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Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding: A Randomized Controlled Trial. J Clin Gastroenterol 2020; 54:255-262. [PMID: 31008867 DOI: 10.1097/mcg.0000000000001214] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to assess the use of thromboelastography (TEG)-directed blood product transfusion in cirrhotic patients with acute variceal bleeding compared with conventional transfusion for correction of coagulopathy. BACKGROUND Coagulopathy is common in patients with cirrhosis. Recommendations for correction of conventional parameters of coagulation-platelets and the international normalized ratio before endoscopy in patients with acute variceal bleeding-need more validation. STUDY In this randomized controlled trial, cirrhotic patients with severe coagulopathy and acute variceal bleeding were randomized to either TEG-guided blood product transfusion or conventional transfusion from March 2017 to December 2017. The primary outcome was the difference in the amount of fresh frozen plasma and platelet units transfused between the groups. Secondary outcomes were rebleeding at 5 days and 42 days, and 6-week mortality. RESULTS Of the 60 recruited patients, 30 each were randomized to the TEG and conventional transfusion groups. There were no differences in baseline characteristic and endoscopic findings between the 2 groups. Four subjects in the TEG group received blood product transfusions versus all in the conventional transfusion group (13.3% vs. 100%; P<0.001). The control of bleeding on initial endoscopy was similar in the 2 groups. Rebleeding in the TEG and conventional transfusion groups at 5 days was similar [1 (3.3%) vs. 4 (13.3%), P=0.167], whereas it was significantly less in the TEG group at 42 days [3 (10%) vs. 11 (36.7%), P=0.012]. Mortality at 6 weeks was seen in 4 (13.3%) in the TEG group and in 8 (26.7%) patients in the conventional transfusion group (P=0.176). CONCLUSIONS TEG-guided strategy was associated with reduced blood product transfusion to correct coagulopathy without compromising hemostasis in cirrhotic patients (Clinical trial ID: CTRI/2017/02/007864).
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Safety of variceal band ligation in patients with cirrhosis and portal vein thrombosis treated with anticoagulant therapy: A retrospective study. Eur J Gastroenterol Hepatol 2020; 32:395-400. [PMID: 31464780 DOI: 10.1097/meg.0000000000001522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Anticoagulant therapy has been recommended in patients with cirrhosis and portal vein thrombosis especially in candidates for liver transplantation. These patients are also likely to need variceal band ligation. This study aimed to assess the incidence of upper gastrointestinal bleeding after elective variceal band ligation in patients with cirrhosis receiving anticoagulant therapy for portal vein thrombosis. METHODS Patients with cirrhosis and nontumoral portal vein thrombosis treated with anticoagulant therapy undergoing elective variceal band ligation were retrospectively included. We recorded upper gastrointestinal bleeding events occurring within two weeks after variceal band ligation. Postvariceal band ligation bleeding was defined as active bleeding on at least one site of previous ligation at endoscopy. RESULTS Between 2014 and 2017, 32 patients with cirrhosis had scheduled variceal band ligations while on anticoagulant therapy [men 75%; median age 59 years; aetiology of cirrhosis: alcohol (50%), viral (34%), alcohol and viral (16%); and Child-Pugh score: A (31%), B (44%), and C (25%)]. Three (9%) patients presented postvariceal band ligation bleeding during the follow-up. None of these events led to haemorrhagic shock or death. Factors associated with postvariceal band ligation bleeding included variceal band ligation performed as secondary prophylaxis (P = 0.05) and previous decompensation of cirrhosis (P = 0.03). CONCLUSION In this small group of patients under anticoagulation therapy undergoing variceal band ligation, only a minority presented postendoscopic bleeding of minor importance. Nevertheless, particular attention should be paid to patients with previous decompensation of cirrhosis.
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Wang AJ, Wang J, Zheng XL, Liao WD, Yu HQ, Gong Y, Gan N, You Y, Guo GH, Xie BS, Zhong JW, Hong JB, Liu L, Shu X, Zhu Y, Li BM, Zhu X. Second-look endoscopy-guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding. J Dig Dis 2020; 21:170-178. [PMID: 32031737 DOI: 10.1111/1751-2980.12847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To investigate whether second-look endoscopy (SLE)-guided therapy could be used to prevent post-endoscopic variceal ligation (EVL) early bleeding. METHODS Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non-SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post-EVL early rebleeding and mortality rates were compared between the two groups. RESULTS A total of 252 patients were included in the final analysis. Post-EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding-caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post-EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child-Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non-selective β-blocker after randomization (HR 4.68, P = 0.001) and non-SLE (HR 2.63, P = 0.046) were more likely to have post-EVL early rebleeding. No serious adverse events occurred during SLE. CONCLUSION SLE-guided therapy reduces post-EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.
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Affiliation(s)
- An Jiang Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jian Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xue Lian Zheng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Wang Di Liao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Hui Qiang Yu
- Department of Health Statistics, School of Public Health, Nanchang University, Nanchang, Jiangxi Province, China
| | - Yue Gong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Na Gan
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yu You
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Gui Hai Guo
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bu Shan Xie
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jia Wei Zhong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Jun Bo Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Li Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xu Shu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yin Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bi Min Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xuan Zhu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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Ham NS, Lee D, Won SH, Kim J, Jo S, Yi S, So S. Removal of a Trigger Cord Stuck between Bands during Endoscopic Multiple-Band Ligation for Treating Esophageal Variceal Hemorrhage. Clin Endosc 2020; 53:230-231. [PMID: 31337195 PMCID: PMC7137571 DOI: 10.5946/ce.2019.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/01/2019] [Indexed: 11/14/2022] Open
Abstract
Endoscopic variceal ligation is the preferred endoscopic treatment method for esophageal variceal bleeding. The incidence of complications such as chest pain, bleeding, stricture formation, and aspiration pneumonia is low. We report a case wherein a malfunctioning multiple-band ligator could have potentially caused damage to the esophageal varices and massive bleeding. The equipment was safely removed using scissors and forceps. To the best of our knowledge, this is the first published report detailing the management of a case of esophageal variceal bleeding.
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Affiliation(s)
- Nam Seok Ham
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Danbi Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Hyun Won
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeongseok Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seokjung Jo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sangyoung Yi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seol So
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Bestari MB, Joewono IR, Girawan D, Argatio JT, Abdurachman SA. Hemospray® during Emergency Endoscopy: Indonesia's First Experience from 37 Patients. Case Rep Gastroenterol 2020; 14:70-79. [PMID: 32110203 PMCID: PMC7036561 DOI: 10.1159/000505775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 01/06/2020] [Indexed: 01/14/2023] Open
Abstract
Gastrointestinal bleeding (GIB) is one of the main indications for performing endoscopy; this condition can be life threatening. In some cases, emergency endoscopy (EE) is necessary to identify the source and stop the bleeding. Recently, hemostatic powder was introduced, one of which was Hemospray® (Cook Medical, Winston-Salem, NC, USA), which showed promising results for rapid hemostasis in primary treatment and salvage when conventional methods fails. Samples were taken retrospectively for a duration of 3 years since Hemospray was first introduced in Indonesia, from January 2016 to January 2019. The total number of EEs that used Hemospray were 37 procedures for 37 patients; 21 (56.8%) were males and 16 (43.2%) were females, while the average age was 67.8 years. Hemospray was used for upper GIB in 30 cases (81.1%) and for lower GIB in 7 (18.9%). Hemospray was used as monotherapy for 24 patients (64.9%) and as secondary modality for 13 (35.1%). The primary treatment was argon plasma coagulation in 8 cases (21.6%), adrenaline in 4 (10.8%), and Histoacryl® in 1 (2.7%). The mortality rate was 37.8% (n = 14); most deaths occurred within 30 days after the EE was performed, and none of the deaths was related to endoscopy or GIB. Hemospray was able to achieve hemostasis in all cases. Furthermore, there was no event of rebleeding. When conventional modalities alone were inadequate, the combination with Hemospray appeared to be able to control the bleeding. One of the main advantages of Hemospray is the ease in reaching difficult areas, and it require less skill compared to conventional modalities.
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Affiliation(s)
- Muhammad Begawan Bestari
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
| | - Ignatius Ronaldi Joewono
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Dolvy Girawan
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
| | | | - Siti Aminah Abdurachman
- Division of Gastroenterohepatology, Department of Internal Medicine, Hasan Sadikin General Hospital-Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.,Santo Borromeus Hospital Bandung, Bandung, Indonesia
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Bansal R, Khan R, Scaffidi MA, Gimpaya N, Genis S, Bukhari A, Dhillon J, Dao K, Bonneau C, Grover SC. Undisclosed payments by pharmaceutical and medical device manufacturers to authors of endoscopy guidelines in the United States. Gastrointest Endosc 2020; 91:266-273. [PMID: 31738925 DOI: 10.1016/j.gie.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Payments from pharmaceutical and medical device manufacturers to authors of clinical practice guidelines (CPGs) may influence practice recommendations. It is therefore important to evaluate the completeness of financial conflict of interest (FCOI) declarations among CPG authors. METHODS We performed a cross-sectional analysis of industry payments to authors of endoscopy guidelines published by 5 GI societies between 2014 and 2017. For each author we identified payments using the disclosure section of CPGs and the Centers for Medicare & Medicaid Services Open Payments (CMS-OP) database. We calculated the prevalence, monetary value, and type of declared and undeclared payments among authors. Payments were assessed for the calendar year of and before publication. RESULTS Thirty-seven CPGs were included in the analysis comprising 569 author entries (91 unique individuals; 66.43% men, 92.6% physicians, 66.4% academically affiliated). Four hundred fifty-one episodes (79%) involved FCOIs, 451 (79%) had undisclosed FCOIs in the CMS-OP, and 445 (77%) had FCOIs relevant to a CPG recommendation. The median undisclosed payment value was $4807.26 (interquartile range, $334.84-$20,579.75). Male authors (odds ratio, 2.23; 95% confidence interval, 1.47-3.39) and academically affiliated authors (odds ratio, 8.87; 95% confidence interval, 5.57-14.13) were significantly more likely to have undeclared payments (P < .001). No CPGs met all National Academy of Medicine criteria. CONCLUSIONS Recognizing concerns about the accuracy of the CMS-OP, there are substantial discrepancies between industry-reported payments and author self-disclosure. Additionally, there is a high prevalence of undisclosed payments by pharmaceutical and medical device manufacturers to these authors. Given the potential impact of these discrepancies and undisclosed payments on CPGs, more accurate reporting and alternative strategies for managing FCOI are needed.
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Affiliation(s)
- Rishi Bansal
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Shai Genis
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Abbas Bukhari
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Jeevan Dhillon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Kathy Dao
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Chris Bonneau
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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McCarty TR, Bazarbashi AN, Hathorn KE, Thompson CC, Ryou M. Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9:6-15. [PMID: 31417066 PMCID: PMC7038733 DOI: 10.4103/eus.eus_37_19] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I2 statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98–100]; I2 = 30.54%), 97% ([95% CI 92–100]; I2 = 59.99%), and 14% ([95% CI 6–23]; I2 = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Huo XX, Niu WW, Zhao YW, Zhang XL. Portal vein thrombosis with superior mesenteric venous thrombosis: A case report and review of the literature. Shijie Huaren Xiaohua Zazhi 2019; 27:1460-1464. [DOI: 10.11569/wcjd.v27.i23.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic variceal ligation is a first-line treatment for esophagogastric variceal bleeding patients. Portal vein thrombosis (PVT) with superior mesenteric venous thrombosis (MVT) after intensive endoscopic variceal band ligation is extremely rare.
CASE SUMMARY We report a rare case developing PVT and superior MVT after intensive endoscopic variceal band ligation. The thrombosis disappeared after full anticoagulation therapy.
CONCLUSION Our case suggested that, when ligation is required to treat esophagogastric variceal bleeding patients with a history of splenectomy caused by liver cirrhosis, especially those with chronic portal vein thrombosis, if ligation is required, too dense ligation and blocking entire blood flow should be avoided to prevent the development of PVT or MVT.
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Affiliation(s)
- Xiao-Xia Huo
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Wei-Wei Niu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Yi-Wen Zhao
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Xiao-Lan Zhang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
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Goldis A, Goldis R, Chirila TV. Biomaterials in Gastroenterology: A Critical Overview. ACTA ACUST UNITED AC 2019; 55:medicina55110734. [PMID: 31726779 PMCID: PMC6915447 DOI: 10.3390/medicina55110734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.
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Affiliation(s)
- Adrian Goldis
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | | | - Traian V. Chirila
- Queensland Eye Institute, South Brisbane, QL 4101, Australia;
- Science & Engineering Faculty, Queensland University of Technology, Brisbane, QL 4000, Australia
- Faculty of Medicine, University of Queensland, Herston, QL 4029, Australia
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, St Lucia, 4072 QL, Australia
- Faculty of Science, University of Western Australia, Crawley, WA 6009, Australia
- University of Medicine, Pharmacy, Sciences and Technology, 540139 Targu Mures, Romania
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Solanki S, Haq KF, Chakinala RC, Khan Z, Aronow WS, Ali Khan M, Siddiqui MT, Haq KS, Frager S, Alimirah M, Nabors C, Samson DJ, Lebovics E, Wolf DC. Inpatient burden of esophageal varices in the United States: analysis of trends in demographics, cost of care, and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:480. [PMID: 31700916 DOI: 10.21037/atm.2019.08.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Esophageal variceal bleeding remains a common reason for hospitalization in the United States. The main objective of this study was to analyze demographic variations and outcomes in hospitalizations related to esophageal varices (EV) in the US. Methods We performed a retrospective observational cohort study using National Inpatient Sample (NIS) database for all hospitalizations with discharge diagnoses of EV, with and without hemorrhage from 2001 to 2011. Results In 2001, there were 19,167 hospitalizations with discharge diagnoses of EV with and without bleeding compared to 45,578 in 2011 (P<0.001). There was a 138% increase in the number of total EV hospitalizations, a 221% increase in hospitalizations with EV without hemorrhage, and a 7% increase in hospitalizations for patients with EV and hemorrhage. Age group 50-64 was the most affected, accounting for 31.4% of EV hospitalizations in 2001 and 46.7% of EV hospitalizations in 2011 (P<0.001). The overall in-hospital mortality rate was 3.4% for patients with EV without hemorrhage and 8.7% for patients with EV with hemorrhage (P=0.0003). Conclusions The number of hospitalizations for patients with asymptomatic EV increased significantly between 2001 to 2011, with only a small concurrent increase in the number of hospitalizations for patients with esophageal variceal bleeding.
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Affiliation(s)
- Shantanu Solanki
- Hospitalist Department, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | - Raja Chandra Chakinala
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Zubair Khan
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mohamed Tausif Siddiqui
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Khwaja Saad Haq
- Department of Medicine, Kingsbrook Jewish Medical Center, Brooklyn, NY, USA
| | - Shalom Frager
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Maryam Alimirah
- Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Christopher Nabors
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - David J Samson
- Clinical Research Unit, Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Edward Lebovics
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - David Cary Wolf
- Division of Gastroenterology & Hepatobiliary Diseases, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
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Abstract
PURPOSE OF REVIEW There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence. RECENT FINDINGS In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions. SUMMARY Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.
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Affiliation(s)
- Ahmad Najdat Bazarbashi
- Department of Medicine, Brigham and Women's Hospital, Division of Gastroenterology, Hepatology and Endoscopy, Boston, Massachusetts, USA
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Onofrio FDQ, Pereira-Lima JC, Valença FM, Azeredo-da-Silva ALF, Tetelbom Stein A. Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis. Endosc Int Open 2019; 7:E1503-E1514. [PMID: 31673624 PMCID: PMC6811355 DOI: 10.1055/a-0901-7146] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/04/2019] [Indexed: 01/14/2023] Open
Abstract
Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.
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Affiliation(s)
- Fernanda de Quadros Onofrio
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Julio Carlos Pereira-Lima
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Felipe Marquezi Valença
- Department of Gastroenterology and Hepatology, Santa Casa Hospital, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | - Airton Tetelbom Stein
- Department of Public Health, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
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63
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Al-Khazraji A, Curry MP. The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:893-897. [PMID: 31389265 DOI: 10.1080/17474124.2019.1652092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.
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Affiliation(s)
- Ahmed Al-Khazraji
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Michael P Curry
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
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Goral V, Yılmaz N. Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO. ACTA ACUST UNITED AC 2019; 55:medicina55070335. [PMID: 31277322 PMCID: PMC6681371 DOI: 10.3390/medicina55070335] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022]
Abstract
Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.
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Affiliation(s)
- Vedat Goral
- Istanbul Medipol University, School of Medicine Department of Gastroenterology, 34214 Istanbul, Turkey.
| | - Nevin Yılmaz
- Department of Gastroenterology, School of Medicine, Near East University, 99138 Nicosia, Cyprus
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Castillo L, Prachuapthunyachart S, Hall M, Shelby S, Quiros-Tejeira RE, Vo HD. Antibiotic use in cirrhotic children with acute upper gastrointestinal bleeding: A retrospective study using the pediatric health information system (PHIS) database. Medicine (Baltimore) 2019; 98:e16505. [PMID: 31335721 PMCID: PMC6709249 DOI: 10.1097/md.0000000000016505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prior studies have demonstrated positive impacts of antibiotic use on reducing mortality, rebleeding events, and length of hospitalization in adult cirrhotic patients with acute upper gastrointestinal bleeding (UGIB). We aimed to investigate the use of antibiotics in cirrhotic children with acute UGIB and its impact on patient outcomes.This was a retrospective study using the Pediatric Health Information System database. Cirrhotic patients aged 0 to 18 years with acute UGIB, admitted between October 2005 and September 2015, were identified based on ICD-9 codes. Patients with no documented endoscopy during admission were excluded.Forty-four (23 females) cirrhotic children were eligible for data analysis. The median patient age was 6 years. Etiology of acute UGIB included esophageal varices (n = 37), non-variceal bleeding (n = 4), and both (n = 3). A significant proportion of cirrhotic children with acute UGIB (n = 30, 68%) were given intravenous antibiotics within 48 hours of admission. Among children who did not develop bacteremia, 68% received antibiotics vs. 32% who did not (P = .6). The rate of readmission within 30 days of discharge was 7% in patients with antibiotics vs. 21% in those without antibiotics (P = .3).This study suggested that antibiotic use within 48 hours of admission in cirrhotic children with acute UGIB might have a positive impact on the percentage of children free of bacteremia and the readmission rate. A prospective study should investigate whether prophylactic antibiotics should be targeted only to a subgroup of cirrhotic children with acute UGIB who are particularly at high risk for bacterial infection.
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Affiliation(s)
- Lina Castillo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Sittichoke Prachuapthunyachart
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Mel Hall
- Performance Improvement, Children's Hospital and Medical Center, Omaha, NE, USA
| | - Shaija Shelby
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Ruben E Quiros-Tejeira
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
| | - Hanh D Vo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Nebraska Medical Center
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66
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Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101618. [PMID: 31785731 DOI: 10.1016/j.bpg.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/23/2019] [Indexed: 01/31/2023]
Abstract
Endoscopy is the gold standard for evaluating and treating acute upper gastrointestinal bleeding (UGIB). The optimal timing of endoscopy is a very important consideration in the overall management of UGIB, but there is on going uncertainty regarding timing of the procedure, particularly in those with more severe bleeding. This is reflected by inconsistencies between current guidelines. Although evidence suggests endoscopy should be undertaken within 24 h for all admitted patients with UGIB, a small group of patients with severe bleeding or high-risk features may require more urgent endoscopy. The exact timing of the procedure in this high-risk group remains unclear, with recent data suggesting that performing endoscopy too early may be associated with worse outcome. In this article we examine the evidence for optimal timing of endoscopy in patients presenting with UGIB and suggest a clinical approach to this important aspect of patient management.
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Guo C, Guo G, Zhou X, Chen Y, Han Z, Yang C, Zhao S, Su H, Lian Z, Leung PSC, Gershwin ME, Zhou X, Han Y. Long-term Outcomes of Autologous Peripheral Blood Stem Cell Transplantation in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2019; 17:1175-1182.e2. [PMID: 30613001 DOI: 10.1016/j.cgh.2018.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/27/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Peripheral blood stem cells (PBSCs) mobilized with colony-stimulating factor can promote liver regeneration and increase liver function in patients with liver diseases. However, the long-term effects of stem cell treatments on survival and risk of hepatocellular carcinoma (HCC) in patients with cirrhosis have not been determined. We investigated the long-term effects of autologous stem cell transplantation and risk of HCC in patients with cirrhosis. METHODS We performed a retrospective analysis of 2 cohorts of patients with decompensated cirrhosis who received transplantations of autologous PBSCs (n = 282) or standard medical treatment (SMT, n = 286) in China from January 1, 2006, through December 31, 2016. Patients were followed up until death or liver transplantation. Mortality data were obtained by case records and confirmed by telephone calls. Survival time was calculated and HCC was confirmed by computed tomography or ultrasound. We used propensity score matching to adjust the differences between the 2 groups. Survival and incidence of HCC were analyzed and Cox proportional hazard regression was used to determine the prognostic factors. RESULTS After propensity score matching, time of survival was significantly higher in the PBSC group than the SMT group (P = .001). The adjusted rate of 5-year survival was 71.2% in the PBSC group and 52.1% in the SMT group. The overall incidence of HCC did not differ significantly between the PBSC and SMT groups (21.1% vs 20.4%; P = .999). Significant improvement of liver functions was observed at 1 year, 2 years, 3 years, and 5 years after PBSC transplantation compared with the SMT group. CONCLUSIONS In a long-term analysis of patients with decompensated cirrhosis, autologous transplants of PBSCs significantly improved long-term survival compared with a control group. PBSC transplant did not appear to increase the risk of HCC.
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Affiliation(s)
- Changcun Guo
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Guanya Guo
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Xia Zhou
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Yu Chen
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Zheyi Han
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Caifeng Yang
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Shimin Zhao
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Hongling Su
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Zhexiong Lian
- Institute of Life Sciences, South China University of Technology, Guangzhou, People's Republic of China
| | - Patrick S C Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis School of Medicine, Davis, California
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis School of Medicine, Davis, California
| | - Xinmin Zhou
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China
| | - Ying Han
- Department of Gastroenterology, Xijing Hospital, The Fourth Military Medical University, Xi'an, People's Republic of China; National Clinical Research Center for Digestive Diseases, Xi'an, People's Republic of China.
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Vine LJ, Subhani M, Acevedo JG. Update on management of gastric varices. World J Hepatol 2019; 11:250-260. [PMID: 30967903 PMCID: PMC6447419 DOI: 10.4254/wjh.v11.i3.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
Gastric varices (GV) have different physiology and clinical characteristics compared to oesophageal varices (OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies’ recommendations are based are scrutinised in this review and areas of research are identified.
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Affiliation(s)
- Louisa J Vine
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL68DH, United Kingdom
| | - Mohsan Subhani
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL68DH, United Kingdom
| | - Juan G Acevedo
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, PL68DH, United Kingdom
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69
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Zheng J, Zhang Y, Li P, Zhang S, Li Y, Li L, Ding H. The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study. BMC Gastroenterol 2019; 19:32. [PMID: 30782139 PMCID: PMC6380022 DOI: 10.1186/s12876-019-0943-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
Background The recurrence of esophageal varices remains high in patients with hepatic portal hypertension after the endoscopic esophageal variceal eradication therapies, including endoscopic variceal band ligation (EVL), injection sclerotherapy (EIS) or EVL plus EIS. The aim of this study was to evaluate the endoscopic ultrasound probe examinations (EUP) findings in the prediction of recurrence following esophageal variceal eradication in a prospective cohort. Methods A total of 206 cirrhotic portal hypertension patients with esophageal variceal eradication, who underwent endoscopic variceal therapy (EVL or EIS or EVL plus EIS) were initially enrolled. All patients were scheduled for a follow-up every 6 months for up to 3 years. EUP was performed to evaluate peri-esophageal collateral veins (peri-ECVs), perforating veins (PFV) and para-esophageal collateral veins (para-ECVs). In addition, computed tomography (CT) were conducted to detect portal vein diameter, portal vein embolus, and major portosystemic collateral shunts. The relationship between esophageal variceal recurrence and EUP findings were analyzed. Results We found that as high as 93.5% of patients developed esophageal variceal recurrence in the 3-year follow-up. The time of esophageal variceal recurrence after variceal eradication was 13.4 months (13.4 ± 9.2 months). Furthermore, the median time of recurrence in patients who were undertaken EVL,EIS and EVL plus EIS was 10, 13 and 12 months, respectively. We identified that the risk factors, including EVL (OR 0.23, 95% CI 0.08–0.71, p < 0.01), Child-Pugh score (OR 3.32,95% CI 1.31–35.35, p < 0.05), large peri-ECVs (OR 4.56, 95% CI 2.17–9.58, p < 0.0001), and existence of PFV (OR 2.14, 95% CI 1.44–3.16, p < 0.001), were significantly associated with the recurrence of esophageal varices. The peri-ECVs and PFV showed better ability to predict esophageal variceal recurrence. When cut-off value of peri-ECVs diameter was 3.5 mm, the specificity of prediction 1-year variceal recurrence was 86% and the sensitivity was 45%. Conclusions The EUP appears to be very effective, convenient and economical examinations to predict esophageal varices recurrence after variceal eradication by endoscopic therapies. The high Child-pugh score, large peri-ECVs, and PFV are independent risk factors related to esophageal varices recurrence.
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Affiliation(s)
- Junfu Zheng
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Peng Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Shibin Zhang
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Yue Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China.
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You An Hospital affiliated to the Capital Medical University, 8 Xi Tou Tiao, Youanmen wai, Beijing, 100069, China.
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Jung K, Moon W. Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World J Gastrointest Endosc 2019; 11:68-83. [PMID: 30788026 PMCID: PMC6379746 DOI: 10.4253/wjge.v11.i2.68] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/02/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.
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Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, South Korea
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71
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Tseng Y, Ma L, Luo T, Zeng X, Li F, Li N, Wei Y, Chen S. Patient Response to Endoscopic Therapy for Gastroesophageal Varices Based on Endoscopic Ultrasound Findings. Gut Liver 2019; 12:562-570. [PMID: 29699062 PMCID: PMC6143452 DOI: 10.5009/gnl17471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/11/2017] [Accepted: 12/21/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Gastroesophageal variceal hemorrhage is a common complication of portal hypertension. Endoscopic therapy is currently recommended for preventing gastroesophageal variceal rebleed. However, the rate of variceal rebleed and its associated mortality remain concerning. This study is aimed at differentiating patient response to endoscopic therapy based on endoscopic ultrasound (EUS) findings. Methods One-hundred seventy patients previously treated with repeat endoscopic therapy for secondary prophylaxis were enrolled and classified into two groups based on treatment response. Prior to consolidation therapy, all patients received an EUS examination to observe for extraluminal phenomena. All available follow-up endoscopic examination records were retrieved to validate study results. Results Of the 170 subjects, 106 were poor responders, while 64 were good responders. The presence of para-gastric, gastric perforating, and esophageal perforating veins was associated with poor patient response (p<0.001). The odds ratio for para-gastric veins was 5.374. Follow-up endoscopic findings for poor responders with incomplete variceal obliteration was closely correlated with the presence of para-gastric veins (p=0.002). Conclusions The presence of para-gastric veins is a characteristic of poor response to endoscopic therapy for treating gastroesophageal varices. Early identification of this subgroup necessitates a change in course of treatment to improve overall patient outcome.
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Affiliation(s)
- Yujen Tseng
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lili Ma
- Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiancheng Luo
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoqing Zeng
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Na Li
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yichao Wei
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Evidence-Based Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, China
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Chapman W, Siau K, Thomas F, Ernest S, Begum S, Iqbal T, Bhala N. Acute upper gastrointestinal bleeding: a guide for nurses. ACTA ACUST UNITED AC 2019; 28:53-59. [PMID: 30620657 DOI: 10.12968/bjon.2019.28.1.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This article outlines latest evidence-based care for patients with acute upper gastrointestinal (GI) bleeding. It aims to help gastroenterology and general medical ward nurses plan nursing interventions and understand the diagnostic treatment options available. Acute upper GI bleeding can present as variceal or non-variceal bleeding and has a high death rate. Endoscopy is used for diagnosis and to provide therapy, prior to which the patient should be adequately resuscitated and assessed. Various therapies can be initiated at endoscopy, depending on the source of bleeding. If bleeding continues in spite of these therapies, further interventions such as the Sengstaken tube, oesophageal stents, radiological or surgical treatments may be required. After endoscopy, it is important to have a plan for ongoing treatment. Patients may require acid suppression treatment or eradication of Helicobacter pylori as part of their treatment plan. They may in additional require correction of their haemoglobin levels and follow-up endoscopy. It is essential that nurses caring for such patients are aware of the current UK guidance and help patients to adhere to agreed treatment plans.
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Affiliation(s)
- Warren Chapman
- Advanced Clinical Practitioner (Endoscopist), Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
| | - Keith Siau
- Endoscopy Research Fellow, Dudley Group Hospitals NHS Foundation Trust, Dudley
| | - Fiona Thomas
- Endoscopy Senior Sister, Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
| | - Selvajothi Ernest
- Advanced Clinical Practitioner (Endoscopist), Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
| | - Shriya Begum
- Endoscopy Sister, Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
| | - Tariq Iqbal
- Consultant Gastroenterologist, Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
| | - Neeraj Bhala
- Consultant Gastroenterologist, Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham
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Jung K, Park MI. When Should We Perform Endoscopy for Patients with Upper Gastrointestinal Bleeding? Clin Endosc 2019; 52:1-2. [PMID: 30650946 PMCID: PMC6370928 DOI: 10.5946/ce.2019.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/22/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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74
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Wang L, Xu X, Hou Y, Shao X, Guo X, Qi X. Acute mesenteric vein thrombosis after endoscopic injection sclerotherapy for esophageal varices in a patient with liver cirrhosis. Drug Discov Ther 2019; 13:118-121. [PMID: 31080203 DOI: 10.5582/ddt.2019.01014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) is a common complication of liver cirrhosis. The association between endoscopic injection sclerotherapy (EIS) and PVT is unclear. In this paper, we reported that a male cirrhotic patient developed acute mesenteric vein thrombosis after EIS for secondary prophylaxis of esophageal variceal bleeding. Immediate anticoagulation therapy was effective and safe in this patient.
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Affiliation(s)
- Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command
- Postgraduate College, Dalian Medical University
| | - Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command
| | - Yue Hou
- Department of Gastroenterology, General Hospital of Northern Theater Command
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command
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75
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Wei ZG, Wei FX, Shao ZW, Su GH, Qi XP, Zhang YC. Lowering hepatic venous pressure agent carvedilol versus variceal banding ligation for clinical outcomes of cirrhotic portal hypertension. Ther Clin Risk Manag 2018; 15:45-57. [PMID: 30636878 PMCID: PMC6307671 DOI: 10.2147/tcrm.s184863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Carvedilol is nonselective beta-blocker with a mild anti-alpha-1-adrenergic effect. Several studies proposed improved hemodynamic effects of carvedilol compared with propanolol. Our study was to perform a systematic review and meta-analysis of randomized control trials comparing carvedilol with variceal banding ligation (VBL). METHODS Studies were searched on online databases MEDLINE, EMBASE(Ovid), the Cochrane Library, Chinese Wanfang Database, and China National Knowledge Infrastructure between January 2000 and May 2018. Incidence of bleeding and mortality were main outcome measures. Subgroup analysis and sensitivity analysis were conducted to ensure the robustness of pooled estimates. RESULTS Ten randomized control trials including 1,269 cirrhotic patients were chosen. Compared with VBL, carvedilol showed similar preventive efficacy of risk ratios (RRs) in variceal bleeding, and bleeding-related mortality over different follow-up periods from 6 months to 24 months. Also, significant differences between carvedilol and VBL in overall mortality and other causes of mortality were failed to be found. Carvedilol achieved a lower incidence of portal hypertension gastropathy in both 6 months (RR=0.49, 95% CI: 0.38-0.64, P<0.00001) and 12 months (RR=0.35, 95% CI: 0.26-0.47, P<0.00001). Two trials compared combination of carvedilol and VBL with VBL alone; however, the results failed to find an improved preventive efficacy of bleeding (RR=0.71, 95% CI: 0.15-3.30, P=0.67). CONCLUSION Carvedilol is equivalent to invasive VBL for variceal bleeding prevention. It can be well tolerated and may be of benefit to portal hypertension gastropathy. However, available data during 24 months follow-up did not support a potential advantage of carvedilol for prognosis as a lowering hepatic venous pressure agent.
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Affiliation(s)
- Zhen-Gang Wei
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Hepato-Biliary-Pancreatic Institute, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
| | - Feng-Xian Wei
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Hepato-Biliary-Pancreatic Institute, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
| | - Zi-Wei Shao
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Hepato-Biliary-Pancreatic Institute, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
| | - Guo-Hong Su
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Hepato-Biliary-Pancreatic Institute, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
| | - Xue-Ping Qi
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
| | - You-Cheng Zhang
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Hepato-Biliary-Pancreatic Institute, Lanzhou University Second Hospital, Lanzhou 730030, China,
- Lanzhou University Second Clinical Medical College, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China,
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Gaiani F, De'Angelis N, Kayali S, Manfredi M, Di Mario F, Leandro G, Ghiselli A, Fornaroli F, De'Angelis GL. Clinical approach to the patient with acute gastrointestinal bleeding. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:12-19. [PMID: 30561412 PMCID: PMC6502216 DOI: 10.23750/abm.v89i8-s.7861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 12/03/2022]
Abstract
Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery. (www.actabiomedica.it)
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Affiliation(s)
- Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Abstract
Modern radiotherapy techniques have enabled high focal doses of radiation to be delivered to patients with primary and secondary malignancies of the liver. The current clinical practice of radiation oncology has benefitted from decades of research that have informed how to achieve excellent local control and survival outcomes with minimal toxicities. Still, one of the most devastating consequences of radiation to the liver remains a challenge: radiation-induced liver disease (RILD). Here, we will review the current understanding of classic and nonclassic RILD from a clinical perspective, the evaluation and management of patients who are at risk of developing RILD, methods to reduce the likelihood of RILD using modern radiation techniques, and the diagnosis and treatment of radiation-related liver toxicities.
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78
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Wang X, Kong DR. Endoscopic treatment of esophagogastric varices: Problems and thoughts. Shijie Huaren Xiaohua Zazhi 2018; 26:1959-1965. [DOI: 10.11569/wcjd.v26.i34.1959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Esophagogastric variceal bleeding (EVB) is a common digestive emergency, and it is usually severe and is associated with a high mortality. The American Association of Liver Diseases guidelines recommend endoscopic treatment as the first choice for acute EVB. Studies have shown that emergency endoscopic hemostasis can achieve a success rate of > 90% and thus reduce the incidence of early rebleeding and the mortality rate of patients. Endoscopic treatment mainly includes endoscopic variceal ligation, endoscopic injection sclerotherapy, tissue adhesive injection, and endoscopic therapy combined with other treatments. However, the therapeutic effect of endoscopic treatment is related to the operator's skill, portal pressure, collateral circulation, esophageal varices, and other factors. Therefore, endoscopic treatment is not indicated for all cases. In addition, endoscopic treatment may cause serious complications. Here we describe the problems and thoughts on endoscopic treatment of esophagogastric varices.
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Affiliation(s)
- Xi Wang
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
| | - De-Run Kong
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
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Motosugi U, Roldán-Alzate A, Bannas P, Said A, Kelly S, Zea R, Wieben O, Reeder SB. Four-dimensional Flow MRI as a Marker for Risk Stratification of Gastroesophageal Varices in Patients with Liver Cirrhosis. Radiology 2018; 290:101-107. [PMID: 30325278 DOI: 10.1148/radiol.2018180230] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose To assess the feasibility of four-dimensional (4D) flow MRI as a noninvasive imaging marker for stratifying the risk of variceal bleeding in patients with liver cirrhosis. Materials and Methods This study recruited participants scheduled for both liver MRI and gastroesophageal endoscopy. Risk of variceal bleeding was assessed at endoscopy by using a three-point scale: no varices, low risk, and high risk requiring treatment. Four-dimensional flow MRI was used to create angiograms for evaluating visibility of varices and to measure flow volumes in main portal vein (PV), superior mesenteric vein, splenic vein (SV), and azygos vein. Fractional flow changes in PV and SV were calculated to quantify shunting (outflow) from PV and SV into varices. Logistic analysis was used to identify the independent indicator of high-risk varices. Results There were 23 participants (mean age, 52.3 years; age range, 25-75 years), including 14 men (mean age, 51.7 years; age range, 25-75 years) and nine women (mean age, 53.2 years; age range, 31-72 years) with no varices (n = 8), low-risk varices (n = 8), and high-risk varices (n = 7) determined at endoscopy. Four-dimensional flow MRI-based angiography helped radiologists to view varices in four of 15 participants with varices. Independent indicators of high-risk varices were flow volume in the azygos vein greater than 0.1 L/min (P = .034; 100% sensitivity [seven of seven] and 62% specificity [10 of 16]) and fractional flow change in PV of less than 0 (P < .001; 100% sensitivity [seven of seven] and 94% specificity [15 of 16]). Conclusion Azygos flow greater than 0.1 L/min and portal venous flow less than the sum of splenic and superior mesenteric vein flow are useful markers to stratify the risk of gastroesophageal varices bleeding in patients with liver cirrhosis. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Utaroh Motosugi
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Alejandro Roldán-Alzate
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Peter Bannas
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Adnan Said
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Sean Kelly
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Ryan Zea
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Oliver Wieben
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
| | - Scott B Reeder
- From the Department of Radiology (U.M., A.R.A., P.B., O.W., S.B.R.), Department of Mechanical Engineering (A.R.A.), Division of Gastroenterology and Hepatology, Department of Medicine (A.S.), Department of Biostatistics & Medical Informatics (R.Z.), Department of Medical Physics (O.W., S.B.R.), Department of Medicine (S.B.R.), Department of Biomedical Engineering (S.B.R.), and Department of Emergency Medicine (S.B.R.), University of Wisconsin, Madison, Wis; Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan (U.M.); Department of Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany (P.B.); and Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio (S.K.)
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Alexandrino G, Domingues TD, Carvalho R, Costa MN, Lourenço LC, Reis J. Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding. Clin Endosc 2018; 52:47-52. [PMID: 30300984 PMCID: PMC6370919 DOI: 10.5946/ce.2018.093] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/27/2018] [Indexed: 12/26/2022] Open
Abstract
Background/Aims The role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12–24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding.
Methods This retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding. Results A total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome.
Conclusions Very early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified.
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Affiliation(s)
- Gonçalo Alexandrino
- Hospital Professor Doutor Fernando Fonseca, Serviço de Gastrenterologia, Amadora, Portugal
| | - Tiago Dias Domingues
- Centro de Estatística e Aplicações da Universidade de Lisboa (CEAUL), Lisbon, Portugal
| | - Rita Carvalho
- Hospital Professor Doutor Fernando Fonseca, Serviço de Gastrenterologia, Amadora, Portugal
| | - Mariana Nuno Costa
- Hospital Professor Doutor Fernando Fonseca, Serviço de Gastrenterologia, Amadora, Portugal
| | - Luís Carvalho Lourenço
- Hospital Professor Doutor Fernando Fonseca, Serviço de Gastrenterologia, Amadora, Portugal
| | - Jorge Reis
- Hospital Professor Doutor Fernando Fonseca, Serviço de Gastrenterologia, Amadora, Portugal
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81
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Liu X, Wang AJ, Li BM. Progress in endoscopic treatment of gastric varices in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2018; 26:1355-1359. [DOI: 10.11569/wcjd.v26.i22.1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis is defined as diffuse or prolonged hepatic damage caused by one or more etiologies. When liver cirrhosis progresses to decompensation stage, hepatic dysfunction and portal hypertension are the main manifestations. Main symptoms of portal hypertension include collateral circulation, splenomegaly, and ascites. Gastric varices (GV) is one of the most common manifestations of collateral circulation. Gastric variceal bleeding (GVB) is one of the most common complications of cirrhosis, with a high mortality rate. In recent years, there are many studies on GV, but the choice of endoscopic treatments for different types of GV is still controversial. Compared with esophageal variceal bleeding, GVB is associated with large volume of bleeding, high risk, and high mortality. Therefore, selecting an appropriate endoscopic treatment can effectively reduce mortality and improve the prognosis. This article reviews the type of GV and endoscopic treatment of different types of GV.
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Affiliation(s)
- Xia Liu
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - An-Jiang Wang
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bi-Min Li
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Patel M, Molvar C. Evolution of Retrograde Transvenous Obliteration Techniques. Semin Intervent Radiol 2018; 35:185-193. [PMID: 30087521 DOI: 10.1055/s-0038-1660796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.
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Affiliation(s)
- Mihir Patel
- Department of Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Christopher Molvar
- Department of Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
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83
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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84
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Laine L. Treatment of thrombocytopenic patients with GI bleeding. Gastrointest Endosc 2018; 88:62-65. [PMID: 29935628 DOI: 10.1016/j.gie.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA; Veterans Administration Connecticut Healthcare System, West Haven, Connecticut, USA
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85
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Bianchini M, Cavani G, Bonaccorso A, Turco L, Vizzutti F, Sartini A, Gitto S, Merighi A, Banchelli F, Villa E, Schepis F. Low molecular weight heparin does not increase bleeding and mortality post-endoscopic variceal band ligation in cirrhotic patients. Liver Int 2018; 38:1253-1262. [PMID: 29469184 DOI: 10.1111/liv.13728] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Anticoagulants are commonly indicated in cirrhotic patients due to high rate of (pro)thrombotic conditions. Low molecular weight heparin (LMWH) is safe in patients with esophageal varices. However, the safety of LMWH is unknown in patients undergoing prophylactic endoscopic variceal ligation (EVL). To define the 4-week risk of bleeding and death after prophylactic EVL in cirrhotic patients continuously treated with LMWH. METHODS All EVLs performed at a tertiary Italian Center from 2009 to 2016 were retrospectively reviewed. Patients treated with LMWH were classified as on-LMWH; the remaining as no-LMWH. Endoscopic characteristics at first and index EVL (that preceding an endoscopy either showing a bleeding episode or the absence of further treatable varices) and clinical events within 4 weeks from the procedures were recorded. RESULTS AND CONCLUSIONS Five hundred fifty-three EVLs were performed in 265 patients (in 215 as a primary prophylaxis): 169 EVLs in 80 on-LMWH and 384 in 185 no-LMWH (4.9 ± 1.1 vs 4.8 ± 1.0 bands/session, respectively; P = .796). Six patients bled (2.2%) without between-groups difference (3.8% on-LMWH vs 1.6% no-LMWH, Log-rank P = .291). Large varices with red marks (100% vs 51.4%, P = .032), number of bands (5.6 ± 0.5 vs 4.6 ± 1.2, P = .004), underlying portal vein thrombosis (66.7% vs 23.6%, P = .033), and creatinine (2.2 ± 2.7 vs 1.0 ± 0.8 mg/dL, P = .001) at index EVL were significantly different between bleeders and non-bleeders. Six patients died within 4-week from index EVL, without between-groups difference (2.5% on-LMWH vs 2.2% no-LMWH, Log-rank P = .863). LMWH does not increase the risk of post-procedural bleeding and does not affect survival of cirrhotic patients undergoing prophylactic EVL.
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Affiliation(s)
- Marcello Bianchini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Cavani
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Ambra Bonaccorso
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Turco
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Sartini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gitto
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Alberto Merighi
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Banchelli
- Statistics Unit, Department of Clinical, Diagnostic and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
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86
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Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia. Gastrointest Endosc 2018; 88:55-61. [PMID: 29408558 DOI: 10.1016/j.gie.2018.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Gastrointestinal bleeding (GIB) in the setting of thrombocytopenia raises concerns about endoscopic procedure risk. We aimed to assess the safety and outcomes of endoscopy for overt GIB in the setting of severe thrombocytopenia in liver cirrhosis (LC) and non-liver cirrhosis (NLC). METHODS This is a retrospective study on inpatients who underwent endoscopy within 24 hours of presentation for overt GIB with a platelet count (PC) of 20 to <50 × 103/mL. Outcomes included diagnostic and therapeutic yields, procedural adverse events, packed red blood cell (pRBC) and platelet transfusions, recurrent bleeding rate, and all-cause and GIB-related mortality. RESULTS One hundred forty-four patients were identified. The median PC was 41 × 103/mL and 61% had LC. The diagnostic yield was 68% (LC = 61%, NLC = 79%, P = .04). Therapeutic yield was 60% (59% vs 60%, P = 1.00). The initial hemostasis rate was 94% with one adverse event. The median number of pRBC and platelet transfusions decreased after intervention in the entire cohort. Recurrent bleeding rates were 22% at 1 month and 30% at 1 year, with no differences between groups. An increased international normalized ratio (INR) >2 was a predictor of recurrent bleeding. All-cause mortality was 19% at 1 month and 37% at 1 year, whereas GIB-associated mortality in our cohort was only 3% at 1 month and 4% at 1 year, with no significant difference between LC and NLC. Predictors of mortality were INR >2, activated partial thromboplastin time >38 seconds, hypotension, intensive care unit admission, and pulmonary comorbidities. CONCLUSION In this study cohort, we observed that endoscopy for overt GIB in the setting of severe thrombocytopenia in patients with LC and NLC appears safe, has moderate diagnostic and therapeutic yields with high initial hemostasis rate, and is associated with a significant decrease in pRBC and platelet transfusions. Recurrent bleeding and all-cause mortality rates remain high.
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87
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Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update. Gastroenterol Res Pract 2018; 2018:4202091. [PMID: 29977287 PMCID: PMC6011072 DOI: 10.1155/2018/4202091] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/30/2018] [Indexed: 12/14/2022] Open
Abstract
The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.
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88
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Chandra S, Holm A, El Abiad RG, Gerke H. Endoscopic Cyanoacrylate Glue Injection in Management of Gastric Variceal Bleeding: US Tertiary Care Center Experience. J Clin Exp Hepatol 2018; 8:181-187. [PMID: 29892182 PMCID: PMC5992314 DOI: 10.1016/j.jceh.2017.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. METHODS Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. RESULTS Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. CONCLUSION ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.
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Key Words
- BRTO, balloon-occluded retrograde transvenous obliteration
- CT, computed tomography
- ECGI, endoscopic cyanoacrylate glue injection
- GV, gastric varices
- ICD-9CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- IQR, interquartile range
- TIPS, transjugular intrahepatic portosystemic shunt
- US, United States
- endoscopic cyanoacrylate glue injection
- gastric varices
- hemostasis
- variceal bleeding
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Affiliation(s)
| | | | | | - Henning Gerke
- Address for correspondence: Henning Gerke, Clinical Professor, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospital and Clinics, Iowa City, IA 52242, United States. Tel.: +1 319 356 2197; fax: +1 319 353 6399.
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Zhu J, Qi X, Yu H, Su C, Guo X. Acid suppression in patients treated with endoscopic therapy for the management of gastroesophageal varices: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2018; 12:617-624. [PMID: 29564926 DOI: 10.1080/17474124.2018.1456918] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic therapy is the cornerstone choice for the management of varices and variceal hemorrhage. The aim of the present systematic review and meta-analysis was to evaluate the efficacy of acid suppression in patients treated with endoscopic therapy for gastroesophageal varices. METHODS All eligible studies were searched via the PubMed, EMBASE, and Cochrane Library databases. Incidence of bleeding, mortality, ulcers, chest pain, and dysphagia after endoscopic therapy and length of stay were analyzed. Subgroup analyses were performed according to the types and major indications of endoscopic treatments. Odds ratios (ORs) with 95% confidence intervals (95%CIs) were calculated. RESULTS Nine studies with 1470 patients were included. Acid suppression could significantly decrease the incidence of bleeding (OR = 0.39, 95%CI: 0.19-0.81, P = 0.01) and diminish the ulcer size (OR = 0.78, 95%CI: 0.38-1.57, P = 0.48) after endoscopic therapy. The subgroup analyses showed that acid suppression could significantly decrease the incidence of bleeding in patients undergoing prophylactic EVL, rather than in patients undergoing therapeutic EVL. There was no significant difference in the incidence of mortality, ulcers, chest pain, and dysphagia and length of stay between patients treated with and without acid suppression. CONCLUSION Acid suppression might be considered in patients undergoing prophylactic EVL for gastroesophageal varices.
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Affiliation(s)
- Jia Zhu
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
- b Postgraduate College , Shenyang Pharmaceutical University , Shenyang , China
| | - Xingshun Qi
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Haonan Yu
- b Postgraduate College , Shenyang Pharmaceutical University , Shenyang , China
| | - Chunping Su
- c Library of Fourth Military Medical University , Xi'an , China
| | - Xiaozhong Guo
- a Liver Cirrhosis Study Group, Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
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Transparent cap-assisted endoscopic sclerotherapy in esophageal varices: a randomized-controlled trial. Eur J Gastroenterol Hepatol 2018; 30:626-630. [PMID: 29505477 DOI: 10.1097/meg.0000000000001107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices. PATIENTS AND METHODS A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61). RESULTS The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563). CONCLUSION Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.
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91
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Ortiz AM, Garcia CJ, Othman MO, Zuckerman MJ. Innovative Technique for Endoscopic Placement of Sengstaken-Blakemore Tube. South Med J 2018; 111:307-311. [PMID: 29767224 DOI: 10.14423/smj.0000000000000806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Sengstaken-Blakemore (SB) tube is used in cases of uncontrolled variceal bleeding. Because of the complexity of the procedure and the lack of visualization, various techniques have been described to avoid blind placement. We report an innovative and simple technique for placement of the SB tube under direct endoscopic visualization. METHODS A grasp-and-place technique for endoscopic placement of SB tubes is described and a retrospective cohort study chart review of endoscopies done for variceal bleeding in our medical center is reported. All patients with uncontrolled variceal bleeding who required placement of an SB tube from July 1, 2013 through December 31, 2015 were included. The primary outcome analyses were technical success of tube placement and achievement of hemostasis. RESULTS Of 143 endoscopies done for variceal bleeding, 10 were managed with SB tubes placed endoscopically after initial endoscopic therapy was unsuccessful. Successful placement of the tube was achieved in all of the patients. Hemostasis was achieved in 9 of the 10 patients. CONCLUSIONS We propose a new grasp-and-place technique for endoscopic placement of SB tubes. Review of our experience shows that massive variceal bleeding can be managed effectively with this technique.
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Affiliation(s)
- Arleen M Ortiz
- From the Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, and Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas
| | - Cesar J Garcia
- From the Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, and Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas
| | - Mohamed O Othman
- From the Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, and Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas
| | - Marc J Zuckerman
- From the Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, and Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas
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92
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The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
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Shi X, Yu S, Wang F, Zhao Q, Xu H, Li B. A gastrointestinal stromal tumor with acute bleeding: Management and nursing. Medicine (Baltimore) 2018; 97:e9874. [PMID: 29489686 PMCID: PMC5851723 DOI: 10.1097/md.0000000000009874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract. A small percentage of GISTs may cause acute gastrointestinal bleeding, which requires urgent surgical intervention. PATIENT CONCERNS In this case report, we present a 62-year-old male patient with who was hospitalized due to acute bleeding. DIAGNOSES The patient was diagnosed as GIST with low risk. INTERVENTIONS The patient was treated endoscopically with polidocanol sclerotherapy. OUTCOMES The mass was removed completely, and the patient was discharged at day 9 after operation. LESSONS This case indicates that GIST can present as massive upper gastrointestinal bleeding and urgent endoscopic sclerotherapy can be life-saving. The endoscopical intervention may be a good alternative for emergency.
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Affiliation(s)
- Xiuju Shi
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University
| | - Shuxia Yu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University
| | - Fenyan Wang
- Department of Gastroenterology, Qianfo Mountain Hospital, Jinan, China
| | - Qi Zhao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University
| | - Hongwei Xu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University
| | - Bin Li
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University
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Laghari MH, Byrne MF, Chatur N, Yau A, Donnellan F. A bleeding vallecular varix, visualized by GI endoscopy, confirmed with CT angiography, and treated with sclerotherapy and cyanoacrylate. VideoGIE 2018; 3:20-22. [PMID: 29905179 PMCID: PMC5965717 DOI: 10.1016/j.vgie.2017.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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95
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Bai Z, Guo X, Shao X, Li Y, Li Q, Xu X, Liang Z, Deng J, Zhang X, Li H, Qi X. Successful treatment of repeated hematemesis secondary to postsclerotherapy esophageal ulcer in a cirrhotic patient: A case report. Drug Discov Ther 2018; 12:309-314. [PMID: 30464164 DOI: 10.5582/ddt.2018.01056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Shenyang Pharmaceutical University
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area
| | - Yingying Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Jinzhou Medical University
| | - Qianqian Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Dalian Medical University
| | - Xiangbo Xu
- Department of Gastroenterology, General Hospital of Shenyang Military Area
- Postgraduate College, Shenyang Pharmaceutical University
| | - Zhendong Liang
- Department of Gastroenterology, General Hospital of Shenyang Military Area
| | - Jiao Deng
- Department of Pharmacology, General Hospital of Shenyang Military Area
| | - Xia Zhang
- No. 4 People Hospital of Shenyang City
| | - Hongyu Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area
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Karakonstantis S, Tzagkarakis E, Kalemaki D, Lydakis C, Paspatis G. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Rev Gastroenterol Hepatol 2018; 12:63-72. [PMID: 29098897 DOI: 10.1080/17474124.2018.1398646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines. Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localization of bleeding? 3) Can nasogastric aspiration identify high risk patients that might benefit from earlier endoscopy? 4) Is there evidence for benefit in terms of outcomes from using nasogastric aspiration? 5) Is nasogastric intubation safe in patients with possible esophageal varices? Our review was conducted according to PRISMA guidelines. Expert commentary: Based on the available literature, nasogastric lavage or aspiration cannot be routinely recommended unless a large properly designed randomized trial (which is currently lacking) proves otherwise. It is a painful and time-consuming procedure with no demonstrated benefit for the patient in terms of outcomes. Other clinical and laboratory parameters, and risk scores, are less invasive and are effective for guiding the stratification and management of patients, while pre-endoscopic erythromycin infusion is a good if not better alternative for improving visualization of the stomach.
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Affiliation(s)
- Stamatis Karakonstantis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | - Emmanouil Tzagkarakis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | | | - Charalampos Lydakis
- a The Second Department of Internal Medicine , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
| | - Gregorios Paspatis
- c Department of Gastroenterology , Venizeleio Pananeio General Hospital of Heraklion , Heraklion , Greece
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Ye W, Narkewicz MR, Leung DH, Karnsakul W, Murray KF, Alonso EM, Magee JC, Schwarzenberg SJ, Weymann A, Molleston JP. Variceal Hemorrhage and Adverse Liver Outcomes in Patients With Cystic Fibrosis Cirrhosis. J Pediatr Gastroenterol Nutr 2018; 66:122-127. [PMID: 28906321 PMCID: PMC5745284 DOI: 10.1097/mpg.0000000000001728] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Cirrhosis occurs in 5% to 10% of cystic fibrosis (CF) patients, often accompanied by portal hypertension. We analyzed 3 adverse liver outcomes, variceal bleeding (VB), liver transplant (LT), and liver-related death (LD), and risk factors for these in CF Foundation Patient Registry subjects with reported cirrhosis. METHODS We determined 10-year incidence rates for VB, LT, LD, and all-cause mortality (ACM), and examined risk factors using competing risk models and Cox-proportional hazard regression. RESULTS From 2003 to 2012, 943 participants (41% females, mean age 18.1 years) had newly reported cirrhosis; 24.7% required insulin, 85% had previous pseudomonas. Seventy-three subjects had reported VB: 38 with first VB and new cirrhosis reported simultaneously and 35 with VB after cirrhosis report. Ten-year cumulative VB, LT, and LD rates were 6.6% (95% confidence interval [CI]: 4.0, 9.1%), 9.9% (95% CI: 6.6%, 13.2%), and 6.9% (95% CI: 4.0%, 9.8%), respectively, with an ACM of 39.2% (95% CI: 30.8, 36.6%). ACM was not increased in subjects with VB compared to those without (hazard ratio [HR] 1.10, 95% CI: 0.59, 2.08). CF-related diabetes (HR: 3.141, 95% CI:1.56, 6.34) and VB (HR: 4.837, 95% CI: 2.33, 10.0) were associated with higher LT risk, whereas only worse lung function was associated with increased LD in multivariate analysis. Death rate among subjects with VB was 24% with LT and 20.4% with native liver. CONCLUSIONS VB is an uncommon complication of CF cirrhosis and can herald the diagnosis, but does not affect ACM. Adverse liver outcomes and ACM are frequent by 10 years after cirrhosis report.
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Affiliation(s)
- Wen Ye
- University of Michigan, Ann Arbor, MI
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Daniel H Leung
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | | | - Karen F Murray
- Seattle Children's Hospital and University of Washington, Seattle, WA
| | | | | | | | | | - Jean P Molleston
- Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
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Tian Y, Abu-Sbeih H, Wang Y. Immune Checkpoint Inhibitors-Induced Colitis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 995:151-157. [DOI: 10.1007/978-3-030-02505-2_7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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99
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Abstract
Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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100
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Abstract
Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, E-Da Hospital, Kaohsiung, School of Medicine for International Students, I-Shou University, 1, Yi-Da Road, Kaohsiung, 824, Taiwan.
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