Endoscopic management of bleeding gastric varices--an updated overview

Comparison of the management of gastric variceal bleeding techniques

Background and Aim

Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding.

Methods

We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage.

Results

Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone.

Conclusion

EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.

Balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic cyanoacrylate injection for treating gastric varices draining through gastrorenal shunts

BACKGROUND AND STUDY AIMS

Balloon-occluded retrograde transvenous obliteration-assisted endoscopic cyanoacrylate injection (E-BRTO) temporarily treats gastric fundic varices draining through gastrorenal shunts (GRS) occluding the GRS with a balloon, then endoscopically injecting cyanoacrylate. We retrospectively examined the safety, feasibility, and efficacy of E-BRTO.

PATIENTS AND METHODS

We enrolled 85 patients with hepatic cirrhosis plus gastric fundic varices with GRS; 34 underwent E-BRTO. The 51 patients who refused all secondary prophylactic treatments served as controls.

RESULTS

Finally, 33 of the 34 patients underwent successful E-BRTO without major adverse events. Gastric varices were eradicated from all 33 patients in the E-BRTO group; the average follow-up time was 161.0 (74.0) weeks (mean [SD]). Four end-point events (12%) were recorded during the follow-up period. In the control group, 33 patients (65%) suffered repeat variceal bleeding, resulting in seven deaths. The cumulative rebleeding rates of the E-BRTO group on the 6th, 24th, 48th, 96th, 144th, 192nd, 240th, and 288th week were 0%, 3%, 9%, 9%, 13%, 13%, 13%, and 13%, while the cumulative rebleeding rates of the control group in the same period were 10%, 20%, 35%, 46%, 55%, 65%, 76%, and 76%.

CONCLUSIONS

E-BRTO was safe, feasible, and well tolerated by patients with hepatic cirrhosis plus gastric fundic varices with GRS. Over the long-term follow-up period, the E-BRTO group demonstrated a lower rate of repeat bleeding than the control group.

Gastric varices

PURPOSE OF REVIEW

Gastric varices are a rare cause of gastrointestinal bleeding in patients with portal hypertension. There have been significantly advances within endoscopic ultrasound for treatment of gastric varices over the past 5 years in addition to the conventional endoscopic and endovascular therapies. In this review, we will review the latest literature on gastric varices with emphasis on changes to the conventional classification systems and comparisons among the different treatment options for gastric varices in terms of efficacy and safety.

RECENT FINDINGS

There have been new guidelines proposed by the American Gastrointestinal Association on a simpler classification system compared to the conventional Sarin classification. In addition, endoscopic ultrasound guided coil embolization, a novel treatment pioneered over the past 5 years for gastric varices, has shown increased efficacy and reduced adverse event profile compared to cyanoacrylate glue, the more traditional therapy for gastric variceal bleeding. Options for endovascular therapy overall have not significantly changed over the recent years.

SUMMARY

Based on our literature review, we recommend a step-up approach with initial medical and endoscopic management with consideration of endovascular therapies when initial therapies fail.

Synchronous hybrid procedure combining interventional radiology and endoscopy for esophagogastric varices with large gastro-renal shunt

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.

Risk stratification for secondary prophylaxis of gastric varices due to portal hypertension

BACKGROUND

Gastroesophageal variceal hemorrhage is a common complication associated with portal hypertension. Current guidelines provide well-established recommendations for esophageal varices, while that of gastric varices remain scarce and lack evidential strength. The aim of the study is to identify a feasible risk stratification method based on imaging findings to evaluate patient response to cyanoacrylate injection for the treatment of gastric varices.

METHODS

A prospective cohort study including patients diagnosed with gastric varices admitted for initial secondary prophylactic treatment for GV was conducted. Routine endoscopic examination and endoscopic ultrasound (EUS) were performed on all subjects to evaluate extraluminal collaterals. All patients with gastric varices were treated uniformly with cyanoacrylate injection. Patients were prospectively followed for at least 12 months and any occurrence of variceal rebleed was recorded.

RESULTS

102 subjects were enrolled in the study, 66.7% had GOV Type 2, 27.5% had GOV Type 1 and 5.9% had IGV Type 1. During the 12 months follow-up, 33.3% patients experienced variceal rebleed. A risk assessment scoring system was proposed based on endoscopic and EUS findings. A Cox regression analysis demonstrated a significant association between the merited risk score and incidence of variceal rebleed (P < 0.001).

CONCLUSIONS

Presence of red wales sign, size of varix, and presence of para-gastric vein were all independent risk factors for variceal rebleed after endoscopic therapy for the treatment of gastric varices. Early identification of this subgroup, especially those with higher risk scores, necessitates a change in course of treatment, which can improve prognosis and overall patient outcome.

Esophageal Hemorrhagic Syndromes

Esophageal  bleeding is  one of  the most  common medical emergencies. It takes  the  3rd place among  all digestive hemorrhages, and accounts for 14–16 % among all gastrointestinal bleeding. The most common cause of esophageal hemorrhages is Mallory – Weiss esophageal tear (10–12 %), less often – varicose veins of the esophagus in portal hypertension syndrome (up to 4 %) and, in some cases, is esophagitis of various etiologies (up to 1.6 %). The problem of  esophageal  bleeding  is  characterized  by  high  incidence,  high  mortality  rate  due  to  constant  increase  of  portal hyper tension cases, recurrences, difficulties in diagnosis, anatomical and physiological features of the esophagus, low efficiency of the main methods of hemostasis. There are various surgical and conservative methods of hemostasis, which show a variety of opinions in the solution to the problem of stopping esophageal bleeding. In Mallory – Weiss syndrome, endoscopic hemostasis is considered to be the preferred method of treatment. Management of portal hypertension is the most difficult task; a wide range of operations is used from the minimally invasive operations to the liver transplantation, as well as endoscopic hemostasis (ligation, sclerotherapy). In esophageal bleeding, due to reflux esophagitis, mainly conservative treatment is suggested, operations are performed with recurrences or complications. Each kind of esophageal hemorrhage is considered as a separate problem.

Balloon-occluded Retrograde Transvenous Obliteration of Portovenous Shunts During Endoscopic Therapy for the Treatment of Gastric Varices

INTRODUCTION

To explore the safety and feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) of portovenous shunts during endoscopic cyanoacrylate injection for the treatment gastric varices (E-BRTO) secondary to portal hypertension.

PATIENTS AND METHODS

A total of 28 cirrhotic patients with gastroesophageal varices and concurrent gastrorenal or gastrosplenorenal shunt, treated with E-BRTO, were enrolled. Operative details were recorded to evaluate the safety, feasibility, and efficacy of the procedure. Short-term follow-up was conducted to denote any incidence of distant emboli, variceal rebleeding, or mortality (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A179).

RESULTS

All the patients successfully received E-BRTO without intraoperative complications. The average volume of cyanoacrylate was 2.4±1.3 mL. During the 90 days follow-up, none of the patients experienced distant systemic emboli. However, 8 patients suffered from gastrointestinal rebleeding, including one death, while 2 patients were lost to follow-up. The short-term rebleeding rate (intention to treat) was about 36% in E-BRTO for this subset of patients.

CONCLUSIONS

BRTO during endoscopic cyanoacrylate injection is an alternative selection for cirrhotic patients with portovenous shunts. The procedure is feasible and procedurally safe, but the associated high rebleeding rate may require a multimodality approach.

Patient Response to Endoscopic Therapy for Gastroesophageal Varices Based on Endoscopic Ultrasound Findings

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.

The Efficacy and the Safety of Prophylactic N-Butyl-2-Cyanoacrylate Injection for Gastric Varices Using a Modified Injection Technique

BACKGROUND

Primary prophylactic N-butyl-2-cyanoacrylate (NBC) injection for nonbleeding gastric varices (GVs) remains controversial. In addition, there is still no consensus concerning the technique, its safety, and long-term results.

AIM

To analyze the safety and the efficacy of NBC for primary prophylaxis of GVs using a modified injection technique.

METHODS

Between February 2004 and June 2014, a total of 72 patients with GVs with a high risk of bleeding, who received undiluted NBC injection using a modified "sandwich" method for primary prophylaxis in General Hospital of Chengdu Military Command, were enrolled in this retrospective study. All patients were followed up at 1 to 2 weeks, 3 months, 6 months, and thereafter every 6 months or whenever required, using endoscope detection. The rate of obliteration, bleeding, recurrence, and complications was evaluated.

RESULTS

According to the standard Sarin classification, 28 patients were IGV1 and 44 patients were GEV2. Hepatitis B virus infection was the major cause of portal hypertension. The mean number of sessions were 1.4 (1 to 3) and the mean volume of NBC per session was 3.5 mL (1 to 6 mL). One injection per session was used in 41 patients (56.9%) and 2 or more injections were used in the remaining 31 patients (43.1%). During the follow-up (27 mo; range, 12 to 67 mo), complete obliteration of GVs was achieved in 93.1% of the patients (67/72). One session of NBC injection was enough to obliterate GVs in 49 patients (68.1%), and 2 or more sessions were needed in 23 patients (31.9%). In addition, the bleeding and the recurrence rate were 11.1% (8/72) and 15.3% (11/72), respectively, during the follow-up. The cumulative bleeding-free rate at 1, 3, and 5 years was 95.8%, 91.7%, and 88.9%, respectively. Worsening of esophageal varices was observed in 13 patients (9 in GEV2 and 4 in IGV1). No serious complications, such as distal embolism, were observed in all patients.

CONCLUSIONS

Prophylactic endoscopic NBC injection using a modified injection technique may be a safe and effective treatment for gastric fundal varices with a high risk of bleeding.

A Comprehensive Review of Portosystemic Collaterals in Cirrhosis: Historical Aspects, Anatomy, and Classifications

Portosystemic collateral formation in cirrhosis plays an important part in events that define the natural history in affected patients. A detailed understanding of collateral anatomy and hemodynamics in cirrhotics is essential to envisage diagnosis, management, and outcomes of portal hypertension. In this review, we provide detailed insights into the historical, anatomical, and hemodynamic aspects to portal hypertension and collateral pathways in cirrhosis with emphasis on the various classification systems.

Selective precision endoscopic treatment of gastroesophageal varices

AIM: To evaluate the therapeutics effects of precision endoscopic treatment of gastroesophageal varices and observe the disappearance of blood vessels and side effects.

METHODS: One hundred and four patients with esophagogastric variceal bleeding who underwent precision endoscopic treatment were divided into three treatment groups: treatment above the cardia (n = 68), below the cardia (n = 15) and the combination of both (n = 21). The total effective rate, rate of improvement, rate of significant improvement, rebleeding rate and rate of complications were compared among the three groups.

RESULTS: The total effective rates, improvement rates and significant improve rates were 63.2%, 23.5% and 39.7%, respectively, for the group treated above the cardia; the corresponding percentages were 80.0%, 20.0% and 60.0% for the group treated below the cardia, and 90.5%, 28.6% and 61.9% for the combination group. There were significant differences in the total effective rate (χ² = 6.444, P = 0.039) as well as the improvment rate and significant improvement rate (χ² = 6.235, P = 0.044). The rebleeding rates at 2 wk and 3 mo after treatment were 11.8% and 19.1% for the group treated above the cardia, 6.7% and 13.3% for that below the cardia, and 9.5% and 14.3% for the combination group. There were no statistical differences in the rebleeding rates among the three groups (P > 0.05). No serious complications occurred in all the three groups. The incidence rates of complications in the three groups were 30.9%, 33.3% and 38.1%, respectively, and there was no statistical difference among them (P > 0.05).

CONCLUSION: The combination group had the best curative effect.

BRTO assisted endoscopic Histoacryl injection in treating gastric varices with gastrorenal shunt

AIMS

We evaluated the feasibility, efficacy and safety of a novel technique of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic Histoacryl (N-buthyl-2-cyanoacrylate) injection.

MATERIAL AND METHODS

A total with 11 patients were enrolled and analyzed in this single center, open-label, prospective study. Patients with high-risk gastric varices (defined as fundal varices, large GV (>5 mm), presence of a red spot, and Child-Pugh score C) and concurrent gastrorenal shunt underwent endoscopic Histoacryl injection while the gastrorenal shunt was temporarily occluded with an occlusion balloon. Feasibility, hemostatic effect, intra- and postoperative complications, and varices recurrence were evaluated.

RESULTS

All procedures were successfully done per protocol. Except for one patient who underwent rescue Histoacryl injection due to residual varices, single therapy was sufficient to eliminate gastric varices in ten patients. Intra-operative hemorrhage occurred in one case and was stopped after additional Histoacryl injection. One patient was confirmed to have treatment-related fungemia. No death or major complications occurred, including ectopic embolism, worsening of hepatic and renal function, etc. No recurrence of the varices was found during a median follow-up time (mean ± SD) of 228 ± 153 days.

CONCLUSIONS

BRTO assisted endoscopic Histoacryl injection is effective and safe for patients with high-risk gastric varices and concurrent gastrorenal shunt.

Gastrointestinal endoscopy in the cirrhotic patient

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.