Esophageal squamous cell carcinoma complicated with varices successfully treated by endoscopic injection sclerotherapy and argon plasma coagulation: A case report

Treatment guidelines for esophageal squamous cell carcinoma (ESCC) with concomitant esophageal varices (EVs), which increase the risk of bleeding, are unavailable. A 66-year-old man with a history of total gastrectomy was admitted to the hospital owing to hematemesis. Emergency upper gastrointestinal endoscopy revealed variceal bleeding near the anastomosis between the esophagus and jejunum, and endoscopic clipping stopped the bleeding. Upper gastrointestinal endoscopy following hemostasis revealed four EVs and a two-thirds ESCC circumference. The ESCC depth was suspected to be up to the mucosa. The patient underwent intravariceal endoscopic injection sclerotherapy (EIS) for EVs, followed by paravariceal EIS. However, after these treatments, blood flow in the EVs just below the ESCC remained, and endoscopic resection of the ESCC was judged to be difficult to perform. Therefore, we prioritized EV treatment and performed a second EIS on the ESCC, followed by argon plasma coagulation (APC). APC was expected to not only solidify the EVs but also eliminate the ESCC existing in the mucosa. Finally, EVs and ESCC were treated by EIS and APC. EIS followed by APC may be useful for treating concurrent EVs and intramucosal ESCC in patients with liver cirrhosis when embolization of the EVs is ineffective.

Outcomes and Recurrence Rate of Esophageal Varices after Endoscopic Treatment in Patients with Alcoholic Cirrhosis and Viral Cirrhosis

BACKGROUND

The incidence of alcoholic liver cirrhosis (ALC) is increasing. However, few reports have focused on ALC-derived esophageal varices (EV). We retrospectively examined differences in overall survival (OS) and EV recurrence rate in patients after endoscopic injection sclerotherapy (EIS) for ALC and hepatic B/C virus liver cirrhosis (B/C-LC).

METHODS

We analyzed data from 215 patients (B/C-LC, 147; ALC, 68) who underwent EIS. The primary endpoints were OS and EV recurrence in patients with unsuccessful abstinence ALC and those with uncontrolled B/C-LC, before and after propensity score matching (PSM) to unify the patients' background. The secondary endpoints were predictors associated with these factors, as determined by multivariate analysis.

RESULTS

The observation period was 1,430 ± 1,363 days. In the analysis of all patients, OS was significantly higher in the ALC group than in the B/C-LC group (p = 0.039); however, there was no difference in EV recurrence rate (p = 0.502). Ascites and history of hepatocellular carcinoma (HCC) (p = 0.019 and p < 0.001, respectively) predicted OS, whereas age and EV size predicted recurrence (p = 0.011 and 0.024, respectively). In total, 96 patients without an HCC history were matched by PSM, and there was no significant difference in OS or EV recurrence rate (p = 0.508 and 0.246, respectively).

CONCLUSION

When limited to patients without a history of HCC, OS and the EV recurrence rate were comparable in patients with ALC who continued to consume alcohol and those with B/C-LC without viral control.

Large intramural hematoma of the esophagus after endoscopic injection sclerotherapy: A case report

RATIONALE

Endoscopic injection sclerotherapy (EIS) is a common treatment for patients with liver cirrhosis and esophageal varices. It can effectively treat variceal rupture and bleeding caused by liver cirrhosis. However, EIS has many complications, including postoperative bleeding, retrosternal pain, esophageal ulcers, esophageal stenosis, and ectopic embolism. Intramural hematoma of the esophagus (IHE) is a rare complication of EIS that can lead to chest tightness, chest pain, and dysphagia.

PATIENTS CONCERNS

A 55-year-old man developed severe nausea and vomiting accompanied by chest pain after EIS.

DIAGNOSIS

Comprehensive imaging features, the patient was diagnosed as IHE.

INTERVENTIONS

A vascular clamp was used for hemostasia, and a feeding tube was placed in the patient's jejunum.

OUTCOMES

After the removal of the jejunal feeding tube and the intake of a semiliquid diet, the patient had no episodes of chest pain, chest tightness, or dysphagia and was discharged after 2 days of observation.

LESSONS

Although IHE rarely occurs after EIS, we should not overlook its risk. The occurrence of IHE is not directly related to the number of EISs received or the degree of liver cirrhosis but is more likely related to postoperative nausea and vomiting. Therefore, timely medication and observation are particularly important for patients with nausea and vomiting after endoscopic treatment.

Balloon-Occluded Esophageal Variceal Obliteration Procedure: A Novel Technique Report from Three Centers

Introduction: Esophageal variceal bleeding (EVB) is a potentially fatal complication of cirrhosis. The purpose of the present study was to evaluate the safety and efficacy of a novel technique of balloon-occluded esophageal varices (EVs) obliteration (BEVO) for EVs classified as F2 (medium size, F2-EVs) and F3 (large size, F3-EVs). Materials and Methods: Between December 2020 and December 2021, a total of 73 consecutive patients with EVs were treated using BEVO. An injection of sclerosant was administered via direct puncture of the varices during balloon occlusion. Immediate postprocedural Doppler endoscopic ultrasonography (EUS) was conducted to evaluate the blood flow in the EVs. Several factors, including the technical success, controlling of acute bleeding, intraoperative bleeding at the injection site, variceal eradication, variceal recurrence, and BEVO-related complications, were assessed. Results: BEVO was successfully performed in all patients. Immediate hemostasis was achieved in 100% (25/25) of patients with active EVB. The incidence of injection site intraoperative bleeding presenting as oozing and spurting bleeding was 76.71% (56/73) and 8.22% (6/73), respectively. Based on Doppler EUS and endoscopic examination, EVs were completely eradicated in 71 out of 73 patients (97.26%) after three sessions. A total of 3 (4.11%) patients were diagnosed with EV recurrence during follow-up after complete EV eradication. Retrosternal chest discomfort (13.70%; 10/73) and abdominal bloating (2.74%; 2/73) were spontaneously relieved after a few days. No serious BEVO-related complications were observed. Discussion: BEVO is a convenient and effective treatment for obliterating F2 and F3 EVs. Clinical Trial Registration No. ChiCTR2000039974.

A case of esophageal carcinoma on esophageal varices treated by endoscopic submucosal dissection after endoscopic injection sclerotherapy

Esophageal varices (EVs) are often treated using endoscopic injection sclerotherapy. Endoscopic submucosal dissection (ESD) has been used for early esophageal epithelial neoplasia worldwide. We report a case of early esophageal squamous cell carcinoma (ESCC) that occurred over EVs, in which the EVs were treated with endoscopic injection sclerotherapy before the early ESCC was treated with endoscopic submucosal dissection. Argon plasma coagulation was finally performed to prevent the recurrence of varices. No serious complications, such as severe bleeding or perforation, were observed. Histopathological examination revealed submucosal veins occluded with an organized thrombus for which endoscopic injection sclerotherapy with an intravariceal injection of sclerosant had been performed, but no fibrosis was observed outside the blood vessels. This explains that the injected sclerosant into EVs did not cause any tissue reaction like fibrosis in the submucosa surrounding the vein, which may have made endoscopic submucosal dissection safer and easier. Varices have not recurred, and ESCC has also not recurred for 5 years. We demonstrated a successful treatment of ESCC on EVs and no submucosal fibrosis other than inside the occluded vessels and verified it histologically.

Comparison of transjugular intrahepatic portosystemic with endoscopic treatment plus anticoagulation for esophageal variceal bleeding and portal vein thrombosis in liver cirrhosis

BACKGROUND AND AIM

The optimal management of esophageal variceal bleeding (EVB) and portal vein thrombosis (PVT) in liver cirrhosis has not been well-established. The aim of the present study was to compare the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic treatment (ET) plus anticoagulation in cirrhotic patients with EVB and PVT.

PATIENTS AND METHODS

A total of 66 cirrhotic patients with PVT and EVB (31 in the TIPS group and 35 in the ET plus anticoagulation group) were evaluated retrospectively between January 2016 and January 2022.

RESULTS

During the follow-up period, 85.5% of patients in the TIPS group achieved complete recanalization of the portal vein, as compared with 19.6% in the ET plus anticoagulation group (p < .001). The cumulative 5-year rate of variceal rebleeding in the TIPS group was significantly lower than that in the ET plus anticoagulation group (31.0 vs. 50.1%; p = .017). The TIPS group exhibited a significantly higher incidence of overt hepatic encephalopathy (HE) than the ET plus anticoagulation group (25.8 vs. 5.7%; p = .037). No difference in the 5-year survival rate (74.1 vs. 85.7%; p = .692) and probability of other complications was observed between the two groups.

CONCLUSION

TIPS was superior to ET plus anticoagulation in preventing variceal rebleeding and achieving recanalization of PVT but increased the incidence of overt HE without improving the survival rate.

Pipeline Esophagogastric Varices Secondary to Extrahepatic Portal Vein Obstruction Treated Endoscopically with the Assistance of Transileocolic Obliteration

Endoscopic injection sclerotherapy (EIS) for esophagogastric varices (EGV) was attempted for a 29-year-old man with extrahepatic portal vein obstruction. However, pipeline varices characterized by a large blood flow volume were present, and the sclerosant did not accumulate sufficiently in them. Transileocolic obliteration (TIO) using coils was performed, but some EGVs and palisading veins remained. Thus, EIS was performed once again immediately after TIO. Since a reduction in the intravariceal blood flow was achieved by preceding TIO, effective injection of sclerosant into the vessels was possible. For pipeline varices difficult to treat endoscopically, combination therapy with TIO may be effective.

Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report

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.

A Case of Duodenal Variceal Rupture during Atezolizumab and Bevacizumab Treatment for Hepatocellular Carcinoma

Duodenal varices are detected infrequently, and their rupture is very rare. We encountered an 87-year-old man who developed duodenal varices rupture during chemotherapy with atezolizumab and bevacizumab (ATZ/BV) for hepatocellular carcinoma. We identified massive bleeding of a ruptured varix in the horizontal portion of the duodenum with emergency esophagogastroduodenoscopy (EGD). Successful hemostasis was achieved by endoscopic injection sclerotherapy with Histoacryl. Although ATZ/BV can cause esophageal varices rupture, there have been no cases of duodenal varices rupture. We should take care to check the duodenal varices as well as esophagogastric varices before ATZ/BV treatment.

The Risk of Bleeding in Small/Straight Esophageal Varices with Red Color Sign on Endoscopy: A Retrospective Analysis from the Natural Course

Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012−29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group’s bleeding rate was 10% (5/49). The follow-up group’s bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274−1582] days vs. 105 [1−336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.

Treatment Strategies in Emergency Endoscopy for Acute Esophageal Variceal Bleeding (CHESS1905): A Nationwide Cohort Study

Background and Aims

Emergency endoscopy is recommended for patients with acute esophageal variceal bleeding (EVB) and their prognosis has improved markedly over past decades due to the increased specialization of endoscopic practice. The study aimed to compare outcomes following emergency endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) in cirrhotic patients with acute EVB.

Methods

Cirrhotic patients with acute EVB who underwent emergency endoscopy were retrospectively enrolled from 2013 to 2020 across 34 university hospitals from 30 cities. The primary outcome was the incidence of 5-day rebleeding after emergency endoscopy. Subgroup analysis was stratified by Child-Pugh class and bleeding history. A 1:1 propensity score matching (PSM) analysis was performed.

Results

A total of 1,017 and 382 patients were included in EIS group and EVL group, respectively. The 5-day rebleeding incidence was similar between EIS group and EVL group (4% vs. 5%, P = 0.45). The result remained the same after PSM (P = 1.00). Among Child-Pugh class A, B and C patients, there were no differences in the 5-day rebleeding incidence between the two groups after PSM (P = 0.25, 0.82, and 0.21, respectively). As for the patients with or without bleeding history, the differences between EIS group and EVL group were not significant after PSM (P = 1.00 and 0.26, respectively).

Conclusion

The nationwide cohort study indicates that EIS and EVL are both efficient emergency endoscopic treatment strategies for acute EVB. EIS should not be dismissed as an economical and effective emergency endoscopic treatment strategy of acute EVB. ClincialTrials.gov number NCT04307264.

Clinical characteristics of reflux esophagitis among patients with liver cirrhosis: a case-control study

BACKGROUND

Reflux esophagitis (RE) can cause esophageal varices bleeding and largely reduce life quality of liver cirrhosis (LC) patients.

AIMS

To clarify the prevalence, severity and risk factors of RE among LC patients.

METHODS

A case-control study that enrolled 420 endoscopy-confirmed LC patients with RE as a case cohort and 409 LC patients without RE as a control group was conducted. Logistic regression was used to determine the risk factors for RE among LC patients.

RESULTS

The 10-year cumulative incidence rate of RE was 4.79% among the LC patients. The severity of RE among the LC patients was higher than that among the non-LC patients (p<.05). The LC patients with RE patients were older (56 years vs. 53 years) and had higher rates of male patients (77.14% vs. 65.77%), smoking (46.90% vs. 32.76%), alcohol intake (50.24% vs. 41.08%), past endoscopic variceal ligation (EVL) (9.05% vs. 4.65%), endoscopic injection sclerotherapy (EIS) (16.19% vs. 2.69%), hiatus hernia (7.14% vs. 0.13%) and portal vein thrombosis (PVT) (14.05% vs. 4.01%). Logistic regression demonstrated that hiatus hernia, past EIS, PVT, smoking, white blood cell count, age, spleen thickness and platelet (PLT) count were risk factors for RE among the LC patients.

CONCLUSIONS

Patients with LC tended to have severer RE than non-LC patients. The special risk factors of RE among LC patients included past EIS and PVT, which deserved extra attention for hepatologists as well as gastroenterologists to prevent.

Red dichromatic imaging reduces endoscopic treatment time of esophageal varices by increasing bleeding point visibility (with video)

BACKGROUND

Red dichromatic imaging (RDI) is a novel image-enhanced endoscopy released in 2020, which increases the visibility of deeper vessels. In this study, we retrospectively investigated whether RDI can shorten treatment times of endoscopic injection sclerotherapy (EIS), and which operational procedure times are affected compared with white light imaging (WLI).

METHODS

A total of 155 patients (RDI, 70; WLI, 85) with risky esophageal varices (EV), who were treated with EIS were analyzed. Treatment times were compared, and predictors associated with treatment time were analyzed by multivariate analysis. For 24 cases (RDI, 12; WLI, 12) in which treatment videos were recorded, the procedure times of each step (observation of EV, needle flush, positioning, puncture, observation of bleeding, hemostasis, observation after hemostasis) were measured. Regarding the seven patients with EV bleeding, color differences were calculated between the bleeding point and the blood pool using the CIE (L*a*b*) color measurement method, and results were compared between using RDI and WLI.

RESULTS

Treatment times were shorter in the RDI group (RDI vs. WLI = 35.1 vs. 42.2 min; P < 0.01). 'RDI function' and 'amount of sclerosant' were extracted as independent predictors of treatment time. Times for 'observation of EV' and 'observation of bleeding' were shorter in the RDI group (P = 0.01 and <0.01, respectively). Regarding the color difference, RDI significantly increased bleeding point visibility (RDI vs. WLI = 31.4 ± 11.8 vs. 8.6 ± 6.2, P < 0.001).

CONCLUSION

Red dichromatic imaging can shorten the treatment time of EIS by increasing bleeding point visibility.

Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with the propensity score matching: Multivariate analysis with propensity score matching

BACKGROUND

Peri-esophageal collateral veins have been reported to be associated with the recurrence of esophageal varices (EVs). In this study, we retrospectively analyzed whether endoscopic ultrasonography (EUS) findings obtained just before endoscopic injection sclerotherapy (EIS) are associated with the success rate of intravariceal injection, recurrence rate of EVs, and overall survival rate (OS) of patients. Furthermore, we investigated the independent predictors associated with these factors by multivariate analysis.

METHODS

A total of 91 patients with risky EVs treated by EIS were analyzed. The primary endpoint was to identify independent predictors associated with the success rate of intravariceal injection, recurrence rate, and OS by multivariate analysis, to confirm the usefulness of EUS examination. The secondary endpoint was to clarify differences in recurrence rate and OS between patients who underwent additional argon plasma coagulation (APC) and those who did not, by the propensity score matching method.

RESULTS

Luminal diameter of EVs and F factor were predictors of the success rate of intravariceal injection. APC was predictor of OS and recurrence of EVs. EUS findings were not associated with these factors. Propensity score matching (APC, 23; without APC, 23) showed that recurrence rate was significantly improved in the APC group (P = 0.050) and that OS had the tendency to be higher in the APC group (P = 0.068).

CONCLUSION

Endoscopic ultrasonography findings before EIS were associated with successful intravariceal injection but were not associated with recurrence rate or OS. Additional APC could improve OS and reduce the recurrence of EVs.

Transarterial Chemoembolization Combined With Endoscopic Therapy Is Beneficial for Unresectable Hepatocellular Carcinoma With Esophagogastric Varices

Background

The efficacy of transarterial chemoembolization (TACE) combined with endoscopic therapy for unresectable hepatocellular carcinoma with esophagogastric varices remains unclear.

Methods

The study has been registered on ClinicalTrials.gov with the number NCT05017922 (https://register.clinicaltrials.gov). Eligible patients were divided into combined group (received TACE plus endoscopic therapy) and control group (only received TACE). The occurrence of death and bleeding episodes during the follow-up was recorded. Kaplan–Meier analysis was used to compare outcomes between the two groups. Cox proportional hazard model was used to determine independent predictors for the survival.

Results

Eighty-nine patients were included, 42 in the combined group, others in the control group. During the follow-up, 51 patients died, the 1-year, 2-year, and 3-year survival rates were 64.9%, 45.5%, and 34.5%. The cumulative survival was significantly higher in the combined group than in the control group (p = 0.027); the 1-year, 2-year, and 3-year survival rates were 75.5%, 55.9%, 43.8% and 55.0%, 35.9%, 26.6%, respectively. Forty-four patients experienced bleeding, the bleeding rate was significantly higher in the control group than in the combined group (77.4% vs. 56.8%, p = 0.016). Multivariate analysis showed that treatment, hemoglobin, portal vein tumor thrombosis, and aspartate aminotransferase were independent predictors for overall survival; the first three factors were also independent predictors for bleeding-free survival. Patients who received primary prophylaxis had longer overall survival (p = 0.042) and bleeding-free survival (p = 0.029) than those who received secondary prophylaxis.

Conclusions

TACE combined with endoscopic therapy significantly improved survival and reduced bleeding rates in unresectable hepatocellular carcinoma with esophagogastric varices patients. Portal vein tumor thrombosis was a strong negative prognostic factor for both overall survival and bleeding-free survival. Primary prophylaxis improved survival benefits compared with secondary prophylaxis.

Efficacy and Safety of Ligation Combined With Sclerotherapy for Patients With Acute Esophageal Variceal Bleeding in Cirrhosis: A Meta-Analysis

Objective: To evaluate the efficacy and safety of endoscopic variceal ligation + endoscopic injection sclerotherapy (EVL+EIS) to control acute variceal bleeding (AVB). Methods: Online databases, including Web of Science, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM) disc, VIP, and Wanfang, were searched to identify the studies comparing the differences between EVB+EIS and EVB, EIS from the inception of the databases up to December 30, 2020. STATA 13.0 was used for the meta-analysis. Results: A total of eight studies involving 595 patients (317 patients in the EVL group and 278 patients in the EVL+EIS group) were included. The results of the meta-analysis did not reveal any statistically significant differences in the efficacy of acute bleeding control (P = 0.981), overall rebleeding (P = 0.415), variceal eradication (P = 0.960), and overall mortality (P = 0.314), but a significant difference was noted in the overall complications (P = 0.01). Conclusion: EVL is superior to the combination of EVL and EIS in safety, while no statistically significant differences were detected in efficacy. Further studies should be designed with a large sample size, multiple centers, and randomized controlled trials to assess both clinical interventions.

Secure intravariceal sclerotherapy with red dichromatic imaging decreases the recurrence rate of esophageal varices: A propensity score matching analysis

BACKGROUND

Red dichromatic imaging (RDI) is next-generation image-enhanced endoscopy technique released in July 2020. We previously reported that RDI can predict esophageal varices (EV) depth and decrease their recurrence rate by accurate intravariceal injections during endoscopic injection sclerotherapy (EIS) using unreleased prototype RDI endoscope. In this study, we analyzed whether RDI improves the overall survival (OS) rate and whether it is more accurate independent predictor of EV recurrence than white light imaging (WLI), using propensity score matching.

METHODS

A total of 179 patients were enrolled. Patients were matched for age, platelet count, liver function, EV size, luminal diameter, and EV depth using propensity score matching, and 78 patients (RDI, 39; WLI, 39) were finally matched. Primary endpoints were OS and recurrence rates. Secondary endpoints were success rate of intravariceal injection, operating time, incidence of adverse events (AEs), and predictors associated with OS and recurrence rates.

RESULTS

There was no difference in OS (P = .193), but the cumulative recurrence rate in the RDI group was significantly lower than in the WLI group (P = .002). Success rates of intrainjection, operating time, and incidence of AEs were better in the RDI group (p = 0.035, .026, and .0019, respectively). Independent predictors associated with recurrence rate by Cox proportional regression were RDI function and luminal diameter (P < .001 and .017, respectively).

CONCLUSION

RDI did not improve OS but decreased the recurrence rate. Independent predictors of recurrence rate were RDI and luminal diameter, resulting from secure intravariceal injections in EIS.

The Role of Endoscopic Ultrasound for Esophageal Varices

Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care.

Transparent cap-assisted endoscopic injection sclerotherapy for the treatment of patients with esophageal varices

The aim of this study was to compare the efficacy and safety of cap-assisted endoscopic injection sclerotherapy (EIS) versus direct EIS in the management of esophageal variceal bleeding in patients with cirrhosis.This retrospective study included patients with cirrhosis and esophageal variceal bleeding who underwent EIS with or without the use of a transparent cap at Shandong Provincial Hospital between December 2014 and April 2017. Patients were divided into two groups: Group A (EIS with transparent cap, n = 50) and Group B (direct EIS, n = 45). Data collected included patients' demographics, procedure details, and rates of variceal eradication, variceal rebleeding, variceal recurrence, and survival during the follow-up period. All data were expressed as mean ± SD. Quantitative variables were compared with Student t test; qualitative variables were compared with the Fisher exact test or chi-square test. P values less than .05 were considered significant.The mean follow-up duration was similar in both groups (16.3 ± 10.2 mo in Group A and 15.5 ± 9.5 mo in Group B). The volume of sclerosant (64.86 ± 10.62 vs 104.73 ± 21.25 ml, P = .044), mean number of sessions (2.37 ± 1.15 vs 5.70 ± 1.57, P = .042), time required to perform endoscopic treatment (6.57 ± 1.50 vs 11.22 ± 2.29 minutes, P = .049), and time to initial esophageal varices eradication (5.43 ± 1.38 vs 8.93 ± 1.5 wk, P = .041) were significantly smaller in the cap-assisted EIS group than in the direct EIS group. The probability of variceal recurrence and rebleeding was significantly higher in the direct EIS group than in the cap-assisted EIS group (14% versus 35.6% and 20% versus 40%). Only 22 patients (44%) developed complications in the cap-assisted group versus 30 patients (66.7%) in the EIS group (P = .039). The probability of survival was similar in both groups (86% versus 75.6%, P = .133).Modified EIS with the use of a transparent cap resulted in lower rates of esophageal variceal recurrence, rebleeding, and complications, compared with direct EIS.

Delayed esophagopleural fistula after endoscopic injection sclerotherapy for esophageal varices: A case report

RATIONALE

Esophagopleural fistula (EPF) is a rare critical life-threatening condition that features high misdiagnosis rate. Although various surgical and conservative techniques have been developed for the treatment of EPF, the mortality rate of EPF remains high.

PATIENT CONCERNS

An 81-year-old man with hepatic cirrhosis caused by schistosomiasis was admitted with upper gastrointestinal bleeding.

DIAGNOSES

Upper endoscopy revealed bleeding large esophageal varices, and endoscopic injection sclerotherapy (EIS) was performed. Two weeks after the EIS was performed, the patient developed pyrexia, left-sided pleuritic chest pain. Air and pleural effusion were showed in the left pleural cavity by high-resolution computed tomography (HRCT), and a linear fistulous communication was noticed from the distal esophagus. These findings were consistent with hepatic cirrhosis, esophageal varices, upper gastrointestinal bleeding, and esophagopleural fistula.

INTERVENTIONS

The patient was intensively treated with endoscopic self-expandable metallic stent (covered-SEMS) implantation and comprehensive treatments (including thoracic closed drainage, antibiotics, nasojejunal nutrition, and antacids).

OUTCOMES

The patient was completely cured without recurrence during a 6 months of follow-up by comprehensive conservative treatments.

LESSONS

This case indicates that pleural effusion with food residue is a specific finding in EPF. Thorax CT exhibited high sensitivity for the diagnosis of EPF. Endoscopic self-expandable metallic stent implantation and comprehensive conservative treatments may be preferable for the severe liver disease with EPF.

Gastroesophageal variceal bleeding - An overview of current treatment options

Gastroesophageal variceal hemorrhage is the most important clinical event that results from portal hypertension. It is a lifethreatening condition that demands rapid and efficient treatment. The first step in bleeding control is hemodynamic stabilization and pharmacological treatment, which includes administration of vasoactive drugs and short-term antibiotic prophylaxis. After initial hemodynamic stabilization, endoscopic therapy should be performed. The first choice of endoscopic treatment for esophageal bleeding is endoscopic variceal ligation (EVL), or endoscopic injection sclerotherapy (EIS) if EVL cannot be performed. Several rescue therapies, such as application of balloon tamponade, a selfexpandable metal stent (SEMS), or a transjugular intrahepatic portosystemic shunt (TIPS), are available in cases of resistant variceal bleeding that cannot be controlled with endoscopic therapies. Gastric varices have a lower incidence than esophageal varices, but bleeding from gastric varices is associated with higher mortality and morbidity rates. The first-line treatment, as with esophageal variceal bleeding, is stabilization of the patient. After that, control of bleeding can be attempted. Optimal management of gastric variceal bleeding is not yet standardized due to diverse underlying pathologies and the lack of large, randomized controlled trials. Among endoscopic techniques, endoscopic variceal obturation (EVO) has been acknowledged as reliable. Among rescue therapies, balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices and TIPS are the most common techniques.

Successful treatment of repeated hematemesis secondary to postsclerotherapy esophageal ulcer in a cirrhotic patient: A case report

Esophageal variceal bleeding is a common lethal complication of cirrhosis. Endoscopic injection sclerotherapy (EIS) is one of the major endoscopic approaches for treating esophageal variceal bleeding. However, complications may occur after EIS, which mainly include retrosternal discomfort/pain, dysphagia, re-bleeding, esophageal ulcer, esophageal strictures, and esophageal perforation, etc. In this article, we reported a 36-year-old male who developed esophageal ulcer related bleeding after EIS. Currently, there is no consensus on the treatment strategy for esophageal ulcer-related bleeding after EIS. In the present case, the following treatment strategy may be effective for ulcer related bleeding. The first step is to inhibit gastric acid secretion and reduce portal pressure by intravenous infusion of esomeprazole and somatostatin, respectively. The second is local hemostasis by oral norepinephrine and lyophilizing thrombin powder. The third is to protect digestive tract mucosa by oral Kangfuxin Ye and aluminum phosphate.

A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices

INTRODUCTION

The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB).

PATIENTS AND METHODS

In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival.

RESULTS

Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02).

CONCLUSIONS

Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.

Branched-chain amino acid-enriched nutrient increases blood platelet count in patients after endoscopic injection sclerotherapy

AIM

Protein and energy malnutrition is a severe problem for patients with liver cirrhosis (LC) and fasting often induces starvation which is a vitally important outcome. Dietary restriction is essential for endoscopic injection sclerotherapy (EIS) in patients with risky esophageal varices, thereby creating the possible exacerbation of nutritional state and inducing liver dysfunction. Whether EIS induces nutritional deficiency in LC patients and the effects of branched-chain amino acid (BCAA)-enriched nutrient are prospectively investigated.

METHODS

A total of 61 LC patients were randomly divided into an EIS monotherapy group (non-BCAA group, n = 31) and an EIS combined with BCAA therapy group (n = 30). Platelet count, blood chemistry and somatometry values were prospectively measured at five time points.

RESULTS

The platelet counts before treatment were at the same level in both groups (P = 0.72). Three months after treatment, the counts decreased in the non-BCAA group; however, they increased in the BCAA group (P = 0.019). Body mass index, triceps skin fold thickness and arm muscle circumference significantly decreased in both groups. The BCAA and tyrosine ratio value increased only in the BCAA group (P < 0.01). The skeletal muscle volume measured by InBody720 significantly decreased in the non-BCAA group (P < 0.001).

CONCLUSION

EIS induced protein-energy malnutrition, however, skeletal muscle volume was maintained by taking BCAA. Administration of BCAA had some effect in maintaining the nutritional state, and may improve the platelet count. Taking a greater amount of nutrients and shorter dietary restriction period or hospitalization was desirable.

Three-dimensional computed tomography of portopulmonary venous anastomoses in patients with esophageal varices before treatment

AIM

Portopulmonary venous anastomoses (PPVA) are shunts between esophageal varices and pulmonary veins. Because PPVA can cause serious complications at the time of sclerotherapy for esophageal varices, it is essential to confirm the existence of any PPVA before treatment.

METHODS

The study group comprised 101 patients in whom hemodynamics were evaluated on three-dimensional computed tomography (3D-CT) before either elective or prophylactic treatment of esophageal varices at Kitasato University East Hospital from October 2007 through August 2013. The presence or absence of PPVA, laboratory test results and 3D-CT findings were retrospectively examined in these patients.

RESULTS

Nine patients had PPVA, and 92 patients did not. The underlying diseases in the PPVA group were: hepatitis C liver cirrhosis in three; non-B, non-C liver cirrhosis in three; non-alcoholic steatohepatitis in one; primary biliary cirrhosis in one; and autoimmune hepatitis in one. The distribution of underlying diseases did not differ between the PPVA group and the non-PPVA group. When the study variables were statistically compared between the groups, the incidence of large, coil-shaped esophageal varices (grade F3) differed significantly between the groups (P = 0.001). Multivariate analyses of factors related to PPVA revealed that only the grade F3 type of esophageal varices differed significantly between the groups (P = 0.005; hazard ratio, 5.21; 95% confidence interval, 3.1-16.4).

CONCLUSION

In patients with grade F3 esophageal varices, the treatment method should be selected on the basis of an accurate hemodynamic analysis using 3D-CT before therapy.

Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis

AIM

Although rupture of rectal varices is rarely encountered, it may provoke massive and fatal hemorrhage in patients with liver cirrhosis. We examined the clinical features of patients showing bleeding from rectal varices to establish a suitable therapeutic strategy for the lesions.

METHODS

Twelve cirrhotic patients with bleeding rectal varices were enrolled. Surgical suture, endoscopic variceal ligation (EVL) or balloon tamponade was performed to achieve the initial hemostasis. Then, the feeding and drainage vessels of the varices were evaluated by computed tomography, and additional procedures were undertaken: EVL was performed when the sizes of the varices and feeding vessels were small. In contrast, in patients with varices of large sizes, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed when single or two drainage vessels were identified, while endoscopic injection sclerotherapy (EIS) using ethanolamine oleate was carried out for varices with three or more drainage vessels.

RESULTS

The Child-Pugh class was grade A in four, B in six and C in two patients. Eleven patients had received previous therapy for esophageal varices. Initial hemostasis was achieved by surgical suture in three patients, EVL in one patient and balloon tamponade in two patients. EVL, EIS and B-RTO were carried out as additional procedures in seven, three and one patient, respectively. Rebleeding from the rectal varices occurred in only one patient who underwent EVL as an additional procedure.

CONCLUSION

Bleeding from rectal varices was controlled satisfactorily by the therapeutic strategy of selecting EVL, EIS or B-RTO as an additional therapy according to the size and hemodynamics of the varices.

Retrospective analysis of endoscopic injection sclerotherapy for rectal varices compared with band ligation

BACKGROUND AND AIMS

The study's aim was to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) compared with endoscopic band ligation (EBL) in treating rectal varices.

METHODS

Data from 34 consecutive patients who underwent endoscopic treatments for rectal varices were analyzed. The clinical outcomes, including complications, related to EIS or EBL retrospectively.

RESULTS

In 25 of the 34 patients, EIS was performed weekly 2-5 times (mean, 2.7), and the total amount of sclerosant ranged from 3.2 to 12.0 mL (mean, 5.2 mL). After EIS, colonoscopy revealed shrinkage of the rectal varices in all 25 patients, with no complications reported. In 9 of the 34 patients, EBL was performed weekly 1-3 times (mean, 2.2), and bands were placed on the varices at 2-12 sites (mean, 8.0). After EBL, colonoscopy revealed ulcers and shrinkage of the rectal varices in all nine patients, eight of whom experienced no operative complications. The overall recurrence rate for rectal varices was 10 of 24 (41.7%), including 5 of 9 (55.6%) receiving EBL and 5 of 15 (33.3%) receiving EIS, over a 1-year follow-up period (n = 24). All four patients with recurrence of bleeding were EBL cases, versus no EIS cases (P < 0.05).

CONCLUSION

EIS appears superior to EBL with regard to effectiveness and complications after endoscopic treatment of rectal varices.

Hemodynamic evaluation by endoscopic ultrasonography of esophageal varices resistant to injection sclerotherapy

PURPOSE

Some esophageal variceal cases are resistant to endoscopic injection sclerotherapy (EIS) using 5% ethanolamine oleate (5% EO). We evaluated the hemodynamics of esophageal varices that were resistant to EIS using 5% EO.

METHODS

Selected for this study were 290 consecutive patients who underwent hemodynamic evaluation using endoscopic color Doppler ultrasonography (ECDUS) and an ultrasonic microprobe (UMP) before EIS. EIS was performed using 5% EO with iopamidol (5% EOI) under fluoroscopy. We retrospectively evaluated the hemodynamic differences between patients resistant to and not resistant to EIS using 5% EOI.

RESULTS

Nine patients were resistant to EIS using 5% EOI (group A). Various parameters were compared between the 281 patients who had been given EIS using 5% EOI for esophageal varices (group B) and the 9 patients in group A. The mean number of EIS treatments until shrinkage of esophageal varices was achieved in group A (6.8 ± 3.4) was significantly greater than that in group B (4.4 ± 2.1) (P < 0.01). The mean amount of 5% EOI used in group A (31.1 ± 17.4 ml) was significantly larger than that used in group B (14.9 ± 8.8 ml) (P < 0.001). The mean frequency shift of esophageal varices in group A (452.9 ± 106.6 Hz) was significantly higher than that in group B (313.0 ± 103.2 Hz) (P < 0.001) as determined by ECDUS. The mean diameter of esophageal varices as found by UMP was 8.0 ± 3.5 mm in group A and 4.6 ± 2.4 mm in group B, with the difference being significant (P < 0.01). Perforating veins inflowing from extramural to intramural regions were recognized in 8 (88.9%) of the 9 patients in group A and in 67 (24.1 %) of the 281 patients in group B. The mean diameter of the perforating vein was 3.8 ± 1.9 mm in group A and 2.1 ± 0.5 mm in group B, as shown by UMP, a difference that was statistically significant (P < 0.01).

CONCLUSION

Hemodynamic evaluation revealed that the esophageal varices were of a higher grade in group A than in group B. By using ECDUS and UMP, this study shed light on the hemodynamics of esophageal variceal cases resistant to EIS using 5% EOI.

Hemodynamic evaluation of rectal varices by color Doppler ultrasonography: a case report

A 69-year-old man with liver cirrhosis was admitted to our hospital with general fatigue. Colonoscopy revealed risky red color sign-positive enlarged tortuous rectal varices. Endoscopic injection sclerotherapy (EIS) was performed three times weekly using 5% ethanolamine oleate with iopamidol; the total amount of sclerosant was 7 ml. Images of rectal varices and the outflowing vessel from rectal varices were obtained via color Doppler ultrasonography before EIS, and fast Fourier transform analysis showed a continuous flow with a frequency shift of 276.6 Hz. We successfully performed EIS for this patient, having effective varicealography. After EIS, colonoscopy revealed shrinkage of the varices in the rectum, and color Doppler indicated an extreme decrease of blood flow in the rectal varices. In conclusion, color Doppler is a useful noninvasive modality for detecting rectal varices and for evaluating the therapeutic effects of EIS.

Hemodynamic changes in a patient with esophageal varices after endoscopic injection sclerotherapy evaluated by endoscopic color Doppler ultrasonography

A 46-year-old man with alcoholic cirrhosis was admitted to our hospital for treatment of high-risk esophageal varices in February 2000. Images of the esophageal varices, paraesophageal veins and palisade veins were obtained by endoscopic color Doppler ultrasonography (ECDUS) before endoscopic injection sclerotherapy (EIS). Prophylactic EIS was performed six times per week for esophageal varices, and EIS was continued until the esophageal varices were completely eradicated. In July 2002, endoscopy revealed esophageal varices graded as Cb, F1, Lm, and RC(-), and color flow images of the palisade veins (hepatofugal flow), esophageal varices, and a developed paraesophageal vein were obtained with ECDUS. In April 2003, endoscopy showed esophageal varices graded as Cb, F1, Lm, and RC(-), and color flow images of the palisade veins and esophageal varices were obtained using ECDUS. The blood in the palisade veins flowed in an alternate direction on color flow images, and pulsatile waves were delineated at the gastroesophageal junction. In January 2004, endoscopy revealed esophageal varices graded as F0 and RC(-), and pulsatile waves were delineated in the lower esophagus with ECDUS. However, the esophageal varices and palisade veins had disappeared from color flow images. In conclusion, ECDUS was useful for evaluating hemodynamic changes after EIS.

Endoscopic injection sclerotherapy in patients with bleeding esophageal varices: a retrospective analysis

Endoscopic injection sclerotherapy has been accepted as the procedure of choice for patients with variceal hemorrhage. To evaluate the efficiency of endoscopic injection sclerotherapy in patients with bleeding esophageal varices, we did a retrospective study of 52 patients (non-sclerotherapy group) with bleeding esophageal varices who were admitted to hospitals and did not receive sclerotherapy and of 50 patients (sclerotherapy group) who received sclerotherapy with ethanolamine oleate. The mortality (sclerotherapy group vs. non-sclerotherapy group: 18.0% vs. 32.7%) during index hospitalization, the bleeding risk factor (the number of rebleeds per patient/month; 1.56 +/- 2.76 vs. 4.96 +/- 9.99: mean +/- SEM) and the mortality due to bleeding (14.0% vs. 36.5%) were higher in the non-sclerotherapy group than in the sclerotherapy group. Only those in Child's class C who received sclerotherapy had a significantly better survival rate than the non-sclerotherapy group (p less than 0.05). Although formal comparisons were not made because of the retrospective nature of this study, endoscopic injection sclerotherapy is effective and appears to be superior to conventional medical treatments.