Nankoku, Japan.,Center for Photodynamic Medicine, Kochi Medical School Hospital, Nankoku, Japan
| | - Jun Iwabu
- Department of Surgery, Kochi Medical School, Nankoku, Japan
| | | | - Sunao Uemura
- Department of Surgery, Kochi Medical School, Nankoku, Japan
| | | | | | - Taku Nakayama
- Center for Photodynamic Medicine, Kochi Medical School Hospital, Nankoku, Japan
| | - Hideo Fukuhara
- Center for Photodynamic Medicine, Kochi Medical School Hospital, Nankoku, Japan.,Department of Urology, Kochi Medical School Hospital, Nankoku, Japan
| | - Keiji Inoue
- Center for Photodynamic Medicine, Kochi Medical School Hospital, Nankoku, Japan.,Department of Urology, Kochi Medical School Hospital, Nankoku, Japan
| | - Mariam Al-Sheikh
- Medical Department, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Bahrain
| | - Nalin Jaiswal
- Medical Department, Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Bahrain
| | - Michiya Kobayashi
- Department of Human Health and Medical Sciences, Kochi Medical School, Nankoku, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Nankoku, Japan.,Center for Photodynamic Medicine, Kochi Medical School Hospital, Nankoku, Japan
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16
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Hong J, Zuo W, Wang A, Zhu L, Zhou X, Zhou X, Li G, Liu Z, Liu P, Zhen H, Zhu Y, Ma J, Yuan J, Shu X, Zhu Y, Lu N, Chen Y. Efficacy and safety of ERCP in patients with gastroesophageal varices. Medicine (Baltimore) 2020; 99:e22051. [PMID: 32925738 PMCID: PMC7489748 DOI: 10.1097/md.0000000000022051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Addressing pancreaticobiliary disorders concomitant with gastroesophageal varices remains challenging. The goal of this study was to evaluate and compare the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotic and noncirrhotic patients with gastroesophageal varices.We retrospectively analyzed the data of consecutive patients with gastroesophageal varices who underwent ERCP.Two hundred seventy ERCP procedures were performed on 208 patients. The overall technical success rate was 98.5%, and no difference was found between cirrhotic and noncirrhotic patients (98.7% vs 97.7%, P = .511); of these, endoscopic retrograde biliary drainage, endoscopic metal biliary endoprosthesis placement, endoscopic retrograde pancreatic drainage, and stone extraction were conducted in 173/270 (64.1%), 27/270 (10.0%), 26/270 (9.6%), and 116/270 (43.0%) cases, respectively. Endoscopic retrograde biliary drainage and stone extraction were more frequently performed in cirrhotic cases (67.7% versus 45.5%, P = .005; 46.5% versus 25.0%, P = .009, respectively), while the noncirrhotic group had significantly higher rates of endoscopic metal biliary endoprosthesis placement (31.8% versus 5.8%, P = .000) and endoscopic retrograde pancreatic drainage (18.2% versus 8.0%, P = .036) than the cirrhotic group. The overall rate of adverse events was 21.1%, including fever (6.7%), post-ERCP pancreatitis ( 3.0%), hyperamylasemia (6.3%), duodenal papilla bleeding (3.3%), cardiac mucosal laceration (1.1%), and perforation (0.4%). No differences in any of the adverse events were found between the 2 groups. Additionally, gastroesophageal variceal bleeding occurred in 1 patient with grade III varices 7 days after ERCP.ERCP may be effective and safe for patients with gastroesophageal varices, irrespective of the etiologies caused by liver cirrhosis.
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Affiliation(s)
| | - Wei Zuo
- Departments of Respiratory Medicine
| | | | | | | | | | | | | | - Pi Liu
- Departments of Gastroenterology
| | | | | | | | - Jianhui Yuan
- Department of Anesthesiology, Endoscopy Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xu Shu
- Departments of Gastroenterology
| | - Yin Zhu
- Departments of Gastroenterology
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17
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Tamaki N, Kurosaki M, Higuchi M, Kirino S, Inada K, Yamashita K, Sekiguchi S, Hayakawa Y, Osawa L, Takaura K, Maeyashiki C, Kaneko S, Yasui Y, Tsuchiya K, Nakanishi H, Itakura J, Izumi N. Validation of albumin, bilirubin, and platelet criteria for avoiding screening endoscopy in patients with advanced fibrosis. Hepatol Res 2020; 50:996-999. [PMID: 32515534 DOI: 10.1111/hepr.13533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/28/2020] [Accepted: 06/06/2020] [Indexed: 12/15/2022]
Abstract
AIM The albumin, bilirubin, and platelet (ABP) criteria was proposed to avoid screening endoscopy for detecting high-risk varices (HRV) and it has high diagnostic accuracy. We carried out a retrospective cross-sectional study to verify the diagnostic accuracy. METHODS A total of 610 patients with advanced fibrosis were enrolled in the study. ABP criteria are defined as follows: albumin >4.0 g/dL, bilirubin <22 μmol/L, and platelets >114 000/μL. RESULTS Background liver disease were hepatitis C/hepatitis B/non-alcoholic fatty liver disease/others:405 (66.4%)/67 (10.5%)/78 (12.8%)/60 (10.3%). A total of 105 patients (17.2%) had HRV. In multivariate analysis, serum bilirubin <22 μmol/L (HR 2.00, 95% CI 1.2-3.4), albumin >4.0 g/dL (HR 2.56, 95% CI 1.7-3.8), and platelets >114 000/μL (HR 3.52, 95% CI 2.1-5.8) levels were independently associated with no presence of HRV. When the ABP criteria were examined, 200 patients (32.8%) fulfilled the criteria, and 194 patients had no HRV (positive predictive value 97.0%) When classified by etiologies (hepatitis C/hepatitis B/non-alcoholic fatty liver disease), positive predictive value were 97.7/100/92.0%, respectively. CONCLUSIONS The ABP criteria are easy to examine, because they use only standard laboratory tests, and they are available for screening patients who might avoid endoscopy regardless of etiologies.
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Affiliation(s)
- Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Mayu Higuchi
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Sakura Kirino
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Kento Inada
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Koji Yamashita
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Shuhei Sekiguchi
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Yuka Hayakawa
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Leona Osawa
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Kenta Takaura
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Chiaki Maeyashiki
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Shun Kaneko
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Yutaka Yasui
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Kaoru Tsuchiya
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Hiroyuki Nakanishi
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Jun Itakura
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musasino Red Cross Hospital, Tokyo, Japan
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Hayashi T, Tamaki N, Kurosaki M, Wang W, Okada M, Higuchi M, Takaura K, Takada H, Yasui Y, Tsuchiya K, Nakanishi H, Itakura J, Harada M, Izumi N. Use of the Serum Wisteria floribunda Agglutinin-Positive Mac2 Binding Protein as a Marker of Gastroesophageal Varices and Liver-Related Events in Chronic Hepatitis C Patients. Diagnostics (Basel) 2020; 10:diagnostics10030173. [PMID: 32235806 PMCID: PMC7151084 DOI: 10.3390/diagnostics10030173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A test to narrow down patients who require esophagogastroduodenoscopy (EGD) with a high probability of having gastroesophageal varices (GEV) and a high-risk of liver-related events is an unmet need. METHODS The measurement of serum fibrosis markers and EGD was performed in 166 consecutive chronic hepatitis C patients. The correlation between the grades of GEV and fibrosis markers and the subsequent occurrence of liver-related and fibrosis markers were examined. RESULTS Wisteria floribunda agglutinin-positive human Mac-2 binding protein (WFA+-M2BP) levels increased according to the grade of GEV (3.4 (0.2-18.6) for no GEV, 7.9 (1.8-20.0) for small GEV, and 11.4 (4.0-20.0) for large GEV; p < 0.001). The diagnostic accuracy of the WFA+-M2BP was superior compared to other serum fibrosis markers, and WFA+-M2BP was an independent predictor of GEV in the multivariate analysis. Furthermore, the cumulative incidence of liver-related events at one year was 2.3% in patients with WFA+-M2BP levels ≤ 7.0 and 37.5% in patients with WFA+-M2BP levels > 7.0 (p < 0.001). WFA+-M2BP > 7.0 was a significant predictive factor for liver-related events (Hazard ratio 6.7, p = 0.004) independent of Child-Pughclass. CONCLUSIONS WFA+-M2BP could be used to estimate the presence and grade of GEV and is linked to liver-related events in chronic hepatitis C patients.
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Affiliation(s)
- Tsuguru Hayashi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu 807-8555, Japan;
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Wan Wang
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Mao Okada
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Mayu Higuchi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Kenta Takaura
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Hitomi Takada
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Yutaka Yasui
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Kaoru Tsuchiya
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Hiroyuki Nakanishi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Jun Itakura
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
| | - Masaru Harada
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu 807-8555, Japan;
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; (T.H.); (N.T.); (M.K.); (W.W.); (M.O.); (M.H.); (K.T.); (H.T.); (Y.Y.); (K.T.); (H.N.); (J.I.)
- Correspondence: ; Tel.: +81-422-32-3111; Fax: +81-422-32-9551
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Yuri Y, Nishikawa H, Enomoto H, Yoh K, Iwata Y, Sakai Y, Kishino K, Ikeda N, Takashima T, Aizawa N, Takata R, Hasegawa K, Ishii N, Nishimura T, Iijima H, Nishiguchi S. Impact of Sustained Virological Response for Gastroesophageal Varices in Hepatitis-C-Virus-Related Liver Cirrhosis. J Clin Med 2019; 9:E95. [PMID: 31905953 DOI: 10.3390/jcm9010095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/27/2019] [Indexed: 12/11/2022] Open
Abstract
We aimed to clarify the relationship between sustained virological response (SVR) and gastroesophageal varices (GEVs) progression among hepatitis C virus (HCV)-related liver cirrhosis (LC) patients treated with interferon (IFN)-based therapies (n = 18) and direct-acting antiviral (DAA)-based therapies (n = 37), and LC patients with no SVR (n = 71) who had already developed GEVs. Factors influencing GEVs progression were also examined. During the follow-up period, GEVs progression was observed in 50 patients (39.7%). The 3-year cumulative GEVs progression rates in the DAA-SVR group, the IFN-SVR group, and the non-SVR group were 32.27%, 5.88%, and 33.76%, respectively (overall p value = 0.0108). Multivariate analysis revealed that sex (p = 0.0430), esophageal varices (EVs) F2 or more (p < 0.0001), and DAA-SVR (p = 0.0126, IFN-SVR as a reference) and non-SVR (p = 0.0012, IFN-SVR as a reference) were independent predictors for GEVs progression. The proportion of GEVs progression in patients with no or F1 EVs was significantly lower than that in patients with F2 or F3 EVs (33.9% (38/112) vs. 85.7% (12/14), p = 0.0003). In conclusion, IFN-based therapies can have a favorable impact for preventing GEVs progression in HCV-related LC patients with GEVs. Clinicians should be aware of a point of no return where SVR is no longer capable of avoiding GEVs progression.
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Shetty A, Jun Yum J, Saab S. The Gastroenterologist's Guide to Preventive Management of Compensated Cirrhosis. Gastroenterol Hepatol (N Y) 2019; 15:423-430. [PMID: 31592079 PMCID: PMC6771034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Despite advances in medical care, the prevalence and mortality associated with cirrhosis continue to rise. The majority of medical care and physician efforts are devoted to the management of decompensated cirrhosis and its complications of gastrointestinal hemorrhage, hepatic encephalopathy, and ascites; however, limited efforts are placed on the medical management of compensated cirrhosis. Patients with compensated cirrhosis carry a higher survival rate, and, when diagnosed early, may be screened for future decompensation. When possible, these patients can be treated for their underlying disease to prevent disease progression and avoid the need for liver transplantation. This article reviews the importance of early diagnosis, outpatient management of compensated cirrhosis, early screening for potential decompensation, and patient education.
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Affiliation(s)
- Akshay Shetty
- Dr Shetty is a fellow in the Department of Medicine, Mr Yum is a research assistant in the Department of Surgery, and Dr Saab is a professor in the Departments of Medicine and Surgery at the University of California, Los Angeles in Los Angeles, California
| | - Jung Jun Yum
- Dr Shetty is a fellow in the Department of Medicine, Mr Yum is a research assistant in the Department of Surgery, and Dr Saab is a professor in the Departments of Medicine and Surgery at the University of California, Los Angeles in Los Angeles, California
| | - Sammy Saab
- Dr Shetty is a fellow in the Department of Medicine, Mr Yum is a research assistant in the Department of Surgery, and Dr Saab is a professor in the Departments of Medicine and Surgery at the University of California, Los Angeles in Los Angeles, California
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21
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Zhang Z, Chen X, Li C, Feng H, Yu H, Zhu R, Wang T. Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study. Clinics (Sao Paulo) 2019; 74:e704. [PMID: 31433045 PMCID: PMC6691837 DOI: 10.6061/clinics/2019/e704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/13/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension. METHODS Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared. RESULTS Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p<0.001): one patient in Group A and 6 patients in Group B had partial response, and all 9 patients in Group C had remission (2 complete, 7 partial). Two Group A patients and one Group B patient developed recurrent gastrointestinal bleeding postoperatively within 12 months. No postoperative recurrence or bleeding was observed in Group C, and no sclerotherapy-related complications were observed. CONCLUSIONS Shunt surgery combined with foam sclerotherapy obliterates varices more effectively than shunt surgery alone does, decreasing the risk of postoperative rebleeding from residual gastroesophageal varices. This novel surgery is safe and effective with good short-term outcomes.
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Affiliation(s)
- Zhe Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Chenyu Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Hongzhi Yu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Renming Zhu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
| | - Tianyou Wang
- Department of Thoracic Surgery, Beijing Friendship Hospital, Capital Medical University, ChinaChina
- Corresponding author. E-mail:
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22
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Llop E, Lopez M, de la Revilla J, Fernandez N, Trapero M, Hernandez M, Fernández-Carrillo C, Pons F, Martinez JL, Calleja JL. Validation of noninvasive methods to predict the presence of gastroesophageal varices in a cohort of patients with compensated advanced chronic liver disease. J Gastroenterol Hepatol 2017; 32:1867-1872. [PMID: 28295587 DOI: 10.1111/jgh.13781] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The aim was to validate noninvasive methods to predict the presence of gastroesophageal varices (GEV) in patients with suspected compensated advanced chronic liver disease. METHODS We retrospectively reviewed clinical and radiological data collected prospectively between September 2013 and September 2015. We reviewed 442 consecutive patients with suspected compensated advanced chronic liver disease measured by transient elastography (TE) and a gastroscopy. We evaluated platelets, spleen diameter, TE, liver stiffness × spleen size/platelets (LSPS), variceal risk index (VRI), Baveno VI strategy, and Augustin algorithm. RESULTS One hundred sixty-one out of 442 patients were included. Patients with GEV were compared with patients without GEV and showed statistically significant differences in platelet count (117 SD 51 vs 149 SD 62; P = 0.02), spleen diameter (13.0 SD 1.9 vs 11.5 SD 2; P = 0.003), and TE (28 SD 15 vs 19 SD 10; P = 0.001). Single methods (platelet count and TE) diagnosed correctly 51% and 71.4% of patients. Combined methods (LSPS, VRI, Baveno VI, and Augustin algorithm) diagnosed correctly 78%, 83.6%, 45.3%, and 57.1% of patients. Patients with GEV misdiagnosed: platelets 5/161 (3.1%), TE 6/161 (3.7%), LSPS 16/159 (10%), VRI 18/159 (11.3%), Baveno VI 3/161 (1.8%), and Augustin algorithm 6/161 (3.7%). Rate of unnecessary gastroscopies: platelets 46%, TE 25%, LSPS 13%, VRI 6%, Baveno VI 53%, and Augustin algorithm 39.1%. CONCLUSIONS A significant number of patients were classified correctly using TE, LSPS, and VRI; however, LSPS and VRI had unacceptable rates of misdiagnoses. TE is the best noninvasive single method and the Baveno VI strategy the best combined method.
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Affiliation(s)
- Elba Llop
- Liver Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Marta Lopez
- Liver Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | - Maria Trapero
- Liver Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Marta Hernandez
- Liver Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | - Fernando Pons
- Liver Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
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23
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Abstract
A 53-year-old male patient with a history of hepatocellular carcinoma developed gastroesophageal varices refractory to endoscopic injection sclerotherapy (EIS). He required EIS six times in 2 years for recurring variceal bleeding. After hepatic resection, he developed massive splenomegaly. Partial splenic embolization (PSE) was performed to reduce the portal pressure. Varices and variceal bleeding were not detected during 13-year follow up, until the patient died of hepatocellular carcinoma. This is a unique case of gastroesophageal varices controlled by PSE and improved portal hypertension.
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Affiliation(s)
- Takayuki Kogure
- Division of Gastroenterology1, Tohoku University Hospital, Japan
| | - Jun Inoue
- Division of Gastroenterology1, Tohoku University Hospital, Japan
| | - Eiji Kakazu
- Division of Gastroenterology1, Tohoku University Hospital, Japan
| | - Masashi Ninomiya
- Division of Gastroenterology1, Tohoku University Hospital, Japan
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24
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Sekimoto T, Maruyama H, Kobayashi K, Kiyono S, Kondo T, Shimada T, Takahashi M, Yokosuka O. Well-tolerated portal hypertension and favorable prognosis in adult patients with extrahepatic portal vein obstruction in Japan. Hepatol Res 2016; 46:505-13. [PMID: 26333179 DOI: 10.1111/hepr.12581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/13/2015] [Accepted: 08/17/2015] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the clinical features and prognoses in adult patients with extrahepatic portal vein obstruction (EHO) from the aspect of portal hypertension during the last 20 years in Japan. METHODS There were 40 EHO patients (aged 21-77 years; mean ± standard deviation [SD], 54.6 ± 15.0). Clinical findings and prognoses were examined retrospectively during the median observation period of 71.6 months. RESULTS Twenty-two patients (55%) showed positive signs of portal hypertension; 18 with esophageal varices (F0, one; F1, eight; F2, nine), two with gastric varices (F1, one; F2, one) and seven with mild ascites. Multivariate analysis showed that platelet count and spleen size were significant factors for the presence of gastroesophageal varices, with odds ratios of 0.989 (95% confidence interval [CI], 0.980-0.997; P = 0.011) for platelet count and 1.003 (95% CI, 1.001-1.005; P = 0.003) for spleen size. Ten of 20 patients with gastroesophageal varices received primary prophylaxis and only one patient (10%) showed variceal recurrence. The cumulative overall survival rate was 100% at 1 year, 94.2% at 3-7 years and 68.7% at 10 years. The cumulative survival rates did not differ between the patients with and without gastroesophageal varices, with and without ascites, and patterns of portal cavernoma at baseline. CONCLUSION Forty-five percent of adult EHO patients in Japan were free from signs of portal hypertension, and platelet count and spleen size are predictive for identifying patients with gastroesophageal varices. EHO patients with gastroesophageal varices show favorable prognoses comparable to those without, if primary/secondary prophylaxis was performed appropriately.
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Affiliation(s)
- Tadashi Sekimoto
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hitoshi Maruyama
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazufumi Kobayashi
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takayuki Kondo
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taro Shimada
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masanori Takahashi
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
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25
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Wani ZA, Bhat RA, Bhadoria AS, Maiwall R, Choudhury A. Gastric varices: Classification, endoscopic and ultrasonographic management. J Res Med Sci 2016; 20:1200-7. [PMID: 26958057 PMCID: PMC4766829 DOI: 10.4103/1735-1995.172990] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Gastric varices (GV) are responsible for 10-30% of all variceal hemorrhage. However, they tend to bleed more severely with higher mortality. Around 35-90% rebleed after spontaneous hemostasis. Approximately 50% of patients with cirrhosis of liver harbor gastroesophageal varices. In this review, new treatment modalities in the form of endoscopic treatment options and interventional radiological procedures have been discussed besides discussion on classification and pathophysiology of GV.
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Affiliation(s)
| | - Riyaz Ahmad Bhat
- Department of Gastroenterology, Health and Medical Education Department, Health Services, Kashmir, India
| | | | - Rakhi Maiwall
- Department of Gastroenterology, ILBS, New Dehli, India
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26
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Gaba RC, Couture PM, Lakhoo J. Gastroesophageal Variceal Filling and Drainage Pathways: An Angiographic Description of Afferent and Efferent Venous Anatomic Patterns. J Clin Imaging Sci 2015; 5:61. [PMID: 26713177 PMCID: PMC4683797 DOI: 10.4103/2156-7514.170730] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 10/26/2015] [Indexed: 12/20/2022] Open
Abstract
Varices commonly occur in liver cirrhosis patients and are classified as esophageal (EV), gastroesophageal (GEV), or isolated gastric (IGV) varices. These vessels may be supplied and drained by several different afferent and efferent pathways. A working knowledge of variceal anatomy is imperative for Interventional Radiologists performing transjugular intrahepatic portosystemic shunt and embolization/obliteration procedures. This pictorial essay characterizes the angiographic anatomy of varices in terms of type and frequency of venous filling and drainage, showing that different varices have distinct vascular anatomy. EVs typically show left gastric vein filling and "uphill" drainage, and GEVs and IGVs exhibit additional posterior/short gastric vein contribution and "downhill" outflow. An understanding of these variceal filling and drainage pathways can facilitate successful portal decompression and embolization/obliteration procedures.
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Affiliation(s)
- Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | | | - Janesh Lakhoo
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
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27
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Abstract
Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.
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Affiliation(s)
- Ahmad Parvinian
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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28
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Rosołowski M, Hartleb M, Marek T, Milewski J, Linke K, Wallner G, Dąbrowski A, Rydzewska G. Therapeutic and prophylactic management of bleeding from oesophageal and gastric varices - recommendations of the Working Group of the National Consultant for Gastroenterology. Prz Gastroenterol 2014; 9:63-8. [PMID: 25061484 PMCID: PMC4108746 DOI: 10.5114/pg.2014.42497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
Gastroesophageal varices are one of the most serious consequences of portal hypertension. One-third of patients with varices will develop variceal haemorrhage. Despite significant improvements in the outcomes of treatment, mortality due to bleeding from gastro-oesophageal varices still remains very high. These recommendations present optimal management of patients with non-bleeding and bleeding varices.
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Affiliation(s)
- Mariusz Rosołowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland
| | - Marek Hartleb
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Marek
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Janusz Milewski
- Department of Internal Medicine and Gastroenterology, Central Clinical Hospital of Ministry of Internal Affairs, Warsaw, Poland
| | - Krzysztof Linke
- Department of Gastroenterology, Human Nutrition and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Grzegorz Wallner
- Department and Clinic of General Surgery, Gastroenterology and Digestive Tract Neoplasm, Medical University of Lublin, Poland
| | - Andrzej Dąbrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland
| | - Grażyna Rydzewska
- Department of Internal Medicine and Gastroenterology, Central Clinical Hospital of Ministry of Internal Affairs, Warsaw, Poland
- Faculty of Sciences, University of Jan Kochanowski, Kielce, Poland
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29
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Sharma BC, Banka AK, Rawat A, Srivastava S. Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection. J Clin Exp Hepatol 2013; 3:19-23. [PMID: 25755467 PMCID: PMC3940531 DOI: 10.1016/j.jceh.2013.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 01/15/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gastric varices are found in patients with portal hypertension. Incidence of bleeding from gastric varices is relatively low, but tends to be more severe, and is associated with higher mortality than esophageal variceal bleeding. AIMS AND OBJECTIVES To compare the prevalence and types of gastric varices in cirrhosis versus extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection. METHODS Eighty six patients presenting with bleeding from gastric varices between August 2010 and August 2011 were retrospectively analyzed. RESULTS Of 86 patients, 65% (n = 56) were cirrhotics and 35% (n = 30) had EHPVO. Distribution of types of gastric varices showed GOV1 in 14% (n = 8) of cirrhotics vs. 7% (n = 2) of EHPVO, GOV2 in 80% (n = 45) of cirrhotics vs. 53% (n = 16) of EHPVO, IGV1 in 40% (n = 12) of patients with EHPVO vs. 4% (n = 2) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 3.7 ± 2.58 ml over a median of 1 session (range: 1-8). The total volume of glue required was lower in cirrhotics (3.2 ± 2 ml vs. 4.7 ± 3.1 ml, p < 0.05) than in EHPVO patients. Twenty (36%) of cirrhotics required >1 sessions of glue injection as compared to 17 (57%) of EHPVO patients. Over mean follow up of 12 months, rebleeding (9% vs. 10%) and mortality (11% vs. 3%) were similar in patients with cirrhosis and EHPVO. CONCLUSIONS In patients with bleeding from gastric varices, GOV2 is more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for gastric varix obturation.
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Key Words
- EHPVO, extrahepatic portal venous obstruction
- EVL, endoscopic variceal ligation
- GOV, gastroesophageal varices
- GV, gastric varices
- GVH, gastric variceal hemorrhage
- IGV, isolated gastric varices
- NBC, N-butyl-2-cyanoacrylate
- PHT, portal hypertension
- SPSS, Statistical Package for Social Sciences
- TIPS, transjugular intrahepatic portosystemic shunt
- endoscopic variceal ligation
- extrahepatic portal venous obstruction
- gastroesophageal varices
- isolated gastric varix
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Affiliation(s)
- Barjesh C. Sharma
- Address for correspondence. Barjesh C. Sharma, Professor, Department of Gastroenterology, Room 203, Academic Block, GB Pant Hospital, JL Nehru Marg, New Delhi 110002, India. Tel.: +91 (0) 9718599203 (mobile); fax: +91 11 23219222.
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Biecker E, Heller J, Schmitz V, Lammert F, Sauerbruch T. Diagnosis and management of upper gastrointestinal bleeding. Dtsch Arztebl Int 2008; 105:85-94. [PMID: 19633792 DOI: 10.3238/arztebl.2008.0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 12/17/2007] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Upper gastrointestinal (GI) bleeding is defined as bleeding proximal to ligament of Treitz. Its clinical presentations are hematemesis, melena stool, or even fresh bleeding per rectum. This paper reviews the diagnosis and treatment of upper GI bleeding. METHODS Selective literature review. RESULTS Common causes of upper GI bleeding are peptic ulcer disease, bleeding from gastroesophageal varices, angiodysplasias, and Mallory-Weiss lesions. The most important diagnostic intervention is endoscopy, which allows therapeutic interventions if needed. Peptic ulcer disease is treated endoscopically with injection therapy and endoclips. Acute bleeding from oesophageal varices is treated by banding. Endoscopic treatment is accompanied by medical treatment with proton pump inhibitors for the treatment of peptic ulcer disease, and vasoactive drugs for the treatment of bleeding oesophageal varices. DISCUSSION Modern endoscopy affords good localization of the bleeding site and successful treatment for most patients with upper GI bleeding.
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Affiliation(s)
- Erwin Biecker
- Universitätsklinikum Bonn, Sigmund-Freud-Strasse 25, Bonn, Germany
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