Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins

Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound

Gastric varices (GVs) are notorious to bleed massively and often difficult to manage with conventional techniques. This mini-review addresses endoscopic management principles for gastric variceal bleeding, including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration. The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos)

BACKGROUND

Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative.

OBJECTIVES

To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability.

DESIGN

Retrospective analysis of a prospectively maintained database.

SETTING

Multicenter study, tertiary referral centers.

PATIENTS AND INTERVENTIONS

Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment.

RESULTS

There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding.

LIMITATIONS

Nonrandomized; EUS expertise necessary.

CONCLUSIONS

EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

EUS-Guided Vascular Procedures: A Literature Review

Endoscopic ultrasound (EUS) is continuously stepping into the therapeutic arena, simultaneously evolving in different directions, such as the management of pancreatic and biliary diseases, celiac neurolysis, delivering local intratumoral therapy, and EUS-guided endosurgery. EUS-guided vascular procedures are also challenging, considering the variety of vascular pathology, proximity of the vascular structures to the GI tract wall, high resolution, and real-time guidance offering an attractive access route and precise delivery of the intervention. The literature on vascular therapeutic EUS demonstrates techniques for the management of upper GI variceal and nonvariceal bleeding, pseudoaneurysms, and coiling and embolization procedures, as well as the creation of intrahepatic portosystemic shunts. The paucity of studies, diversity of study designs, and the number of animal model studies hamper a systematic approach to the conclusion and decision making important to clinicians and healthcare policy makers. Nevertheless, theoretical benefits and findings up to date concerning technical feasibility, efficacy, and safety of the procedures drive further research and development in this rather young therapeutic arena.

The safety and efficacy of gastric fundal variceal obliteration using N-butyl-2-cyanoacrylate; the experience of a single canadian tertiary care centre

BACKGROUND/AIM

Bleeding from Gastric Varices (GV) is not only life threatening, but also leads to many hospitalizations, contributes to morbidity and is resource intensive. GV are difficult to diagnose and their treatment can be challenging due to their location and complex structure. To assess the safety and efficacy of endoscopic gastric fundal variceal gluing using periodic endoscopic injections of N-butyl-2-cyanoacylate (NBCA) and to assess the utility of endoscopic ultrasound (EUS) in assessing for the eradication of GV post-NBCA treatment.

MATERIALS AND METHODS

Analysis of prospectively collected data of a cohort of patients with GV who underwent periodic endoscopic variceal gluing from 2005 to 2011. Outcomes included success of GV obliteration, incidence of rebleeding, complications from the procedure, and analysis of factors that might predict GV rebleeding. The success of GV eradication was assessed by both EUS and direct endoscopy.

RESULTS

The cohort consisted of 29 consecutive patients that had undergone NBCA injection for GV. The mean age was 60.8 years standard deviations (SD 13.3, range 20-81). The average follow-up was 28 months (SD 19.61, range 1-64) and the most common cause for GV was alcoholic liver cirrhosis (34.48%). A total of 91 sessions of NBCA injections were carried out for 29 patients (average of 3.14 sessions/patient, SD 1.79, range 1-8) with a total of 124 injections applied (average of 4.28 injections/patient, SD 3.09, range 1-13). 24 patients were treated for previously documented GV bleeding while five were treated for primary prevention. Overall, 79% of patients were free of rebleeding once three sessions of histoacryl ® injection were completed. None of the patients treated for primary prevention developed bleeding during follow-up. 11 of the 24 patients (46%) with previous bleeding however had rebleeding. 4/11 (36%) patients had GV rebleeding while awaiting scheduled additional NBCA sessions. 19/29 (60%) patients had complete eradication of GV, 11/19 (58%) documented by endoscopic assessment alone, 4/19 (21%) by EUS alone and 4/19 (21%) by both techniques. Two of the 11 (18%) patients that had rebleeding had recurrence of GV bleeding after documented eradication by EUS compared to 5/11 (45%) patients documented eradication by endoscopic assessment and 2/11 (18%) patients that had rebleeding after documented eradication by both modalities. Twenty five patients in total had documented residual GV by EUS (14, 56%), direct endoscopic assessment (18, 72%) or both modalities (9, 36%), two of which developed recurrent bleeding (13%). No immediate or long-term complications of NBCA injection occurred, nor any related endoscopic complications were reported in any of these cases during the time of follow-up.

CONCLUSION

NBCA injection of GV is a safe and successful therapeutic intervention. A minimum of three endoscopic sessions is required to significantly decrease the risk of bleeding/rebleeding. In this small sample of patients, neither EUS nor direct endoscopic assessment was reliable in predicting the recurrence of GV bleeding.

Usefulness of endoscopic ultrasound in esophagogastric varices

Endoscopic ultrasound (EUS) is a useful diagnostic tool for evaluation of esophagogastric varices and guidance of endoscopic therapy. EUS can visualize not only collateral veins around the esophagus but also perforating veins that connect esophageal varices with collateral veins. They are associated with high risk of bleeding and early recurrence after initial variceal eradication. Isolated gastric varices can be easily diagnosed using EUS that mimic thickened gastric folds or subepithelial tumors. EUS-guided endoscopic therapy is a challenging field of variceal bleeding. It has a potential role for assistance of interventions and evaluation of treatment outcome.

EUS-guided vascular access and therapy

The gastrointestinal tract provides a unique window to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with standard fine-needle aspiration. EUS-guided treatment of varices has been largely reserved as rescue therapy for refractory bleeding but has theoretic advantages over conventional endoscopy-guided treatment. Data are limited and multicenter, prospective controlled trials are needed to show clinical effectiveness and safety in humans. The development of new tools designed for EUS-guided vascular therapy is needed.

Levels of evidence in endoscopic ultrasonography: a systematic review

BACKGROUND AND AIMS

A prolific trend currently designates endoscopic ultrasonography (EUS) literature. We aimed to record all EUS-studies published during the past decade and evaluate them in terms of scientific quality, creating a stratification based on levels of evidence (LE).

METHODS

All articles on EUS published between January 2001 and December 2010 were retrieved using a Pubmed and Cochrane Library search. Inclusion criteria were: original research papers (randomized controlled trials-RCTs, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS. Levels of evidence (LE) were assessed using the North of England evidence-based guidelines.

RESULTS

Overall, 1,832 eligible articles were reviewed. The majority (46.1%) of reports comprised retrospective descriptive studies (LE III). Expert reviews and committee reports (LE IV) accounted for 28.9%, well-designed quasi-experimental studies (LE IIb) for 20.1%, RCTs (LE Ib) for 2.4%, prospective controlled trials (LE IIa) for 1.4%, and meta-analyses (LE Ia) for 1.1% of the total. High LE (Ia-Ib) were assigned to loco-regional staging of luminal gastrointestinal cancers; mediastinal staging of lung cancer; diagnostic work-up of solid pancreatic tumors, suspected biliary obstruction and choledocholithiasis; celiac plexus neurolysis; and pancreatic pseudocysts drainage. Intermediate to low LE (IIa-IV) were assigned to submucosal tumors, pancreatic cysts, chronic pancreatitis and novel therapeutic applications (pancreato-biliary drainage, tumor ablation).

CONCLUSIONS

Diagnostic and staging EUS has matured and has proven its clinical impact on patient management. Therapeutic or interventional EUS is still evolving and more quality research and data are needed to establish EUS as the best next intervention to perform once firm evidence is available.

Update of endoscopy in liver disease: More than just treating varices

The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.

Usefulness of endoscopic ultrasonography in hepatology

Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.

Endoscopic management of portal hypertension

Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.

Clinical significance of GRIM-19 expression in hepatocellular carcinoma

AIM: To investigate the clinical significance of expression of gene associated with retinoid-interferon-induced mortality-19 (GRIM-19) in hepatocellular carcinoma (HCC).

METHODS: The expression of GRIM-19 mRNA and protein in 40 cases of HCC tissues and matched non-cancerous tissues was detected by reverse transcription-polymerase chain reaction (RT-PCR), immunohistochemistry and Western blot. The correlation between GRIM-19 expression and clinicopathologic features of HCC was analyzed statistically.

RESULTS: The expression of GRIM-19 mRNA was significantly lower in HCC than in matched non-cancerous tissue (0.40 ± 0.31 vs 0.56 ± 0.67, P < 0.05). The positive rate of GRIM-19 protein expression in HCC was significantly lower than that in matched non-cancerous tissue (47.5% vs 80%, P < 0.05). The expression level of GRIM-19 protein was also significantly lower in HCC than in matched non-cancerous tissue (0.30 ± 0.29 vs 0.57 ± 0.10, P < 0.05). GRIM-19 expression differed significantly between patients with stages I + II disease and those with stages III+IV disease (0.57 ± 0.38 vs 0.30 ± 0.20, P < 0.05) as well as between patients with and without portal vein thrombosis (0.04 ± 0.02 vs 0.44 ± 0.32, P < 0.05). The expression of GRIM-19 was negatively correlated with serum AFP (r = -0.352, P < 0.05).

CONCLUSION: Decreased GRIM-19 expression is probably a significant event in the carcinogenesis of HCC and may be associated with tumor development, progression and invasion.

Endoscopic diagnosis and treatment of ulcerative colitis

Ulcerative colitis (UC), one of non-specific chronic inflammatory conditions of the gastrointestinal tract with unknown complex etiology, is a chronic inflammatory bowel disorder characterized by diffuse mucosal inflammation of the colorectum with exacerbations and remissions. Nowadays, the diagnosis of UC is based mainly on symptoms, endoscopic findings, and histopathologic grading of biopsy specimens. However, there is a lack of a gold standard for the diagnosis of UC. Endoscopy is the cornerstone for diagnosis and evaluation of UC and plays a significant role in diagnosis, evaluating disease activity, malignancy surveillance and treatment. Over recent decades, the emergence of new imaging techniques, including endoscopic ultraonography, chromoendoscopy, magnification endoscopy, narrow-band endoscopic imaging, and laser scanning confocal microendoscopy, has provided a great boost to endoscopic diagnosis and treatment of UC. In this article, we will review the recent advances in endoscopic diagnosis and treatment of UC.

The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia

INTRODUCTION

Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS).

METHODS

We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test.

RESULTS

68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS.

CONCLUSIONS

These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.

Endoscopic ultrasound guided vascular access and therapy: A promising indication

Endoscopic ultrasound (EUS) is an imaging technique that has consolidated its role as an important tool for diagnosis and therapeutics. In recent years we have seen a dramatic increase in the number of EUS-guided therapeutic indications (celiac plexus neurolysis/block, pseudocyst drainage, etc). Preliminary reports have suggested EUS may also be used to guide vascular access for both imaging and treating different vascular diseases. This review aims to objectively describe the existing evidence in the field.

Current staging and diagnosis of gastroesophageal varices

Portal hypertension is defined as an increase in hepatic sinusoidal pressure to 6 mm Hg or higher. Cirrhosis is the most common cause of portal hypertension in the western world and results from increased resistance to blood flow at the hepatic sinusoidal level.

Endoscopic ultrasonography for the evaluation of portal hypertension

Since the 1980s, endoscopic ultrasonography (EUS) has been useful in the evaluation of portal hypertension, either for the diagnostic aspects or for the evaluation of therapy and risk of bleeding. More recently, it has been described as a method for guiding interventions such as variceal injection, portal vein catheterization, or even for creating an intrahepatic portosystemic shunt in the animal laboratory. The new generation of radial electronic echoendoscopes is equipped with color Doppler capability, allowing for measurement of any hemodynamic parameter of the portal circulation. This article summarizes the current knowledge on the role of EUS for the evaluation of portal hypertension.

Intramural esophageal hematoma after elective injection sclerotherapy

CONTEXT

Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established.

OBJECTIVE

To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved.

METHODS

This is a retrospective observational study made at the 'Hospital Universitário Clementino Fraga Filho', Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search.

RESULTS

A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases.

CONCLUSION

Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.

Endoscopic ultrasonography and portal hypertension: where are we in 2009?

Endoscopic ultrasonography is currently a sensitive diagnostic and therapeutic tool with established indications, but its role in the management of portal hypertension is not well defined. This article briefly reviews indications, technologic improvements, diagnostic and interventional applications of endoscopic ultrasonography in portal hypertension.

Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding

BACKGROUND

There are well-established methods for treating gastrointestinal (GI) bleeding, although some lesions prove refractory to conventional techniques. Little consideration has been directed toward the use of endoscopic ultrasound (EUS) in the management of refractory bleeding.

AIMS

To discuss patient selection, technique, and clinical outcomes for EUS-guided angiotherapy for severe refractory bleeding after conventional therapies.

METHODS

The EUS database was reviewed to identify all patients who underwent EUS-directed angiotherapy.

RESULTS

Five patients, four with severe bleeding from hemosuccus pancreaticus, Dieulafoy lesion, duodenal ulcer, or gastrointestinal stromal tumor (GIST) and one with occult GI bleeding, had an average of three prior episodes (range 2-4) of severe bleeding and had received 18 (range 14-25) units of packed red blood cells (PRBC). All had failed in at least two conventional attempts to control the bleeding. Under EUS guidance, 99% alcohol was injected (4-7 mL) in two patients, one each with a pancreatic pseudoaneurysm and a duodenal Dieulafoy lesion. In three other patients, cyanoacrylate (3-5 mL) was injected into a duodenal ulcer, and in two patients with a GIST. No patient rebled and no complications were reported.

CONCLUSIONS

EUS-guided angiotherapy appears safe and effective in managing selected patients with clinically severe or occult GI bleeding from lesions potentially refractory to standard endoscopic and/or angiographic techniques. Further studies are needed to confirm the safety and efficacy and to refine the selection criteria in an effort to improve patient care.

EUS-guided angiography: a novel approach to diagnostic and therapeutic interventions in the vascular system

BACKGROUND

Indications for diagnostic and therapeutic procedures under EUS guidance continue to expand.

OBJECTIVE

To assess the feasibility and safety of EUS-guided angiography in a live porcine model.

SETTING

Five acute experiments under general anesthesia.

DESIGN AND INTERVENTIONS

A linear echoendoscope was advanced into the stomach. Thoracic and abdominal aorta, celiac axis, superior mesenteric and splenic artery, splenic, portal, and hepatic veins were injected with contrast by using FNA needles under fluoroscopy. The animals were then killed for postmortem examination.

MAIN OUTCOME MEASUREMENTS

Ability to achieve angiography without complications.

RESULTS

All vessels were identified and punctured without technical difficulties. Injections of the large-caliber vessels resulted in a blush of contrast, whereas selective injection of the smaller vessels (splenic artery, hepatic veins) demonstrated clear vascular opacification. Injection of contrast was technically easiest with the 19-gauge FNA needle and most difficult with the 25-gauge needle. There were no changes in vital signs and hemodynamic parameters during vascular injection of any vessel. At necropsy, the 25-gauge FNA needle did not cause any visible vascular injury or bleeding. The 22-gauge needle left a visible puncture mark without active bleeding. In 1 of 5 pigs, the 19-gauge needle caused a localized vascular hematoma around large-caliber vessels and 150 mL of intra-abdominal blood.

LIMITATION

Technical challenges remain to achieve an adequate flow rate of contrast for prolonged visualization of large vessels.

CONCLUSION

EUS-guided angiography is technically easy and safe and has potential for a wide array of diagnostic and therapeutic vascular interventions.

EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases

BACKGROUND

Bleeding from gastric varices can be challenging because of its high mortality and recurrent bleeding rates. Endoscopic therapy with tissue adhesives can control acute hemorrhage, but recurrent bleeding could appear if obliteration is not achieved, and endoscopic vision could be troublesome in the case of massive hemorrhage. The glue injected could be responsible for embolic phenomena and local complications. EUS has proved useful in minimizing the risk of recurrent bleeding from gastric varices, accurately showing if they are obturated or not. The presence of perforating veins detected by EUS has been reported as a risk factor for recurrent bleeding from esophageal varices.

OBJECTIVE

To assess the efficacy of EUS-guided cyanoacrylate injection in gastric varices at the entrance of the perforating veins to obtain variceal obturation.

DESIGN

Open-basis case series study.

SETTING

Tertiary care, academic medical center, Seville, Spain.

PATIENTS

Five consecutive patients with gastric varices were enrolled from May 2005 through May 2006.

INTERVENTIONS

We injected cyanoacrylate-lipiodol in gastric varices with 22-gauge needles by EUS guidance.

MAIN OUTCOME MEASUREMENTS

To analyze the obliteration of gastric varices, the recurrent bleeding rate, and safety of EUS-guided cyanoacrylate-lipiodol injection.

RESULTS

EUS-guided injection of the perforating veins by using cyanoacrylate-lipiodol was successful in eradicating gastric varices in the 5 patients treated, without recurrent bleeding or other complications during the study follow-up.

LIMITATION

This is a single-center nonrandomized study.

CONCLUSIONS

EUS-guided injection of cyanoacrylate at the level of the perforating veins in the treatment of gastric varices seems to be a safe, efficient, and accurate approach. Further controlled studies are warranted.

Upper gastrointestinal bleeding

PURPOSE OF REVIEW

This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care.

RECENT FINDINGS

In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions.

SUMMARY

This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?