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Al-Khazraji A, Curry MP. The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:893-897. [PMID: 31389265 DOI: 10.1080/17474124.2019.1652092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.
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Affiliation(s)
- Ahmed Al-Khazraji
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Michael P Curry
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
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Arasu S, Liaquat H, Suri J, Ehrlich AC, Friedenberg FK. Incidence and risk factors of dysphagia after variceal band ligation. Clin Mol Hepatol 2019; 25:374-380. [PMID: 31315388 PMCID: PMC6933116 DOI: 10.3350/cmh.2019.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/12/2019] [Indexed: 01/08/2023] Open
Abstract
Background/Aims There is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL. Methods We identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved “complete eradication” of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded. Results Of the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0–4.0) with a median of 9.0 bands placed (IQR, 3.0–14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all p>0.05). No strictures were identified on subsequent esophageal evaluation. Conclusions Approximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.
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Affiliation(s)
- Saraswathi Arasu
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Hammad Liaquat
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Jaspreet Suri
- Internal Medicine, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Frank K Friedenberg
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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3
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Butt N, Abbasi A, Ali Khan M, Butt S, Ahmad SM. Esophageal Variceal Band Ligation Interval and Number Required for the Obliteration of Varices: A Multi-center Study from Karachi, Pakistan. Cureus 2019; 11:e4993. [PMID: 31497424 PMCID: PMC6707816 DOI: 10.7759/cureus.4993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction Esophageal variceal band ligation (EVBL) is the best form of treatment for variceal bleeding. The frequency of EVBL for the eradication of esophageal varices has no consensus. We evaluated the number and interval of EVBL sessions required for the obliteration of esophageal varices. Methods Esophagogastric varices were treated endoscopically with band ligation on initial presentation and then every after three weeks till the obliteration of the varices. Endoscopic band ligation consists of placing rubber elastic bands on large varices. Frequencies were calculated for qualitative variables and mean ± standard deviations for continuous variables. Results A total of 107 cases with esophagogastric varices were enrolled. Out of them, seven patients with small esophageal varices and large fundal varices were excluded. The remaining 100 with large esophageal varices had EVBL performed. The second session of EVBL was done in 46 patients with large esophageal varices. The third session of EVBL for the obliteration of esophageal varices required in 20 patients with large esophageal varices and the fourth session was required in only two patients. The total sessions required for the complete obliteration for esophageal varices were 2±1. Only one patient developed post-EVBL bleeding one week after band ligation. Conclusion Esophageal variceal ligation was a safe and well-tolerated procedure performed at three-week intervals in patients with large esophageal varices. On average, two to three sessions of EVBL are required for the complete obliteration of esophageal varices.
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Affiliation(s)
- Nazish Butt
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Amanullah Abbasi
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - M Ali Khan
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Sehrish Butt
- Biomedical and Biological Sciences, Dow University of Health Sciences, Karachi, PAK
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Sobotka LA, Ramsey ML, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019; 11:292-297. [PMID: 31040890 PMCID: PMC6475704 DOI: 10.4253/wjge.v11.i4.292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus non-selective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.
CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis, measuring 8 mm in diameter by 1 cm in length, which was dilated.
CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Mitchell L Ramsey
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Michael Wellner
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sean G Kelly
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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5
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Sobotka LA, Ramsey M, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.293] [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: 02/06/2023] Open
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Abstract
Rebleeding after initially successful endoscopic variceal ligation (EVL) occurs in 20-60% of patients, most commonly from band ulcers, and is associated with 20-50% mortality. Although band ulcer bleeding has been treated in a number of different ways, no single therapeutic intervention has shown a clear benefit. Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a relatively new non-contact hemostatic modality used in the management of bleeding peptic ulcers. It is a nano-powder that can be sprayed over a larger mucosal area. Here we describe a patient with end stage liver disease who presented with recurrent bleeding from a deep esophageal ulcer following band ligation and sclerotherapy, effectively managed with multiple sessions of Hemospray.
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Sebek J, Curto S, Eaton-Evans J, Bouchier-Hayes J, Ruvio G, Ganta C, Beard W, Buttar N, Song LWK, Prakash P. Feasibility Assessment of Microwave Ablation for Treating Esophageal Varices. J Med Device 2017. [DOI: 10.1115/1.4037187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Esophageal varices are a significant complication of portal hypertension. Endoscopic variceal ligation (EVL) is one of the clinical standards for treating these varices and preventing their hemorrhage. Limitations of EVL include the risk of stricture formation and postband ulcer bleeding due to the damage caused to the esophageal mucosa, as well as the need for multiple endoscopic treatment sessions to eradicate the varices. The goal of this study is to develop a device and evaluate the technical feasibility of microwave ablation to seal esophageal varices, while preventing thermal damage to the surface mucosal tissue. A microwave applicator with a directional radiation pattern was developed for endoscopic ablation of esophageal varices. Electromagnetic and bioheat transfer computational models were employed to optimize the design of the microwave applicator and evaluate energy delivery strategies for this application. Experiments in ex vivo and in vivo tissue were employed to verify simulation results. Simulations predicted enhanced heating performance of the antenna using an angled monopole radiating element. Further, simulations indicate that while the endoscopic cap attenuated electric fields in tissue, it also enhanced surface cooling of tissue, increasing the likelihood of preserving mucosal tissue. Experiments in ex vivo tissue indicated the feasibility of sealing veins with 77 W microwave power delivered for 30 s. In vivo experiments demonstrated the ability to seal veins, while preserving surface tissue. This study demonstrated the technical feasibility of microwave thermal ablation for treating esophageal varices using a 2.45 GHz water-cooled directional microwave applicator.
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Affiliation(s)
- Jan Sebek
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506; Department of Circuit Theory, Faculty of Electrical Engineering, Czech Technical University in Prague, Technicka 2, Praha 6 166 27, Czech Republic e-mail:
| | - Sergio Curto
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506 e-mail:
| | - Jimmy Eaton-Evans
- School of Engineering and Informatics, NUIG, Galway H91 TK33, Ireland e-mail:
| | | | - Giuseppe Ruvio
- School of Engineering and Informatics, NUIG, Galway H91 TK33, Ireland e-mail:
| | - Chanran Ganta
- Department of Diagnostic Medicine and Pathobiology, Kansas State University, 1800 Denison Avenue, Manhattan, KS 66506 e-mail:
| | - Warren Beard
- Department of Clinical Sciences, Kansas State University, 1800 Denison Avenue, Manhattan, KS 66506 e-mail:
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905 e-mail:
| | - Louis Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905 e-mail:
| | - Punit Prakash
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506 e-mail:
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Lv Y, Yee Lau W, Wu H, Han X, Gong X, Liu N, Yue J, Li Q, Li Y, Deng J. Causes of peripheral cytopenia in hepatitic cirrhosis and portal hypertensive splenomegaly. Exp Biol Med (Maywood) 2017; 242:744-749. [PMID: 28299974 PMCID: PMC5363688 DOI: 10.1177/1535370217693113] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/11/2016] [Indexed: 12/14/2022] Open
Abstract
The clinical data of 183 patients with hepatitic cirrhosis and portal hypertensive splenomegaly complicated by peripheral cytopenia were retrospectively analyzed to investigate the causes of peripheral cytopenia, as well as the proportion of the causes in these patients. All patients underwent splenectomy. Before operation, these patients had one or more types of peripheral cytopenia (cumulative cytopenia: 390 patient-times). After splenectomy, blood counts in 79.2% (309/390) returned to normal, while in 15.9% (62/390) they increased but failed to reach to normal levels, and in 4.9% (19/390) they became lower than before the operations. For the last group of patients ( n = 19), long-term follow-up showed that blood counts returned to normal in five patients. In other words, in 80.5% [(309 + 5)/390 or 314/390] of patient-times, the peripheral cytopenia was due to hypersplenism, in 15.9% it was due to a combination of factors, and in 3.6% [14/390] it had nothing to do with the hypersplenism. Thus, hypersplenism is a major cause, but not the only cause, of peripheral cytopenia in patients with hepatic cirrhosis and portal hypertensive splenomegaly, and splenectormy is an effective treatment for these patients. Impact statement For a long time, the development of peripheral cytopenias as a complication to cirrhotic portal hypertension has been attributed to hypersplenism; however, this has never been fully demonstrated. Dameshek summarized that hypersplenism should be diagnosed by the presence of four conditions: (a) mono- or multi-lineage peripheral cytopenias; (b) compensatory hyperplasia of bone marrow; (c) splenomegaly; and (d) correction of cytopenias after splenectomy. We retrospectively analyzed the clinical data from 183 surgical patients, and found that 80.5% of peripheral cytopenias was caused by hypersplenism, 16% by a combination of factors, and 3.5% by other factors unrelated to hypersplenism. As the first quantitative findings in this field, our results verify that hypersplenism is a major, but not exclusive, cause of peripheral cytopenias, and provides important clinical evidence for investigating the cause of peripheral cytopenias.
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Affiliation(s)
- Yunfu Lv
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Wan Yee Lau
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Hongfei Wu
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - XiaoYu Han
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Xiaoguang Gong
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Ning Liu
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Jie Yue
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Qingqing Li
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - YeJuan Li
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Jie Deng
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
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Tsou YK, Liu CY, Fu KI, Lin CH, Lee MS, Su MY, Ohata K, Chiu CT. Endoscopic Submucosal Dissection of Superficial Esophageal Neoplasms Is Feasible and Not Riskier for Patients with Liver Cirrhosis. Dig Dis Sci 2016; 61:3565-3571. [PMID: 27770376 PMCID: PMC5104793 DOI: 10.1007/s10620-016-4342-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/05/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Esophageal endoscopic submucosal dissection (ESD) has rarely been reported for the treatment of cirrhotic patients. AIM To report the results of ESD treatment of superficial esophageal neoplasms (SENs) for cirrhotic patients. METHODS Forty patients with 50 consecutive SENs undergoing 46 sessions of ESD were retrospectively reviewed. The cirrhotic group included eight patients (11 SENs) with liver cirrhosis consisting of six patients classified as Child-Pugh class A liver cirrhosis and two patients classified as class B liver cirrhosis. Four patients (6 SENs) had coexisting esophageal varices. Parameters were compared between the cirrhotic patients and the non-cirrhotic controls (32 patients, 39 SENs). RESULTS Platelet counts of the cirrhotic group were significantly lower, while international normalized ratio was significantly higher. When the cirrhotic group and non-cirrhotic group were compared, the mean tumor length (4 vs. 3.7 cm, p = 0.56) and median procedure time (15.1 vs. 11.5 min/cm2, p = 0.30) were similar. The en bloc resection rates were 81.8 and 89.7 % (p = 0.60). Within the cirrhotic group, both lesions without en bloc resection were patients with esophageal varices. The rates of submucosal disease for the cirrhotic group and non-cirrhotic groups were 54.5 and 25.6 % (p = 0.064), respectively, while the R0 resection rates were 77.8 and 94.3 % (p = 0.16), respectively. The two lesions without R0 resection in cirrhotic group had positive vertical but not horizontal margins due to submucosal invasion. Intraprocedural bleeding occurred more frequently in cirrhotic patients than non-cirrhotic patients (18.2 vs. 0 %, p = 0.045). None of the patients suffered from esophageal perforation, postoperative bleeding, or death that was related to the ESD. CONCLUSION Esophageal ESD seems to be safely and can be effectively performed on cirrhotic patients, particularly those without severe liver dysfunction.
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Affiliation(s)
- Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Yuan Liu
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Department of Medicine, Mackay Medical College, New Taipei, Taiwan
| | - Kuang-I Fu
- Department of Gastroenterology, Kanma Memorial Hospital, Nasushiobara, Japan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mu-Shien Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, 5-9-22 Higashi-gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Wen CL, He XB. Endoscopic tissue adhesive injection for treatment of gastric variceal bleeding. Shijie Huaren Xiaohua Zazhi 2016; 24:4498-4504. [DOI: 10.11569/wcjd.v24.i33.4498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopy is an important means for the prevention and treatment of gastric variceal bleeding. With definite curative effects and mild side effects, endoscopic tissue adhesive injection has become a preferred first-line treatment for gastric variceal hemorrhage and is now widely used in clinical practice. However, it is still controversial regarding surgical technique, long-term efficacy, risk of complications, and the effect of secondary prevention of gastric variceal bleeding. This article makes a summary of the above points of dispute.
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Hafeez M, Kadir E, Aijaz A. Sucralfate and Lidocain: Antacid 50:50 solution in Post Esophageal Variceal Band Ligation Pain. Pak J Med Sci 2016; 32:896-89. [PMID: 27648035 PMCID: PMC5017098 DOI: 10.12669/pjms.324.9645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of pain relief of Sucralfate and lidocain antacid 50:50 solution in post esophageal variceal band ligation pain. METHODS All patients who had under gone Esophageal Variceal Band Ligation (EVBL) were included in the study. Patients un-willing to be included in the study or those who didn't have post EVBL pain were excluded. Patients with post EVBL pains were divided into two groups: one group was given sucralfate and other was given lidocaine: antacid 50:50 solution. Both were inquired about the duration of the pain relief after the medication. The results were analyzed on SPSS 23. Independent samples T-test was performed to find out whether the difference in duration of pain relief was significantly different in the two groups. RESULTS Out of 110 patients who have EVBL, 66(60.00%) had pain and 44(40.00%) were pain free. In the pain group 46 (69.7%) were given sucralfate and 20 (30.3%) were given lidocain: antacid 50:50 solution. Mean duration of pain relief in two groups was 2.78 (SD ± 2.096) and 2.5 days (SD ±. 0.76) respectively. Independent samples T-test results revealed that there was no statistically significant difference in the duration of pain relief between these two groups with p value 0.426. CONCLUSION Both Sucralfate and Lidocain: antacid 50:50 solutions are effective in relieving the post EVBL pain. However, no statistically significant difference in duration of pain relief was detected in separate groups of patients treated with either treatment.
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Affiliation(s)
- Muhammad Hafeez
- Dr. Muhammad Hafeez, FCPS(Med), FCPS(Gastro) FACG, MASGE(USA), FRSPH, SCE RCP Gastro(UK)
| | - Ehsan Kadir
- Assistant Professor of Medicine and Gastroenterologist, Combined Military Hospital Kharian Cantt Pakistan
| | - Anjum Aijaz
- Dr. Ehsan Kadir, M.Sc Nutrition Assistant Professor of Community Medicine, Combined Military Hospital Multan Pakistan
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Muscatiello N, Facciorusso A. Use of polidocanol in colon polypectomy. Gastrointest Endosc 2016; 83:271. [PMID: 26264435 DOI: 10.1016/j.gie.2015.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Repici A, Pohl H. Revival of a sclerosing agent for prevention of postpolypectomy bleeding. Gastrointest Endosc 2015; 82:359-61. [PMID: 26183495 DOI: 10.1016/j.gie.2015.05.010] [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] [Received: 04/17/2015] [Accepted: 05/01/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milano, Italy
| | - Heiko Pohl
- Section of Gastroenterology, White River Junction VA Medical Center, White River Junction, Vermont, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Abstract
Acute variceal bleeding (AVB) is a milestone event for patients with portal hypertension. Esophageal varices bleed because of an increase in portal pressure that causes the variceal wall to rupture. AVB in a patient with cirrhosis and portal hypertension is associated with significant morbidity and mortality. The initial management of these patients includes proper resuscitation, antibiotic prophylaxis, pharmacologic therapy with vasoconstrictors, and endoscopic therapy. Intravascular fluid management, timing of endoscopy, and endoscopic technique are key in managing these patients. This article reviews the current endoscopic hemostatic strategies for patients with AVB.
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Abstract
Patients with portal hypertension and esophageal varices are at risk of bleeding due to a progressive increase in portal pressure that may rupture the variceal wall. Appropriate treatment with initial general measures, such as resuscitation, a restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy with vasoconstrictors, and endoscopic therapy with endoscopic band ligation are mandatory. However, 10% to 15% of patients fail initial endoscopic therapy and thus rescue therapies are needed. This article reviews the current endoscopic strategies with band ligation and esophageal stents for patients with acute variceal bleeding.
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Miyaaki H, Ichikawa T, Taura N, Miuma S, Isomoto H, Nakao K. Endoscopic management of esophagogastric varices in Japan. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:42. [PMID: 25333017 DOI: 10.3978/j.issn.2305-5839.2014.05.02] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/28/2014] [Indexed: 12/18/2022]
Abstract
Esophagogastric varices are the most common complication in patients with portal hypertension, and endoscopy plays an important role in their diagnosis and in the prevention of acute bleeding from these structures. Recently, new modalities such as endoscopic ultrasonography (EUS) and narrow-band imaging have been introduced for the diagnosis of esophagogastric varices. In Japan, endoscopic therapy has become the first choice for the treatment of acutely bleeding esophageal or gastric varices. The two principal methods used to treat esophageal varices are endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). Recently, combinations of EIS plus EVL and EVL plus argon plasma coagulation were reported to be more effective than EVL or EIS alone. Additionally, endoscopic cyanoacrylate injection is superior to EIS and EVL for the treatment of acutely bleeding gastric varices.
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Affiliation(s)
- Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Tatsuki Ichikawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Naota Taura
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Hajime Isomoto
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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Rajoriya N, Tripathi D. Historical overview and review of current day treatment in the management of acute variceal haemorrhage. World J Gastroenterol 2014; 20:6481-94. [PMID: 24914369 PMCID: PMC4047333 DOI: 10.3748/wjg.v20.i21.6481] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/14/2014] [Accepted: 04/02/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal haemorrhage is one of the most devastating consequences of portal hypertension, with a 1-year mortality of 40%. With the passage of time, acute management strategies have developed with improved survival. The major historical treatment landmarks in the management of variceal haemorrhage can be divided into surgical, medical, endoscopic and radiological breakthroughs. We sought to provide a historical overview of the management of variceal haemorrhage and how treatment modalities over time have impacted on clinical outcomes. A PubMed search of the following terms: portal hypertension, variceal haemorrhage, gastric varices, oesophageal varices, transjugular intrahepatic portosystemic shunt was performed. To complement this, Google™ was searched with the aforementioned terms. Other relevant references were identified after review of the reference lists of articles. The review of therapeutic advances was conducted divided into pre-1970s, 1970/80s, 1990s, 2000-2010 and post-2010. Also, a summary and review on the pathophysiology of portal hypertension and clinical outcomes in variceal haemorrhage was performed. Aided by the development of endoscopic therapies, medication and improved radiological interventions; the management of variceal haemorrhage has changed over recent decades with improved survival from an often-terminating event in recent past.
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Zhang C, Xu JM, Kong DR, Min XK, Chen R. Immediate effects of different schedules of somatostatin on portal pressure in patients with liver cirrhosis. J Clin Pharm Ther 2013; 38:206-11. [PMID: 23437909 DOI: 10.1111/jcpt.12007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Somatostatin (SST) is used for the treatment of acute variceal bleeding based on its ability to decrease portal pressure and collateral blood flow. To date, no studies have focused on the immediate-early effects (between 1 and 30 min) of SST. The aim of this study was to compare the efficacy of different schedules of SST therapy with placebo on portal pressure in patients with portal hypertension treated with portal-azygous disconnection and to test whether an increase in bolus or infusion dose can improve the clinical efficacy of SST therapy. METHODS Patients were treated with four different schedules: (a) standard dose (n = 11): one 250 μg bolus + a continuous infusion of 250 μg/h; (b) medium dose (n = 10): 500 μg bolus + a continuous infusion of 250 μg/h; (c) high dose (n = 10): 250 μg bolus + a continuous infusion of 500 μg/h; (d) control (n = 10): an injection of placebo (saline) followed by a placebo infusion. Following SST or placebo administration, portal pressure, central venous pressure (CVP), systemic blood pressure and heart rate (HR) were measured at 1, 3, 5, 7, 10 and 30 min. RESULTS AND DISCUSSION The three schedules of SST induced a marked, rapid and highly significant decrease in portal pressure. The decline in portal pressure was moderate at 1 min (P < 0·040), achieved a peak effect at 5 min (P < 0·009) and remained decreased at 30 min. The effect of SST on portal pressure was significantly greater than placebo from 1 min after administration. There were no significant differences in portal pressure decrease between the three schedules of SST. The three schedules of SST and the placebo schedule did not induce significant changes in HR, systemic blood pressure and CVP. WHAT IS NEW AND CONCLUSION This study shows that SST is effective in decreasing portal pressure within 30 min of administration in patients with liver cirrhosis. The clinical schedule used in this study was reasonable and safe.
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Affiliation(s)
- C Zhang
- Department of Surgery, Anhui Geriatric Institute, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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19
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Wang HY, Chen MJ, Lin CC, Chen CJ, Liu CY, Wang TE, Sun FJ, Lin SC, Shih SC. Gastric Variceal Bleeding in the Elderly. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Poza Cordon J, Froilan Torres C, Burgos García A, Gea Rodriguez F, Suárez de Parga JM. Endoscopic management of esophageal varices. World J Gastrointest Endosc 2012; 4:312-22. [PMID: 22816012 PMCID: PMC3399010 DOI: 10.4253/wjge.v4.i7.312] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 05/10/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis
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Affiliation(s)
- Joaquin Poza Cordon
- Joaquin Poza Cordon, Consuelo Froilan Torres, Aurora Burgos García, Francisco Gea Rodriguez, Jose Manuel Suárez de Parga, Hospital Universitario la Paz, 28046 Madrid, Spain
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21
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Hsu YC, Chung CS, Wang HP. Application of endoscopy in improving survival of cirrhotic patients with acute variceal hemorrhage. Int J Hepatol 2011; 2011:893973. [PMID: 21994875 PMCID: PMC3170849 DOI: 10.4061/2011/893973] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/12/2011] [Indexed: 12/21/2022] Open
Abstract
Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices.
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Affiliation(s)
- Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung 824, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei 220, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei 100, Taiwan,Department of Internal Medicine, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei 100, Taiwan,*Hsiu-Po Wang:
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Portale Hypertension. PRAXIS DER VISZERALCHIRURGIE. GASTROENTEROLOGISCHE CHIRURGIE 2011. [PMCID: PMC7123479 DOI: 10.1007/978-3-642-14223-9_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Während die Pathologie, die zur portalen Hypertension führt, im prähepatischen, hepatischen und posthepatischen venösen Gefäßbett liegen kann, machen die intrahepatischen Erkrankungen mit Abstand den Großteil aus. In unseren Breitengraden ist es die durch Alkoholabusus bedingte ethyltoxische Leberzirrhose, weltweit die durch Infektionen (HCV, HBV) bedingten Zirrhosen. Die chronische Hepatitis C mit ihren Komplikationen (Leberzellversagen, portale Hypertension und hepatozelluläres Karzinom) wird in den kommenden Jahren trotz moderner Therapieverfahren noch an Bedeutung gewinnen.
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AET, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8:760-6. [PMID: 20621678 DOI: 10.1016/j.cgh.2010.05.019] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 04/30/2010] [Accepted: 05/18/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic variceal obturation with tissue adhesive is used to control gastric variceal bleeding. We investigated the prevalence of serious complications from this therapy. METHODS We performed a retrospective analysis of complications that occurred in 753 patients with gastric variceal hemorrhages who were hospitalized in 2 tertiary referral hospitals. All patients received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation. RESULTS Complications occurred in 51 patients. Thirty-three patients experienced rebleeding because of early-onset (within 3 months) extrusion of the N-butyl-2-cyanoacrylate glue cast (4.4%), 10 patients developed sepsis (1.3%), and 5 patients developed distant embolisms (0.7%; 1 pulmonary, 1 brain, and 3 splenic). One patient had major gastric variceal bleeding after endoscopic variceal obturation (0.1%), 1 developed a large gastric ulcer (0.1%), and 1 had mesentery hematoma, hemoperitoneum, and infection in the abdominal cavity (0.1%). The complication-related mortality was 0.53% (3 deaths from sepsis and 1 death from rebleeding after early-onset glue cast extrusion). CONCLUSIONS The occurrence of complications after endoscopic variceal obturation with N-butyl-2-cyanoacrylate in gastric varices treatment is rare.
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Affiliation(s)
- Liu-Fang Cheng
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing, China
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Abstract
Acute variceal bleeding is one of the most serious and feared complications of patients with portal hypertension. The most common cause of portal hypertension is advanced liver disease. Patients with esophageal and gastric varices may bleed because of a progressive increase in portal pressure that causes them to grow and finally rupture. This article will review the current management strategies for acute variceal bleeding with emphasis on endoscopic therapy for the acute episode.
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Affiliation(s)
- Andrés Cárdenas
- GI Unit / Institut Clinic de Malalties Digestives i Metaboliques, University of Barcelona, Hospital Clinic, Spain.
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