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Dragomir I, Pojoga C, Hagiu C, Seicean R, Procopet B, Seicean A. Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy. Gastroenterol Rep (Oxf) 2024; 12:goae082. [PMID: 39281269 PMCID: PMC11398876 DOI: 10.1093/gastro/goae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/23/2024] [Accepted: 06/07/2024] [Indexed: 09/18/2024] Open
Abstract
Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.
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Affiliation(s)
- Irina Dragomir
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj Napoca, Romania
| | - Cristina Pojoga
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj Napoca, Romania
- UBB Med, Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj Napoca, Romania
| | - Claudia Hagiu
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj Napoca, Romania
| | - Radu Seicean
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj Napoca, Romania
- First Surgical Clinic, County Emergency Hospital, Cluj Napoca, Romania
| | - Bogdan Procopet
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj Napoca, Romania
| | - Andrada Seicean
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj Napoca, Romania
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Zhang HY, He CC, Zhong DF. Endoscopic ultrasound-guided treatment of isolated gastric varices entwined with arteries: A case report. World J Gastrointest Endosc 2024; 16:489-493. [PMID: 39156000 PMCID: PMC11325873 DOI: 10.4253/wjge.v16.i8.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/30/2024] [Accepted: 07/05/2024] [Indexed: 08/01/2024] Open
Abstract
BACKGROUND Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices (IGVs) owing to its precise visualization. CASE SUMMARY A 39-year-old man was diagnosed with a large IGV during a routine physical examination. Endoscopic ultrasonography showed gastric varices entwined with an artery, which greatly increased the difficulty of treatment. We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection. CONCLUSION Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.
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Affiliation(s)
- Hong-Ying Zhang
- Department of Gastroenterology, Jinhua People's Hospital, Jinhua 321000, Zhejiang Province, China
| | - Chen-Cong He
- Department of General Medicine, Jinhua Guangfu Hospital, Jinhua 321001, Zhejiang Province, China
| | - Ding-Fu Zhong
- Department of Gastroenterology, Jinhua People's Hospital, Jinhua 321000, Zhejiang Province, China
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3
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Zeng Z, Wang Z, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Comparison of Endoscopic Ultrasound-guided Cyanoacrylate Injection and Transjugular Intrahepatic Portosystemic Shunt in the Prevention of Gastric Varices Rebleeding. Surg Laparosc Endosc Percutan Tech 2024:00129689-990000000-00259. [PMID: 39056236 DOI: 10.1097/sle.0000000000001312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy and safety of endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) and transjugular intrahepatic portal shunts (TIPSs) in the treatment of patients with cirrhosis with ruptured gastric varices. METHODS In this retrospective study, 105 patients with liver cirrhosis and gastric varicose veins who were admitted to the First Affiliated Hospital of Anhui Medical University between April 2018 and April 2023 without nonselective β-blockers treatment and no portal vein thrombosis were evaluated. The patients were divided into the transjugular intrahepatic portal shunt (TIPS) group (n = 60) and the EUS-CYA group (n = 45) for the purpose of evaluating postoperative rebleeding rates, complications, survival rates, and other factors. RESULTS During the follow-up, there was no significant difference in the rebleeding rates between the TIPS group and EUS-CYA group within 3 months (5% vs 2.2%; P= 0.825; 10% vs 20%, P= 0.147). However, the TIPS group had significantly lower rebleeding rates than the EUS-CYA group at 6 months (10% vs 33.3%; P= 0.030) and 1 year or longer (11.7% vs 42.2%; P < 0.01). In terms of hepatic encephalopathy, the incidence rate of the TIPS group was significantly higher than that of the EUS-CYA group (20% vs 2.2%; P= 0.006). In addition, there was no difference in the survival rates between the two groups (93.3% vs 97.8%; P= 0.552). CONCLUSIONS TIPS is superior to EUS in preventing rebleeding in patients with ruptured varices of the fundus, but it has a higher incidence of hepatic encephalopathy, and there is no difference in long-term survival between the two groups.
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Affiliation(s)
- Zhuang Zeng
- Department of Gastroenterology, Key Laboratory of Digestive Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician: complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc). Minerva Gastroenterol (Torino) 2024; 70:208-224. [PMID: 35262306 DOI: 10.23736/s2724-5985.22.03127-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed to provide defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.
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Affiliation(s)
- Xavier Molero
- Unit of Exocrine Pancreas Research, Department of Gastroenterology, VHIR, CIBERehd, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain -
| | - Juan R Ayuso
- Department of Radiology, CDI, IDIBAPS, Hospital Clínic Barcelona, Barcelona, Spain
| | - Joaquim Balsells
- Department of Hepato-Pancreato-Biliary and Transplantation Surgery, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Jaume Boadas
- Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Juli Busquets
- Department of Hepatobiliary and Pancreatic Surgery, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Anna Casteràs
- Unit of Diabetes and Metabolism Research, VHIR, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Mar Concepción
- Department of Gastroenterology, Santa Creu i Sant Pau Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Míriam Cuatrecasas
- Department of Pathology, CIBEREHD, IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Gloria Fernàndez Esparrach
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Esther Fort
- Department of Gastroenterology, Doctor Josep Trueta University Hospital, Girona, Spain
| | | | - Àngels Ginès
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Lucas Ilzarbe
- Department of Gastroenterology, Hospital del Mar Parc Salut Mar, Barcelona, Spain
| | - Carme Loras
- Department of Gastroenterology, CIBERehd, University of Barcelona, Terrassa, Spain
| | - Miquel Masachs
- Department of Endocopy, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Terrassa, Spain
| | - Xavier Merino
- Department of Radiodiagnostic, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jorge J Olsina
- Department of General Surgery, Institute for Research in Biomedicine of Lleida (IRBLleida), University Hospital Arnau de Vilanova, Lleida, Spain
| | - Valentí Puig-Diví
- Department of Gastroenterology, Parc Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Sabadell, Spain
| | - Sílvia Salord
- Unit of Hepato-Bilio-Pancreatic, Department of Digestive Diseases, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Teresa Serrano
- Department of Pathology, IDIBELL, CIBERehd, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
| | - Eva C Vaquero
- Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
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Chavan R, Baraldo S, Patel N, Gandhi C, Rajput S. Technical tips for EUS-guided embolization of varices and pseudoaneurysms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:211-219. [PMID: 38618622 PMCID: PMC11009482 DOI: 10.1016/j.vgie.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Backgrounds and Aims EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms. Methods This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed. Results Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented. Conclusions Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.
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Affiliation(s)
| | | | - Nishant Patel
- Arnold Palmer Hospital for Children, Orlando Health, Orlando, Florida, USA
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Wang Z, Zhang F, Zeng Z, Bai Y, Chen L, Shi C, Jin J, Zhang Q, Mei X, Kong D. Application of Indian ink markers for locating gastric varices under endoscopic ultrasonography. Surg Endosc 2024; 38:633-639. [PMID: 38012437 DOI: 10.1007/s00464-023-10532-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The present study aimed to investigate the accuracy of endoscopic ultrasonography (EUS) combined with Indian ink in locating target vessels of gastric varices (GVs) compared with conventional endoscopic techniques. Additionally, the characteristics of GVs under conventional endoscopy were also explored. METHODS All 50 cirrhotic patients with GVs between August 2021 and December 2022 were included in the study. Firstly, conventional endoscopy was employed to identify GVs and to record the expected injection sites. Subsequently, EUS was used to locate the perforated vessel and the injection site was them marked with India ink followed by injection with cyanoacrylate (CYA). Finally, conventional endoscopy was used to examine GVs, to identify the marker points of Indian ink and to compare whether the injection points under conventional endoscopy were consistent with those marked with Indian ink. Furthermore, patients with consistent and inconsistent distribution of endoscopic markers and injection sites were divided into two groups. RESULTS EUS could detect the perforating vessels in real time and intuitively. The distribution of markers using EUS was significantly different compared with the injection points obtained by conventional endoscopy (P < 0.001). Therefore, 20 cases were allocated to the consistent group and 30 cases to the non-consistent group. 16 patients who showed red wale signs were obtained in the consistent group and 11 patients in the non-consistent group (P = 0.048). The diameter of the largest GVs was 13.5 (10-15) mm in the consistent group compared with 10 (7.5-10) mm in the non-consistent group (P = 0.006). CONCLUSION EUS could provide the exact location of GVs, thus more accurately describing the endoscopic characteristics of the GVs. Furthermore, the red wale signs and diameter of the largest GVs obtained using conventional endoscopy were helpful in determining the location of target GVs.
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Affiliation(s)
- Zhihong Wang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Yuchuan Bai
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
| | - Derun Kong
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
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Wang Z, Zeng Z, Chen L, Shi C, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Endoscopic ultrasonography-guided injection of cyanoacrylate in the treatment of gastroesophageal varices type 1: a single-center randomized study. Surg Endosc 2023; 37:8277-8284. [PMID: 37674054 DOI: 10.1007/s00464-023-10342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND AIM First, it has been demonstrated that endoscopic ultrasonography (EUS)-guided cyanoacrylate (CYA) injection (EUS-CYA) has greater efficacy than direct endoscopic injection of cyanoacrylate (DEI-CYA) for treating type 1-isolated gastric varices. However, it is necessary to conduct further studies to determine whether EUS has any advantage over the current guidelines for treating gastroesophageal varices type 1 (GOV1). Second, liver function is an important prognostic factor in patients with liver cirrhosis. Therefore, we evaluated the liver function of patients treated with EUS-CYA. METHODS In a single-center study, a prospective cohort from February 2021 to September 2022 involving 89 patients with cirrhosis with GOV1 were assigned to undergo EUS-CYA (n = 45) or DEI-CYA (n = 44). The success rate of CYA injection, the rate of overall rebleeding, the rate of reintervention, the complications during the follow-up period, and the liver function were compared. RESULTS In both groups, 100% of the operations were successful. The follow-up time of the two groups was 290 (153-398) days and 267 (177-416) days, respectively. In the EUS group, the perforating veins had an average diameter of 7.0 ± 2.7 mm, and they had a 100% occlusion rate. A statistically significant difference was found between the two groups regarding the number of sessions needed to eradicate GV (p = 0.005, pairwise comparisons were conducted using the Bonferroni correction method.), the late rebleeding rate after EUS-CYA [n = 3 (6.7%) vs n = 10 (22.7%); p = 0.032], and the incidence of postinjection ulcers [n = 4 (8.9%) vs n = 12 (27.3); p = 0.023)]. Following EUS or DEI-CYA treatment, the patient's liver function did not show any significant deterioration or decline. CONCLUSION EUS-CYA has a higher eradication success rate and fewer complications, recurrences, and rebleeding episodes than DEI-CYA used for GOV1 treatment. In addition, EUS-CYA did not impair liver function.
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Affiliation(s)
- Zhihong Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China.
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Wang TJ, Ryou M. Gastric varices. Curr Opin Gastroenterol 2023; 39:490-495. [PMID: 37678207 DOI: 10.1097/mog.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
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.
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Affiliation(s)
- Thomas J Wang
- Brigham and Women's Hospital, Department of Gastroenterology, Hepatology and Endoscopy
- Harvard Medical School, Boston, Massachusetts, USA
| | - Marvin Ryou
- Brigham and Women's Hospital, Department of Gastroenterology, Hepatology and Endoscopy
- Harvard Medical School, Boston, Massachusetts, USA
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Alqahtani SA, Ausloos F, Park JS, Jang S. The Role of Endoscopic Ultrasound in Hepatology. Gut Liver 2023; 17:204-216. [PMID: 36457262 PMCID: PMC10018300 DOI: 10.5009/gnl220071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/19/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022] Open
Abstract
Endoscopic ultrasound (EUS) has been an indispensable and widely used diagnostic tool in several medical fields, including gastroenterology, cardiology, and urology, due to its diverse therapeutic and diagnostic applications. Many studies show that it is effective and safe in patients with liver conditions where conventional endoscopy or cross-sectional imaging are inefficient or when surgical interventions pose high risks. In this article, we present a review of the current literature for the different diagnostic and therapeutic applications of EUS in liver diseases and their complications and discuss the potential future application of artificial intelligence analysis of EUS.
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Affiliation(s)
- Saleh A Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA.,Liver Transplant Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Floriane Ausloos
- Department of Gastroenterology and Hepatology, CHU Liège, Sart-Tilman, Liège, Belgium
| | - Ji Seok Park
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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Baliss M, Patel D, Madi MY, Bazarbashi AN. EUS-Guided Vascular Interventions. J Clin Med 2023; 12:jcm12062165. [PMID: 36983165 PMCID: PMC10052848 DOI: 10.3390/jcm12062165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has numerous advanced applications as a diagnostic and therapeutic modality in contemporary medicine. Through intraluminal placement, EUS offers a real-time Doppler-guided endoscopic visualization and access to intra-abdominal vasculature, which were previously inaccessible using historical methods. We aim to provide a comprehensive review of key studies on both current and future EUS-guided vascular applications. This review details EUS-based vascular diagnostic techniques of portal pressure measurements in the prognostication of liver disease and portal venous sampling for obtaining circulating tumor cells in the diagnosis of cancer. From an interventional perspective, we describe effective EUS-guided treatments via coiling and cyanoacrylate injections of gastric varices and visceral artery pseudoaneurysms. Specific attention is given to clinical studies on efficacy and procedural techniques described by investigators for each EUS-based application. We explore novel and future emerging EUS-based interventions, such as liver tumor ablation and intrahepatic portosystemic shunt placement.
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Affiliation(s)
- Michelle Baliss
- Division of Gastroenterology, Saint Louis University Hospital, St. Louis, MO 63104, USA
| | - Devan Patel
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Mahmoud Y. Madi
- Division of Gastroenterology, Saint Louis University Hospital, St. Louis, MO 63104, USA
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
- Correspondence:
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Pallio S, Melita G, Shahini E, Vitello A, Sinagra E, Lattanzi B, Facciorusso A, Ramai D, Maida M. Diagnosis and Management of Esophagogastric Varices. Diagnostics (Basel) 2023; 13:diagnostics13061031. [PMID: 36980343 PMCID: PMC10047815 DOI: 10.3390/diagnostics13061031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. Thus, esophagogastric varices represent a major economic and population health issue. Patients with advanced chronic liver disease typically undergo an upper endoscopy to screen for esophagogastric varices. However, upper endoscopy is not recommended for patients with liver stiffness < 20 KPa and platelet count > 150 × 109/L as there is a low probability of high-risk varices. Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt. This article aims to offer a comprehensive review of recommendations from international guidelines as well as recent updates on the management of esophagogastric varices.
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Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
| | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology "S. de Bellis" Research Hospital, Castellana Grotte, 70013 Bari, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Instituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Barbara Lattanzi
- Gastroenterology and Emergency Endoscopy Unit, Sandro Pertini Hospital, 00100 Rome, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy
| | - Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
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12
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Sabry F, Seif S, Eldesoky A, Hakim H, Altonbary AY. EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices. Endosc Int Open 2023; 11:E202-E210. [PMID: 36845270 PMCID: PMC9949986 DOI: 10.1055/a-1984-7070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.
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Affiliation(s)
- Fady Sabry
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Seham Seif
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ayman Eldesoky
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Hazem Hakim
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ahmed Youssef Altonbary
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
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13
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Han JH. Role of endoscopic ultrasound in the secondary prevention of gastric varices. Clin Endosc 2023; 56:50-52. [PMID: 36646421 PMCID: PMC9902684 DOI: 10.5946/ce.2022.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea,Correspondence: Joung-Ho Han Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, 776 1Sunhwan-ro, Seowon-gu, Cheongju 28644, Korea E-mail:
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14
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Huang Z, Zhang W, Lv F, Ma L, Xiao Y, Gao S, Zhang M, Wang Y, Li P, Zhao H, Yu H, Cao J, Ke G, Wang Y, Chen M. Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study. Endosc Ultrasound 2023; 12:74-83. [PMID: 36510863 PMCID: PMC10134943 DOI: 10.4103/eus-d-21-00260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives Gastric varices (GV) with spontaneous portosystemic shunt (SPSS) are associated with ectopic embolism in endoscopic cyanoacrylate. This study targeted to assess the efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration (BRTO) for GV with high-risk ectopic embolism. Materials and Methods We retrospectively analyzed six tertiary hospitals' 104 patients with GV at high-risk ectopic embolism (the narrowest diameter of SPSS was greater than or equal to 5 mm and the maximum diameter usually >8 mm) who underwent EUS-guided coil embolization combined with endoscopic cyanoacrylate injection or BRTO from January 2014 to December 2020. The outcomes included rebleeding, survival, and complications. Results The EUS group and BRTO group contained 59 and 45 patients, respectively. The technical success rate between the two groups was similar (96.6% vs. 95.6%, P = 1.000). During the follow-up, both groups' 5-day rebleeding rate and 6-week mortality rate were 0%. One-year all-cause rebleeding rate (20.0% vs. 18.9%, P = 0.900) and 1-year mortality rate (2.0% vs. 0%, P = 1.000) in the EUS group were similar to the BRTO group. One patient experienced ectopic embolism in the EUS group, while the BRTO group did not. Both groups had similar mean days (16.0 [interquartile range (IQR), 12.0-19.0] vs. 16.5 [IQR, 11.8-26.0], P = 0.165) and cost of hospitalization (¥ 45950.6 [IQR, 39330.2-55768.2] vs. ¥ 51205.8 [IQR, 31628.8-74251.5], P = 0.680). Multivariate analysis showed that the narrowest diameter of the shunt (odds ratio [OR] = 1.86; 95% confidence interval [CI]: 1.062-3.258; P = 0.03) and content of hemoglobin (OR = 0.941; 95% CI: 0.892-0.992; P = 0.025) were the prognostic factors for survival. Conclusions The efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection for GV with high-risk ectopic embolism are comparable to BRTO.
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Affiliation(s)
- Ziyin Huang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Wenhui Zhang
- Department of Digestive System, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Fujing Lv
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lili Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Xiao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Shan Gao
- Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Ming Zhang
- Department of Gastroenterology, Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yanling Wang
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Li
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haiying Zhao
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Honggang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Jiwang Cao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Ge Ke
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Yang Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Mingkai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
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15
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Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Ендоваскулярне лікування варикозно розширених вен шлунка під контролем ендосонографії. EMERGENCY MEDICINE 2022; 18:39-47. [DOI: 10.22141/2224-0586.18.6.2022.1519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Шлункова варикозна кровотеча супроводжується високою летальністю. Ендоскопічна ін’єкція ціаноакрилату є стандартною терапією, однак рецидивна кровотеча та побічні ефекти, такі як виразки в місці ін’єкції та дистальна емболія, є підводним каменем цієї терапії. Ендоскопічне лікування варикозного розширення вен шлунка під ендосонографічним контролем має кілька можливих переваг перед сучасними методами лікування. Воно дозволяє детально оцінити анатомію судин, подібну ефективність і безпеку поточних методів лікування, а також дає змогу оцінити ефект лікування за допомогою ультразвукової допплерівської візуалізації. Ми розглядаємо методи лікування варикозного розширення вен шлунка, включаючи ендоскопічну ін’єкцію ціаноакрилату та спіралей під контролем ендосонографії, окремо або в комбінації, ін’єкцію тромбіну та желатинової губки, що розсмоктується. Відповідний відбір пацієнтів для цих процедур має першорядне значення для забезпечення отримання корисних клінічних даних і безпеки пацієнтів. Ми шукали літературу в базі даних MedLine на платформі PubMed.
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16
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Tan YY, Gong J, Liu DL. Endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis: Complications and management strategies. Shijie Huaren Xiaohua Zazhi 2022; 30:775-782. [DOI: 10.11569/wcjd.v30.i17.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gastric varices is a common clinical presentation of portal hypertension induced by hepatic cirrhosis, and gastric variceal bleeding is an emergency with high mortality. Endoscopic tissue adhesive injection plays an important role in the primary and secondary prophylaxis of gastric variceal bleeding, and acute bleeding control. However, this is a technique-demanding operation with nonnegligible complications, of which some may be fatal, such as ectopic embolism. Therefore, the prevention and treatment of such complications are of great importance. Herein, we present a review summarizing the complications and treatment strategies of endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis.
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Affiliation(s)
- Yu-Yong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
| | - Jian Gong
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
| | - De-Liang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
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17
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Fugazza A, Khalaf K, Colombo M, Carrara S, Spadaccini M, Koleth G, Troncone E, Maselli R, Repici A, Anderloni A. Role of endoscopic ultrasound in vascular interventions: Where are we now? World J Gastrointest Endosc 2022; 14:354-366. [PMID: 35978714 PMCID: PMC9265255 DOI: 10.4253/wjge.v14.i6.354] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/08/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Glenn Koleth
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Roma 00133, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
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18
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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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19
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Penrice DD, Rattan P, Simonetto DA. Artificial Intelligence and the Future of Gastroenterology and Hepatology. GASTRO HEP ADVANCES 2022; 1:581-595. [PMID: 39132066 PMCID: PMC11307848 DOI: 10.1016/j.gastha.2022.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/22/2022] [Indexed: 08/13/2024]
Abstract
The integration of artificial intelligence (AI) into gastroenterology and hepatology (GI) will inevitably transform the practice of GI in the coming decade. While the application of AI in health care is not new, advancements are occurring rapidly, and the future landscape of AI is beginning to come into focus. From endoscopic assistance via computer vision technology to the predictive capabilities of the vast information contained in the electronic health records, AI promises to optimize and expedite clinical and procedural practice and research in GI. The extensive body of literature already available on AI applications in gastroenterology may seem daunting at first; however, this review aims to provide a breakdown of the key studies conducted thus far and demonstrate the many potential ways this technology may impact the field. This review will also take a look into the future and imagine how GI can be transformed over the coming years, as well as potential limitations and pitfalls that must be overcome to realize this future.
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Affiliation(s)
- Daniel D. Penrice
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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20
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Garcia-Sumalla A, Maisterra S, Amador-Navarrete A, Castellote J, Gornals JB. Nonadhesive massive coiling endoscopic ultrasound-guided embolization in a single session for treatment of gastric varices: learning points of a technical variant. Endoscopy 2022; 54:E228-E229. [PMID: 34058753 DOI: 10.1055/a-1492-2182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Albert Garcia-Sumalla
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
| | - Sandra Maisterra
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
| | - Alberto Amador-Navarrete
- Hepatology Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
| | - Jose Castellote
- Hepatology Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
| | - Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain.,Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Catalonia, Spain
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21
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Kalista KF, Hanif SA, Nababan SH, Lesmana CRA, Hasan I, Gani R. The Clinical Role of Endoscopic Ultrasound for Management of Bleeding Esophageal Varices in Liver Cirrhosis. Case Rep Gastroenterol 2022; 16:295-300. [PMID: 35814797 PMCID: PMC9209949 DOI: 10.1159/000524529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/18/2022] [Indexed: 11/19/2022] Open
Abstract
Bleeding esophageal varices (BEV) is a serious clinical condition and can potentially be life-threatening. Esophageal varices are caused by abnormal dilated submucosal and collateral veins in the esophagus wall as a result of portal hypertension due to liver cirrhosis. Consequently, it is important to administer appropriate preventive treatment for the disease in order to decrease morbidity and mortality rates. The current gold standard to identify esophageal varices is the use of esophagogastroduodenoscopy (EGD). However, EGD has limitations due to its inability in observing detailed information of varices morphology and esophagogastric hemodynamics. This report shares the potential role of endoscopic ultrasound (EUS) to overcome the limitation of EGD in clinical practices. Two cases of BEV in hepatitis B liver cirrhosis patients were described in the report. In case 1, large esophageal varices were found through EGD, and large paraesophageal varices were found through EUS. In case 2, small esophageal varices were found through EGD, and submucosal varices with a large periesophageal collateral vein and perforating vein in the distal esophagus were found through EUS. Cyanoacrylate injection guided by EUS was performed in both cases, and no rebleeding occurred after the procedure. In these cases, we showed that EUS is proven to be a potential tool in diagnosis and management of BEV in liver cirrhosis. EUS provides more accurate diagnostic aspects to find varices, assess bleeding risk, and predict bleeding recurrence. EUS also provides more beneficial treatment aspects to guide the treatment procedure and to monitor post treatment response.
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Affiliation(s)
- Kemal Fariz Kalista
- Division of Hepatobiliary, Department of Internal Medicine, Dr Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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22
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Jagadisan B, Dhawan A. Emergencies in paediatric hepatology. J Hepatol 2022; 76:1199-1214. [PMID: 34990749 DOI: 10.1016/j.jhep.2021.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022]
Abstract
The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.
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Affiliation(s)
- Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK.
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Pavic T, Mikolasevic I, Kralj D, Blazevic N, Skrtic A, Budimir I, Lerotic I, Hrabar D. Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand? Diagnostics (Basel) 2021; 11:2021. [PMID: 34829368 PMCID: PMC8618190 DOI: 10.3390/diagnostics11112021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022] Open
Abstract
As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.
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Affiliation(s)
- Tajana Pavic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivana Mikolasevic
- Department of Gastroenterology, University Hospital Center Rijeka, 51000 Rijeka, Croatia;
| | - Dominik Kralj
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Nina Blazevic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Anita Skrtic
- Department of Pathology, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Ivan Budimir
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivan Lerotic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Davor Hrabar
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
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