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Dynamic changes of intrinsic brain activity in cirrhotic patients after transjugular intrahepatic portosystemic shunt: a resting-state FMRI study. PLoS One 2012; 7:e46681. [PMID: 23056400 PMCID: PMC3462766 DOI: 10.1371/journal.pone.0046681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 09/02/2012] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The majority of cirrhotic patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) experienced the first post-TIPS hepatic encephalopathy (HE) episode within the first three months after TIPS insertion. However, so far, little is known about the exact neuro-pathophysiological mechanism of TIPS's effects on brain function. We aimed to investigate the dynamics of brain function alteration of post-TIPS patients using resting-state functional MRI (rs-fMRI). MATERIALS AND METHODS Sixteen cirrhotic patients who were scheduled for TIPS and 16 healthy controls were included in the rs-fMRI scans. Ten patients repeated the MRI study in a median 8-day follow-up interval following TIPS and seven in a median 3-month follow-up. The amplitude of low frequency fluctuation (ALFF), an index reflecting the spontaneous brain activity, was compared between patients before TIPS and healthy controls as well as patients pre- and post-TIPS. RESULTS Compared with healthy controls, patients showed decreased ALFF in frontal and parietal regions and increased ALFF in insula. Patients who underwent the median 8-day follow-up fMRI examinations showed decreased ALFF in posterior cingulate cortex (PCC)/precuneus and increased ALFF in anterior cingulate cortex (ACC). Of 10 patients in this group, 9 had moderate to large increase rate of ALFF value (>20%, mean 49.19%) in ACC, while only one patient with the smallest increase rate of ALFF value (<10%) in ACC, who experienced three episodes of overt HE during the 3-month follow-up. In the median 3-month follow up observation, patients displayed persistently decreased ALFF in PCC, ACC and medial prefrontal cortex (MPFC), while no increased regional ALFF was observed. CONCLUSION TIPS insertion alters cirrhotic patients' ALFF patterns in the resting state, which may imply different short-term and moderate-term effects on cirrhotic patients, i.e., both impairment and compensatory mechanism of brain functions in peri-TIPS and continuous impairment of brain function 3 months following TIPS.
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152
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Clements W, Cavanagh K, Ali F, Kavnoudias H, Kemp W, Roberts S, Lyon S. Variant treatment for gastric varices with polidocanol foam using balloon-occluded retrograde transvenous obliteration: A pilot study. J Med Imaging Radiat Oncol 2012; 56:599-605. [DOI: 10.1111/j.1754-9485.2012.02453.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 05/24/2012] [Indexed: 12/11/2022]
Affiliation(s)
| | | | - Faizal Ali
- Department of Radiology; The Alfred Hospital; Australia
| | | | - William Kemp
- Department of Gastroenterology; The Alfred Hospital; Australia
| | - Stuart Roberts
- Department of Gastroenterology; The Alfred Hospital; Australia
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153
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Al-Osaimi AMS, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Intervent Radiol 2012; 28:273-82. [PMID: 22942544 DOI: 10.1055/s-0031-1284453] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed.
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Affiliation(s)
- Abdullah M S Al-Osaimi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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154
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Saad WEA, Darcy MD. Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2012; 28:339-49. [PMID: 22942552 DOI: 10.1055/s-0031-1284461] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.
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155
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Bosch J, Abraldes JG, Albillos A, Aracil C, Bañares R, Berzigotti A, Calleja JL, de la Peña J, Escorsell A, García-Pagán JC, Genescà J, Hernández-Guerra M, Ripoll C, Planas R, Villanueva C. Hipertensión portal: recomendaciones para su evaluación y tratamiento. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:421-50. [DOI: 10.1016/j.gastrohep.2012.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/15/2012] [Indexed: 12/16/2022]
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156
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Waguri N, Hayashi M, Yokoo T, Sato R, Arao Y, Setsu T, Sato M, Kohisa J, Hama I, Ohsugi K, Aiba T, Yoneyama O, Furukawa K, Sugimura K, Igarashi K, Suda T. Simultaneous combined balloon-occluded retrograde transvenous obliteration and partial splenic embolization for portosystemic shunts. J Vasc Interv Radiol 2012; 23:650-7. [PMID: 22459878 DOI: 10.1016/j.jvir.2012.01.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 01/13/2012] [Accepted: 01/16/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE) for gastric varices and/or hepatic encephalopathy. MATERIALS AND METHODS B-RTO was performed in 19 consecutive patients with gastric varices and/or hepatic encephalopathy, of whom 10 received simultaneous combined B-RTO and PSE (group 1) and nine received B-RTO monotherapy (group 2). To evaluate the safety of these techniques, we analyzed 20 patients who received PSE monotherapy during the same period as a control group (group 3). Outcomes were retrospectively assessed. RESULTS No significant differences were observed in baseline characteristics among the three groups except for significantly lower platelet counts and larger spleen volumes in group 3. In all cases in groups 1 and 2, gastric varices disappeared and hepatic encephalopathy improved after treatment. Procedure times were not significantly different between groups 1 and 2 (P = .7435). In group 1, the volume of sclerosing agent required for B-RTO was significantly lower (P = .0355) and exacerbation of esophageal varices was significantly less frequent (P = .0146) than in group 2. Few serious complications occurred in patients who received combined therapy. CONCLUSIONS This study indicates that concomitant PSE may help diminish the increase in portal venous pressure after B-RTO for portosystemic shunts, and may allow a reduction in the volume of hazardous sclerosing agent used. It is worth evaluating the efficacy of simultaneous B-RTO and PSE in a prospective study.
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Affiliation(s)
- Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, 467-3 Shumoku, Chuo-ku, Niigata 950-1197, Japan.
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157
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Hung HH, Chang CJ, Hou MC, Liao WC, Chan CC, Huang HC, Lin HC, Lee FY, Lee SD. Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol 2012; 56:1025-1032. [PMID: 22266602 DOI: 10.1016/j.jhep.2011.12.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 12/02/2011] [Accepted: 12/03/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Gastric variceal obturation (GVO) therapy is the current treatment of choice for gastric variceal bleeding (GVB). However, the efficacy of non-selective β-blockers (NSBB) in the secondary prevention of GVB is still debatable. This study aimed at evaluating the efficacy of additional NSBB to repeated GVO in the secondary prevention of GVB. METHODS From April 2007 to March 2011, 95 patients with GVB after primary hemostasis using GVO were enrolled. Repeated GVO were performed until GV eradication. Forty-eight and 47 patients were randomized into the GVO alone group (Group A) and the GVO+NSBB group (Group B), respectively. Primary outcomes in terms of re-bleeding and overall survival were analyzed by multivariate analysis. RESULTS After a mean follow-up of 18.10 months in group A, 26 patients bled and 20 died. In group B, 22 patients bled and 22 died after a mean follow-up of 20.29 months. The overall re-bleeding and survival rates analyzed by the Kaplan-Meier method were not different between the two groups (p=0.336 and 0.936, respectively). The model of end-stage liver disease (MELD) score and main portal vein thrombosis (MPT) were independent determinants of re-bleeding while MPT and re-bleeding were independent factors of mortality by time-dependent Cox-regression model. Asthenia was the most common adverse event and was higher in group B (p<0.001). CONCLUSIONS Adding NSBB therapy to repeated GVO provides no benefit for the secondary prevention of bleeding and mortality in patients with GVB.
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Affiliation(s)
- Hung-Hsu Hung
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Jung Chang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Wei-Chih Liao
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan
| | - Che-Chang Chan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Han-Chieh Lin
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shou-Dong Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Deparement of Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Cheng Hsin General Hospital, Taipei, Taiwan
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158
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Lim YS. Practical approach to endoscopic management for bleeding gastric varices. Korean J Radiol 2012; 13 Suppl 1:S40-4. [PMID: 22563286 PMCID: PMC3341459 DOI: 10.3348/kjr.2012.13.s1.s40] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 12/02/2011] [Indexed: 02/07/2023] Open
Abstract
Bleeding from gastric varices is generally more severe than bleeding from esophageal varices, although it occurs less frequently. Recently, new endoscopic treatment options and interventional radiological procedures have broadened the therapeutic armamentarium for gastric varices. This review provides an overview of the classification and pathophysiology of gastric varices, an introduction to current endoscopic and interventional radiological management options for gastric varices, and details of a practical approach to endoscopic variceal obturation using N-butyl-2-cyanoacrylate.
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Affiliation(s)
- Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
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159
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Dadabhai AS, Fenkel JM, Brown DB, Laine L. Balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices. Hepatology 2012; 55:1301-4. [PMID: 22318957 DOI: 10.1002/hep.25635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Alia S Dadabhai
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
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160
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Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012; 2:55-69. [PMID: 25755406 PMCID: PMC3940364 DOI: 10.1016/s0973-6883(12)60088-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/22/2011] [Indexed: 02/06/2023] Open
Abstract
Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10-20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3-30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15-30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0-10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5-4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.
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Affiliation(s)
- Vivek A Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Address for correspondence: Vivek A Saraswat, Professor, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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161
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Krystallis C, Masterton GS, Hayes PC, Plevris JN. Update of endoscopy in liver disease: More than just treating varices. World J Gastroenterol 2012; 18:401-11. [PMID: 22346246 PMCID: PMC3272639 DOI: 10.3748/wjg.v18.i5.401] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 02/06/2023] Open
Abstract
The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.
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162
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Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012; 16:133-46. [PMID: 22321469 DOI: 10.1016/j.cld.2011.12.008] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has been used for more than 20 years to treat some of the complications of portal hypertension. When TIPS was initially proposed, it was claimed that the optimal calibration of the shunt could allow an adequate reduction of portal hypertension, avoiding, at the same time, the occurrence of hepatic encephalopathy (HE), a neurologic syndrome. However, several clinical observations have shown that HE occurred rather frequently after TIPS, and HE has become an important issue to be taken into consideration in TIPS candidates and a problem to be faced after the procedure.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Viale dell'Università 37, 00185 Rome, Italy
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163
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The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status. Int J Hepatol 2012; 2012:167868. [PMID: 22888442 PMCID: PMC3408669 DOI: 10.1155/2012/167868] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
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164
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Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, Mizuguchi Y, Shimizu T, Ueda J, Uchida E. Treatment Modalities for Bleeding Esophagogastric Varices. J NIPPON MED SCH 2012; 79:19-30. [DOI: 10.1272/jnms.79.19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroshi Yoshida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Yasuhiro Mamada
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Nobuhiko Taniai
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Masato Yoshioka
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Atsushi Hirakata
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Youichi Kawano
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yoshiaki Mizuguchi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Tetsuya Shimizu
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Junji Ueda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Eiji Uchida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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165
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Pal S. Current role of surgery in portal hypertension. Indian J Surg 2011; 74:55-66. [PMID: 23372308 DOI: 10.1007/s12262-011-0381-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/17/2011] [Indexed: 12/12/2022] Open
Abstract
Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.
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Affiliation(s)
- Sujoy Pal
- Department of GI surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
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166
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Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74:1019-25. [PMID: 21889139 DOI: 10.1016/j.gie.2011.06.030] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/15/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND There have been numerous reports of glue embolization after endoscopic cyanoacrylate (CYA) glue treatment of gastric fundal varices (GFV), with some cases fatal. Coils with attached synthetic fibers may decrease or eliminate this risk and may decrease the amount of CYA needed to achieve obliteration. OBJECTIVE Assess the feasibility, safety, and outcomes of transesophageal EUS-guided therapy of GFV with combined coil and CYA injection. DESIGN Retrospective query of a prospectively maintained database. SETTING Tertiary care medical center. PATIENTS Patients with hemorrhage from large GFV. INTERVENTION A standardized approach by using EUS-guided coil and CYA treatment. MAIN OUTCOMES MEASUREMENTS Hemostasis, rebleeding rate, complications. RESULTS Thirty patients with GFV were treated between March 2009 and January 2011. At index endoscopy, 2 patients had active hemorrhage and 14 had stigmata of recent hemorrhage. EUS-guided transesophageal treatment of GFV was successful in all. Mean number of GFV treated was 1.3 per patient, and the mean volume of 2-octyl-CYA injected was 1.4 mL per varix. Hemostasis of acute bleeding was 100%. Among 24 patients with a mean follow-up of 193 days (range 24-589 days), GFV were obliterated after a single treatment session in 23 (96%). Rebleeding occurred in 4 patients (16.6%), with none attributed to GFV. There were no procedure-related complications and no symptoms or signs of CYA embolization. LIMITATIONS Single-center, pilot study. CONCLUSION Transesophageal EUS-guided coil and CYA treatment of GFV is feasible and deserves further study to determine whether this novel approach can improve safety and efficacy over standard endoscopic injection of CYA alone.
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Affiliation(s)
- Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA.
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167
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Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol 2011; 9:936-46; quiz e123. [PMID: 21699820 PMCID: PMC3200495 DOI: 10.1016/j.cgh.2011.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/01/2011] [Accepted: 06/05/2011] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.
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Modified Percutaneous Transhepatic Variceal Embolization With 2-Octylcyanoacrylate for Bleeding Gastric Varices: Long-Term Follow-Up Outcomes. AJR Am J Roentgenol 2011; 197:502-9. [PMID: 21785101 DOI: 10.2214/ajr.10.6005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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169
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Mishra SR, Sharma BC, Kumar A, Sarin SK. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial. J Hepatol 2011; 54:1161-7. [PMID: 21145834 DOI: 10.1016/j.jhep.2010.09.031] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 08/28/2010] [Accepted: 09/07/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Gastric variceal bleeding is severe and is associated with high mortality. We compared the efficacy of cyanoacrylate injection and beta-blockers in primary prophylaxis of gastric variceal bleeding. METHODS Cirrhotics with large gastroesophageal varices type 2 with eradicated esophageal varices or large isolated gastric varix type 1, who had never bled from gastric varix, were randomised to cyanoacrylate injection (Group I, n=30), beta-blockers (Group II, n=29) or no treatment (Group III, n=30). Primary end-points were bleeding from gastric varix or death. RESULTS The actuarial probability of bleeding from gastric varices over a median follow-up of 26 months was 13% in Group I, 28% in Group II (p=0.039), and 45% in Group III (p=0.003). The actuarial probability of survival was higher in the cyanoacrylate compared to the no-treatment group (90% vs. 72%, p=0.048). The median hepatic venous pressure gradient (HVPG) was increased in Group I (14-15 mm Hg, p=0.001) and III (14-16 mm Hg, p=0.001) but decreased in Group II (14 to 12 mm Hg, p=0.001) during follow-up. Size of gastric varix >20 mm, a MELD score ≥17, and presence of portal hypertensive gastropathy predicted 'high risk' of first bleeding from gastric varices. CONCLUSIONS Primary prophylaxis is recommended in patients with large and high risk gastric varices to reduce the risk of first bleeding and mortality. Cyanoacrylate injection is more effective than beta-blocker therapy in preventing first gastric variceal bleeding.
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170
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Kang EJ, Jeong SW, Jang JY, Cho JY, Lee SH, Kim HG, Kim SG, Kim YS, Cheon YK, Cho YD, Kim HS, Kim BS. Long-term result of endoscopic Histoacryl ® (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices. World J Gastroenterol 2011; 17:1494-500. [PMID: 21472110 PMCID: PMC3070025 DOI: 10.3748/wjg.v17.i11.1494] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 11/12/2010] [Accepted: 11/19/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl® for treatment of gastric variceal bleeding and prophylaxis.
METHODS: Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl® injections endoscopically. One hundred patients underwent endoscopic Histoacryl® injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure.
RESULTS: According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl® per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl® injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%.
CONCLUSION: Histoacryl® injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.
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Sabri SS, Swee W, Turba UC, Saad WE, Park AW, Al-Osaimi AM, Caldwell SH, Matsumoto AH, Angle JF. Bleeding Gastric Varices Obliteration with Balloon-occluded Retrograde Transvenous Obliteration Using Sodium Tetradecyl Sulfate Foam. J Vasc Interv Radiol 2011; 22:309-16; quiz 316. [DOI: 10.1016/j.jvir.2010.11.022] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 10/06/2010] [Accepted: 11/16/2010] [Indexed: 02/07/2023] Open
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Elfert AA, El-Kalla FS. Gastroenterologists and interventional radiologists: friends or foes? A multidisciplinary approach for solving gastrointestinal problems. Arab J Gastroenterol 2011; 12:5-10. [PMID: 21429447 DOI: 10.1016/j.ajg.2011.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 08/20/2010] [Accepted: 09/25/2010] [Indexed: 12/11/2022]
Abstract
While endoscopy used to have more therapeutic abilities than radiology, interventional radiology is now racing to lead the minimally invasive diagnostic and therapeutic techniques in medicine as well as surgery. Expecting the new epidemic of hepatocellular carcinoma, radiologists and gastroenterologists are on the run competing in many procedures that are needed. While some radiologists worry about non-radiologists who "intervene" in radiology, many gastroenterologists defend their specialty. Both gastroenterologists and radiologists are invited to collaborate in diagnosing and treating many diseases. Treatment of upper gastrointestinal bleeds should be multidisciplinary involving a team of gastroenterologists, radiologists and surgeons. The role of the interventional radiologist and surgeon arises only after the failure of the endoscopic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) is the preferred treatment for variceal bleeding after failed endoscopy. As the entire field of gastroenterology continues towards less invasive, safer and more effective means of diagnosing and treating diseases, digestive endoscopy will continue to expand the ways in which this unique and minimally invasive technology can be applied to the benefit of patients. In line with this trend, there will be a decline in simple diagnostic standard endoscopies. Development of new techniques, such as CT colonography and capsule endoscopy will actually increase the demand for digestive endoscopy. The trend of future digestive endoscopy will continue to move from diagnostic to therapeutic modalities. Future gastroenterologists will be trained and expected to become micro-surgeons of the gastrointestinal tract working in multispecialty teams along with their colleagues: surgeons and radiologists.
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Affiliation(s)
- Asem Ahmed Elfert
- Department of Tropical Medicine and Infectious Diseases, Tanta University, Faculty of Medicine, Tanta, Egypt.
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173
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Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int 2011; 5:607-24. [PMID: 21484145 DOI: 10.1007/s12072-010-9236-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 12/09/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live. METHODS The expert working party, predominantly from the Asia-Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted. RESULTS AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (<30 min of hospitalization) and endoscopic variceal ligation (door to scope time <6 h) is accepted as first-line therapy. Rebleeding (48 h of T (0)) is further sub-classified as very early rebleeding (48 to 120 h from T (0)), early rebleeding (6 to 42 days from T (0)) and late rebleeding (after 42 days from T (0)) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of non-response to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients. CONCLUSION Management of acute variceal bleeding in Asia-Pacific region needs special attention for uniformity of treatment and future clinical trials.
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Thalheimer U, Triantos C, Goulis J, Burroughs AK. Management of varices in cirrhosis. Expert Opin Pharmacother 2011; 12:721-35. [PMID: 21269241 DOI: 10.1517/14656566.2011.537258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute variceal bleeding is a medical emergency and one of the main causes of mortality in patients with cirrhosis. Timely and effective treatment of the acute bleeding episode results in increased survival, and appropriate prophylactic treatment can prevent bleeding or rebleeding from varices. AREAS COVERED We discuss the prevention of development and growth of varices, the primary and secondary prophylaxis of bleeding, the treatment of acute bleeding, and the management of gastric varices. We systematically reviewed studies, without time limits, identified through Medline and searches of reference lists, and provide an overview of the evidence underlying the -treatment options in the management of varices in cirrhosis. EXPERT OPINION The management of variceal hemorrhage relies on nonspecific interventions (e.g., adequate fluid resuscitation, airway protection) and on specific interventions. These are routine prophylactic antibiotics, vasoactive drugs and endoscopic treatment. Procedures such as the placement of a Sengstaken-Blakemore tube or a transjugular intrahepatic portosystemic shunt (TIPS) can be lifesaving. The primary and secondary prophylaxis of bleeding is based on nonselective beta-blockers and endoscopy, even though TIPS or, less frequently, surgery have a role in selected cases.
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Affiliation(s)
- Ulrich Thalheimer
- The Royal Free Sheila Sherlock Liver Centre, University Department of Surgery, Royal Free Hospital, Pond Street, NW3 2QG, London, UK.
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175
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Abstract
Although the incidence of bleeding from gastric varices is relatively low (10%-36%), the bleeding is massive once it has occurred and it increases the patient's mortality. The management of esophageal variceal bleeding is highly differentiated with several effective treatments available. In contrast, bleeding from gastric varices continues to be a therapeutic challenge. In the last decade, there have been increasing reports regarding the management of gastric varices. In this article we review recent progress in the management of gastric varices and discuss further expected studies.
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Affiliation(s)
- Makoto Hashizume
- Department of Advanced Medical Initiatives, Kyushu University, Fukuoka, Japan.
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176
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Rajoriya N, Forrest EH, Gray J, Stuart RC, Carter RC, McKay CJ, Gaya DR, Morris AJ, Stanley AJ. Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding. QJM 2011; 104:41-7. [PMID: 20871126 DOI: 10.1093/qjmed/hcq161] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Variceal bleeding is an acute medical emergency with high mortality. Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding is more severe and more difficult to control. The optimal therapy for gastric variceal bleeding remains unclear although endoscopic injection of N-Butyl-2-Cyanoacrylate (Histoacryl) glue is often used. However, its long-term efficacy is poorly described. We studied the immediate and long-term effects of Histoacryl glue injection as treatment for bleeding gastric varices in a large UK hospital. METHOD Endoscopy records and case notes were used to identify patients receiving Histoacryl injection for gastric variceal bleeding over a 4-year period. RESULTS Thirty-one patients received Histoacryl for gastric variceal bleeding. Seventy-four per cent patients had alcohol-related liver disease and 61% of cirrhotics were Childs Pugh grade B or C. Fifty-eight per cent were actively bleeding during the procedure with 100% haemostasis rates achieved. Two patients developed pyrexia within 24 h of injection settling with antibiotics. No other complications were encountered. Mean overall follow-up was 35 months, with mean follow-up of survivors 57 months. Forty-eight per cent patients had endoscopic ultrasound assessment of varices during follow-up with no effect on rebleeding rates. Thirteen per cent required subsequent transjugular intrahepatic portosystemic shunt placement. Gastric variceal rebleeding rate was 10% at 1 year and 16% in total. One- and two-year mortality was 23% and 35%, respectively. CONCLUSION Endoscopic injection of Histoacryl glue appears to be a safe and effective treatment for gastric variceal bleeding. Further data are required to compare it with other therapies in this situation.
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Affiliation(s)
- N Rajoriya
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4OSF, UK
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Min SK, Kim SG, Kim YS, Bae JY, Lee JC, Lee SH, Kim HS, Jeong SW, Jang JY, Moon JH, Lee MS, Kim BS. Comparison among Endoscopic Variceal Obliteration, Endoscopic Band Ligation, and Balloon-occluded Retrograde Transvenous Obliteration for Treatment of Gastric Variceal Bleeding. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:302-8. [DOI: 10.4166/kjg.2011.57.5.302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Seul Ki Min
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jun Yong Bae
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jong Chan Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Sae Hwan Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Hong Soo Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Moon Sung Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Boo Sung Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
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178
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Lo GH. Is cyanoacrylate therapy really better than transjugular intrahepatic portosystemic shunt for preventing gastric variceal rebleeding? Gastrointest Endosc 2010; 72:1111-2. [PMID: 21034910 DOI: 10.1016/j.gie.2010.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/04/2010] [Indexed: 02/08/2023]
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179
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Kurt M, Akdogan M, Sayilir A, Kuran S, Ozderin YO, Arhan M, Onal IK, Kekilli M, Beyazit Y, Hayran M. Effect of endoscopic injection therapy with combined cyanoacrylate and lipiodol for bleeding gastric varices: A single center experience. J Dig Dis 2010; 11:284-90. [PMID: 20883424 DOI: 10.1111/j.1751-2980.2010.00451.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the endoscopic injection therapy with combined cyanoacrylate and lipiodol for bleeding gastric fundal varices. METHODS The medical records of cirrhotic and non-cirrhotic patients who underwent at least one episode of endoscopic application of N-butyl-2-cyanoacrylate-lipiodol mixture for gastric varices at our gastroenterology clinic between October 2004 and January 2010 were reviewed. The technique comprised the dilution of 0.5 mL of cyanoacrylate with 0.5 mL of lipiodol and repeating intravariceal injections of 1.0 mL each until hemostasis was achieved. RESULTS A total of 66 patients (41 male and 25 female) with gastric varices underwent 86 endoscopic injections of cyanoacrylate for hemostasis. Overall 38 patients (57.6%) had active bleeding during the endoscopic procedure, while the remaining 28 (42.4%) underwent cyanoacrylate under elective conditions. In one patient (1.5%) hemostasis could not be achieved, prompting referral for emergency surgery. The median number of sessions was one (range 1-3). Eleven patients (16.6%) rebled during a median follow-up period of 6.02 months (0.1-62.4 months). There was no bleeding-related death. One patient developed splenic infarction a day after N-butyl-2-cyanoacrylate injection. CONCLUSION Endoscopic injection therapy combining cyanoacrylate and lipiodol is effective for bleeding gastric fundal varices.
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Affiliation(s)
- Mevlut Kurt
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Hacettepe University, Ankara, Turkey.
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180
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Kumar A, Singh S, Madan K, Garg PK, Acharya SK. Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding. Gastrointest Endosc 2010; 72:721-7. [PMID: 20883849 DOI: 10.1016/j.gie.2010.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 06/03/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. N-butyl cyanoacrylate (NBC), mixed with lipiodol, has been shown to be effective in controlling bleeding, but is associated with the risk of distal embolization. OBJECTIVE To study the efficacy and safety of undiluted NBC in the management of gastric varices (GV). DESIGN Prospective cohort study. SETTING Single tertiary care center. PATIENTS 170 consecutive patients with GV. INTERVENTION Standardized technique of undiluted NBC injection for management of GV. MAIN OUTCOME MEASUREMENTS Achievement of initial hemostasis, rate of rebleeding, procedure-related complications, and mortality. RESULTS GV were identified in 170 patients, 87 of whom were treated with 261 injections of undiluted NBC. Among 46 patients with active bleeding of GV, initial hemostasis was achieved in 84.8%. Rebleeding was seen in 23.4% patients over a mean follow-up of 16 months. No case of clinical distal embolization was seen. Large GV size, fundal location, and large esophageal variceal size were predictive of GV bleed. The mortality was 8.8% for all patients with GV; 10.3% for patients with GV treated with NBC, and 7.2% for those with GV not treated with NBC. Child-Pugh status was the only predictor of mortality. LIMITATION Only 1 intervention group. CONCLUSION Undiluted NBC is safe and effective in the management of gastric variceal bleeding.
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Affiliation(s)
- Ajay Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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181
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Huang Q, Wu X, Fan X, Cao J, Han J, Xu L, Li N. Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene-covered stent versus bare stent in transjugular intrahepatic portosystemic shunt. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:353-360. [PMID: 20533444 DOI: 10.1002/jcu.20709] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow-up of ePTFE-covered stents. METHODS Sixty consecutive patients were randomized for bare or covered transjugular TIPS stenting in our institution between April 2007 and April 2009. Data of follow-up Doppler US, angiography, and portosystemic pressure gradient measurements were collected and analyzed. RESULTS The follow-up period was 8.34 + or - 4.42 months in the bare-stent group and 6.16 + or - 3.89 months in the covered-stent group. Baseline clinical characteristics were similar in both groups. Two hundred three US studies were performed in 60 patients, with a mean of 3.4 per patient, and demonstrated abnormalities in 28 patients (21 bare stents, 7 ePTFE-covered stents), 19 of them (13 in bare-stent group, 6 in covered-stent group) showing no clinical evidence of recurrence. Ten of 13 patients in the bare-stent group underwent balloon angioplasty or additional stent placement, whereas only one of six patients in the covered-stent group needed reintervention for intimal hyperplasia. The average peak velocity in the midshunt of ePTFE-covered stent was 139 + or - 26 cm/s after TIPS creation and 125 + or - 20 cm/s during follow-up, which was significantly higher than the bare-stent group (p < 0.05). The main portal vein and hepatic artery showed higher flow velocities in the ePTFE-covered stent group than in the bare-stent group. ePTFE-covered stents maintained lower portosystemic pressure gradient than bare stents (9.5 + or - 2.9 versus 13.2 + or - 1.5 mmHg, p < 0.05). CONCLUSIONS ePTFE-covered stents resulted in higher patency rates and better hemodynamics than bare stents. Routine US surveillance may not be necessary in patients with ePTFE-covered TIPS stent.
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Affiliation(s)
- Qian Huang
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
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182
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Chang CJ, Hou MC, Lin HC, Lee HS, Liao WC, Su CW, Lee SD. The safety and probable therapeutic effect of routine use of antibiotics and simultaneously treating bleeding gastric varices by using endoscopic cyanoacrylate injection and concomitant esophageal varices with banding ligation: a pilot study. Gastrointest Endosc 2010; 71:1141-9. [PMID: 20362285 DOI: 10.1016/j.gie.2009.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 12/03/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroesophageal varices are the most common type of gastric varices. Although endoscopic injection of N-butyl-2-cyanoacrylate is the current treatment of choice for acute gastric variceal bleeding, whether the concomitant esophageal varices should be ligated simultaneously with the first treatment session is currently not known. OBJECTIVE The aim of this study was to evaluate the safety and probable therapeutic effect of simultaneous cyanoacrylate injection for bleeding gastric varices obliteration (GVO) and endoscopic band ligation (EBL) for concomitant esophageal varices in combination with routine antibiotics (simultaneous group), and to compare our results with historical results in which the patients underwent GVO first and then EBL for concomitant esophageal varices (separate group). DESIGN A single-center pilot study. SETTING A tertiary referral center. PATIENTS Patients with liver cirrhosis and gastroesophageal varices, who presented with acute gastric varices bleeding. INTERVENTIONS Simultaneous treatment in the form of GVO and EBL for concomitant esophageal varices in combination with routine antibiotics. MAIN OUTCOME MEASUREMENT Rebleeding and mortality within the first year of index bleeding. RESULTS Twenty patients in the simultaneous group and 67 patients in the separate group were included in the study. The 2 groups had similar baseline characteristics. The hemostasis of active bleeding was 100% in both groups (7/7 vs 20/20). The 1-year rebleeding rate was 10% (2/20) in the simultaneous group and 37.31% (25/67) in the separate group (P = .041). Kaplan-Meier analysis showed higher probability of remaining free of rebleeding in the simultaneous group (88.5% vs 61.1%; P = .044). Multivariate analysis indicated that treatment method (separate group) and high model for end-stage liver disease score (> or = 13) were independent risk factors of rebleeding in 1 year. The treatment failure, complications, 1-year mortality, and survival were similar in both groups. CONCLUSION Simultaneous endoscopic treatment for gastric varices bleeding and concomitant esophageal varices is a safe and effective procedure in combination with antibiotic prophylaxis for patients with cirrhosis. The 1-year mortality rate was similar between the 2 groups. The results need further validation.
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Affiliation(s)
- Chen-Jung Chang
- Current affiliations: National Yang-Ming University School of Medicine and Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan 11217
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183
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Abstract
Acute esophageal variceal hemorrhage (AEVH) is a severe complication of portal hypertension. Its management has rapidly evolved in recent years. Traditional methods included vasoconstrictor and balloon tamponade. Vasoconstrictors were shown to control approximately 80% of the bleeding episodes and are generally used as a first-line therapy. Following the use of vasoconstrictors, endoscopic therapy is often used to arrest the bleeding varices and prevent early rebleeding. A meta-analysis showed that the combination of vasoconstrictor and endoscopic therapy is superior to endoscopic therapy alone for controlling AEVH. Balloon tamponade may be used to achieve temporary control of the hemorrhage in case of severe bleeding. A transjugular intrahepatic portosystemic stent shunt may be needed in patients with refractory acute variceal hemorrhage. Surgical intervention is now widely contraindicated during acute variceal hemorrhage, except for patients with good liver reserve. Conversely, apart from the control of acute variceal hemorrhage, prophylactic antibiotics were shown to be helpful in the prevention of bacterial infection and to prevent early variceal rebleeding. With the introduction of new treatment modalities and the measures taken to manage patients with AEVH, the mortality due to AEVH has significantly decreased in recent years.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education, Digestive Center, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
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184
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Abstract
Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, Institute of Liver and Biliary Sciences, New Delhi, India.
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185
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Kochar R, Dupont AW. Primary and secondary prophylaxis of gastric variceal bleeding. F1000 MEDICINE REPORTS 2010; 2. [PMID: 20948859 PMCID: PMC2948400 DOI: 10.3410/m2-26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastric variceal bleeding is a common problem in patients with cirrhosis and is associated with increased morbidity and mortality. Management is complex and includes pharmacotherapy, endoscopic therapy, and shunt placement. Recent studies indicate that endoscopic therapy with tissue adhesives has similar hemostasis rates and outcomes in terms of mortality as shunt placement but has a lower complication rate and therefore could be considered the first line therapy for acute bleeding and secondary prophylaxis of gastric varices.
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Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology, Hepatology & Nutrition, The University of Texas Health Science Center at Houston 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
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186
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Gastrointestinal bleeding: Endoscopic cyanoacrylate therapy for gastric variceal bleeding. Nat Rev Gastroenterol Hepatol 2010; 7:190-1. [PMID: 20376092 DOI: 10.1038/nrgastro.2010.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bleeding from gastric varices is relatively common and can be life threatening. The optimal treatment strategy for gastric variceal hemorrhage is controversial. Both interventional radiology and endoscopic therapies require a high level of clinical expertise. Which type of therapy is best? A recent study compared endoscopic cyanoacrylate glue injection with the insertion of a transjuglar intrahepatic portosystemic shunt.
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187
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
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188
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Tripathi D. Therapies for bleeding gastric varices: is the fog starting to clear? Gastrointest Endosc 2009; 70:888-91. [PMID: 19879402 DOI: 10.1016/j.gie.2009.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 06/06/2009] [Indexed: 02/08/2023]
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189
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A noninvasive imaging technique to evaluate therapeutic efficacy after injection of n-butyl-2- cyanoacrylate tissue adhesive into gastric varices: a case report. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:412-4. [PMID: 19543570 DOI: 10.1155/2009/182082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A novel use of multidetector computed tomographic intravenous (MDCT IV) portography in the evaluation of gastric varices treated with tissue adhesive is described. A 55-year-old man presented with upper gastrointestinal hemorrhage as a result of bleeding gastric varices. The patient was stabilized and the gastric varices were treated with n-butyl-2-cyanoacrylate (two injections, total 7.5 mL). MDCT IV portography performed after injection revealed thrombosis of all but one of the submucosally based gastric varices. The endoscopist who performed repeat endoscopy three weeks later was then able to direct therapy at the remaining patent submucosally based gastric varix. This represents the first reported use of MDCT IV portography in the evaluation of treatment adequacy in a patient with gastric varices treated with n-butyl-2-cyanoacrylate.
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190
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Could we standardize the injection technique and regimen of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices? Gastrointest Endosc 2009; 70:192-3; author reply 193. [PMID: 19559845 DOI: 10.1016/j.gie.2008.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 10/18/2008] [Indexed: 02/08/2023]
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191
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Abstract
PURPOSE OF REVIEW Portal hypertension is the most common complication of cirrhosis accounting for significant morbidity and mortality mainly because of variceal hemorrhage, ascites, bacterial infections, hepatic encephalopathy, and hepatorenal syndrome. Advances in the diagnosis and management of portal hypertension over the last year are reviewed. RECENT FINDINGS The measurement of the hepatic venous pressure gradient provides important prognostic information in patients with portal hypertension. Noninvasive testing with transient elastography, capsule endoscopy, and computed tomography scanning for the diagnosis of esophageal varices is promising but more information is needed. Easily obtainable clinical data have been identified in patients with acute variceal bleeding that provides important information in determining initial response to therapy and prognosis. New therapies for patients with dilutional hyponatremia with vasopressin antagonists are promising and may improve the management of this condition. Terlipressin is the best medical therapy currently available for the management of hepatorenal syndrome as confirmed in recent studies. Patients with advanced liver disease benefit from the long-term administration of norfloxacin as it prevents the development of hepatorenal syndrome and improves survival. SUMMARY The ongoing advances in the diagnosis and management of patients with cirrhosis and portal hypertension will improve the high morbidity and mortality of the complications of cirrhosis
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192
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Hong CH, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim BI, Hong HP, Shin JH. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2009; 24:372-8. [PMID: 19032446 DOI: 10.1111/j.1440-1746.2008.05651.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Our study aimed to evaluate the therapeutic results of endoscopic N-butyl-2-cyanoacrylate injection (EBC) and balloon-occluded retrograde transvenous obliteration (BRTO) in patients with gastric variceal hemorrhage (GVH) and/or high-risk gastric varices (GV). METHODS Twenty-seven patients with GVH and/or high-risk GV (>or= 5 mm in diameter, those with red spots, and a Child-Pugh grading of B or C liver cirrhosis) who were treated with either EBC or BRTO from April 2005 to December 2007 were included in our study. RESULTS EBC or BRTO was initially used for the treatment of GVH in 14 and 13 patients, respectively. Technical success was achieved in all 14 patients (100%) initially treated with EBC, and 10 of 13 patients (76.9%) initially treated with BRTO. Significant rebleeding occurred in 10 patients (71.4%) of the EBC group, and two patients (15.4%) of BRTO group (P < 0.01). Five of six patients (83.3%) treated with rescue BRTO due to rebleeding after initial EBC achieved technical success, and all six patients who were treated with rescue BRTO had no rebleeding during the median follow up of 17 (range: 2-37) months. The cumulative survival rate of the EBC with the BRTO rescue group/BRTO group was significantly higher than the EBC group. CONCLUSION The therapeutic efficacies of EBC and BRTO for the treatment of active GVH and/or high-risk GV appeared to be similar. However, EBC might be associated with a higher rebleeding rate than BRTO. BRTO could be an effective rescue treatment for patients with GVH after initial treatment of EBC.
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Affiliation(s)
- Cheul Ho Hong
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
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193
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Endoscopic management of gastric varices: efficacy and outcomes of gluing with N-butyl-2-cyanoacrylate in a North American patient population. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 22:931-6. [PMID: 19018339 DOI: 10.1155/2008/389517] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America. AIM To assess the safety and efficacy of gastric variceal glue injection in a North American population. METHODS Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed. RESULTS Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%. CONCLUSIONS The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.
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194
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Marion-Audibert AM, Schoeffler M, Wallet F, Duperret S, Mabrut JY, Bancel B, Pere-Verge D, Wander L, Souquet JC. Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices. ACTA ACUST UNITED AC 2008; 32:926-30. [DOI: 10.1016/j.gcb.2008.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 07/26/2008] [Accepted: 07/28/2008] [Indexed: 12/13/2022]
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195
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Endoscopic therapy for bleeding gastric varices: to clot or glue? Gastrointest Endosc 2008; 68:883-6. [PMID: 18984100 DOI: 10.1016/j.gie.2008.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Accepted: 04/28/2008] [Indexed: 02/06/2023]
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196
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Seewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, Seitz U, Zhong Y, Thonke F, Soehendra N. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 2008; 68:447-54. [PMID: 18760173 DOI: 10.1016/j.gie.2008.02.050] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 02/11/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported. OBJECTIVE Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen. DESIGN Retrospective. SETTING Two tertiary referral centers. PATIENTS A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen. INTERVENTIONS (1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration. MAIN OUTCOME MEASUREMENTS Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate. RESULTS Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively. CONCLUSION Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.
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Affiliation(s)
- Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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197
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Zehetner J, Shamiyeh A, Wayand W, Hubmann R. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22:2149-52. [PMID: 18622540 DOI: 10.1007/s00464-008-0009-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2008] [Revised: 05/05/2008] [Accepted: 05/30/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute bleeding from nontreated esophageal varices is associated with a mortality rate of 30% to 50%. Various pharmacologic and interventional methods to stop acute bleeding are available. However, for 10% to 20% of patients, therapy fails to stop the bleeding. This study aimed to assess the SX-ELLA Stent Danis Set (which has a self-expanding metal stent) instead of a balloon probe for compression of esophageal varices. METHODS Using a multidisciplinary approach, a self-expanding stent was placed in 39 patients between January 2003 and August 2007. For 34 of these patients with ongoing bleeding from esophageal varices, stent implantation was performed with the SX-ELLA Stent Danis Set, and the patients were included in this study. For all these patients, common methods failed to stop hemorrhage. With the SX-ELLA Stent Danis Set, the stent was implanted with a positioning balloon that enabled delivery without X-ray control. After implantation of the stent, its position was controlled by endoscopy and computed tomography (CT) scan. RESULTS For all 34 patients, the implantation of the esophageal stent succeeded in stopping ongoing bleeding. No stent-related complications occurred during or after stent implantation. No bleeding recurrence was observed during the stent implantation (median time, 5 days; range 1-14 days). For all the patients, the stent could be extracted by endoscopy without any complications using an extractor. Nine patients died of hepatic failure within 30 days after the procedure. No rebleeding occurred. CONCLUSIONS The use of a self-expanding stent to stop acute bleeding from esophageal varices is a new therapeutic method. The authors' initial experience, which involved no method-related mortality or complications, is encouraging. More data are necessary to confirm their results.
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Affiliation(s)
- J Zehetner
- Surgical Department, Academic Teaching Hospital, AKH Linz, Ludwig Boltzmann Institute for Operative Laparoscopy, Krankenhausstrasse 9, 4020 Linz, Austria.
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198
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Abstract
Chronic liver failure is an important cause of morbidity and mortality and is the long-term consequence of many chronic liver diseases. In addition to determining the specific cause of the chronic liver disease, which may be amenable to targeted therapy, it is important to treat the sequelae of chronic liver failure effectively to improve quality of life, to prolong survival, and to provide a bridge to liver transplantation. Once a patient who has chronic liver failure develops hepatic decompensation, liver transplantation is the definitive treatment for those who qualify. Management of chronic liver failure is the focus of this article.
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Affiliation(s)
- Gaurav Arora
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room M211, Stanford, CA 94305-5187, USA
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199
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Bosch J, Berzigotti A, Garcia-Pagan JC, Abraldes JG. The management of portal hypertension: rational basis, available treatments and future options. J Hepatol 2008; 48 Suppl 1:S68-92. [PMID: 18304681 DOI: 10.1016/j.jhep.2008.01.021] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal bleeding is the last step in a chain of events initiated by an increase in portal pressure, followed by the development and progressive dilation of varices until these finally rupture and bleed. This sequence of events might be prevented - and reversed - by achieving a sufficient decrease in portal pressure. A different approach is the use of local endoscopic treatments at the varices. This article reviews the rationale for the management of patients with cirrhosis and portal hypertension, the current recommendations for the prevention and treatment of variceal bleeding, and outlines the unsolved issues and the perspectives for the future opened by new research developments.
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Hospital Clínic, C.Villarroel 170, 08036 Barcelona, Spain.
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200
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Berzigotti A, García-Pagán JC. Prevention of recurrent variceal bleeding. Dig Liver Dis 2008; 40:337-42. [PMID: 18291735 DOI: 10.1016/j.dld.2007.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 12/11/2022]
Abstract
Patients surviving a first episode of variceal bleeding have a risk of over 60% of experiencing recurrent haemorrhages within 1 year from the index episode. Because of this, all patients surviving a variceal bleeding should receive active treatments for the prevention of rebleeding. beta-Blockers+/-isosorbide-5-mononitrate and band ligation are effective in preventing recurrent bleeding and both can be used. Combination of beta-blockers+/-isosorbide-5-mononitrate and band ligation may be the best treatment to prevent rebleeding but more studies are needed to confirm this issue. In patients with recurrent variceal bleeding despite appropriate medical and endoscopic treatment, transjugular intrahepatic porto-systemic shunt is highly effective in controlling bleeding. The efficacy is not significantly different from that of shunt surgery (distal splenorenal shunt or 8mm H-graft shunt), especially since the introduction of polytetrafluoroethylene-covered stents. Therefore, in this situation, transjugular intrahepatic porto-systemic shunt using polytetrafluoroethylene stents should be the treatment of choice.
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Affiliation(s)
- A Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, IMD, Hospital Clinic, IDIBAPS and Ciberehd, University of Barcelona, C. Villarroel 170, 08036 Barcelona, Spain
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