Varices: Esophageal, Gastric, and Rectal

Development of a non-invasive diagnostic model for high-risk esophageal varices based on radiomics of spleen CT

PURPOSE

To evaluate the diagnostic performance of radiomics models derived from multi-phase spleen CT for high-risk esophageal varices (HREV) in cirrhotic patients.

METHODS

We retrospectively selected cirrhotic patients with esophageal varices from two hospitals from September 2019 to September 2023. Patients underwent non-contrast and contrast-enhanced CT scans and were categorized into HREV and non-HREV groups based on endoscopic evaluations. Radiomics features were extracted from spleen CT images in non-contrast, arterial, and portal venous phases, with feature selection via lasso regression and Pearson's correlation. Ten machine learning models were developed to diagnose HREV, evaluated by area under the curve (AUC). The AUC values of the three groups of models were statistically compared by the Kruskal-Wallis H test and Bonferroni-corrected Mann-Whitney U test. A p-value less than 0.05 was considered statistically significant.

RESULTS

Among 233 patients, 11, 6, and 11 features were selected from non-contrast, arterial, and portal venous phases, respectively. Significant differences in AUC values were observed across phases (p < 0.05), and the arterial phase models showed the highest AUC values. The best model in arterial phase was the logical regression model, whose AUC value was 0.85, sensitivity was 83.3%, specificity was 80% and F1 score was 0.81.

CONCLUSION

Radiomics models based on spleen CT, especially the arterial phase models, demonstrate high diagnostic accuracy for HREV, offering the potential for early detection and intervention.

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes

BACKGROUND

Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes.

METHODS

This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups.

RESULTS

Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037).

CONCLUSIONS

Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Advances in the endoscopic management of gastric varices

This review provides an overview of the treatment options available for gastric varices (GV) with a focus on endoscopic methods. Various minimally invasive techniques, including endoscopic band ligation, endoscopic cyanoacrylate injection, and transjugular intrahepatic portosystemic shunt, can be applied to the treatment of GV. Endoscopic cyanoacrylate injection is now recognized as a first-line treatment for GV. Endoscopic ultrasound-guided cyanoacrylate injection combined with coils has shown good security and effectiveness. Thrombin injection therapy is a promising treatment, with a similar hemostasis rate to cyanoacrylate injection but with fewer serious complications. With the deepening understanding of the hemodynamics of the GV system, various treatment methods and their combination are gradually evaluated to provide patients with safer and more effective treatment options.

Bleeding Complications of Portal Hypertension

In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.

New sights in ectopic varices in portal hypertension

Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.

Referral for liver transplant following acute variceal bleeding: a multicenter cohort study

OBJECTIVES

Referral for liver transplant (LT) following acute variceal bleeding (AVB) varies widely. We aimed to characterize and assess its impact on clinical outcomes.

METHODS

Observational retrospective cohort including cirrhosis patients with AVB from 3 hospitals in Lisbon, Portugal, from 2018 to 2019. Primary exposure was referral for LT and primary endpoint was all-cause mortality within 2 years of index hospital admission.

RESULTS

Among 143 patients, median (IQR) age was 59 (52-72) years and 90 (62.9%) were males. Median (IQR) MELDNa scores on hospital admission and discharge were 15 (11-21) and 13 (10-16), respectively. Overall, 30 (21.0%) patients were assessed for LT, 13 (9.1%) prior to and 17 (11.9%) within 2 years of hospital admission. Overall, 58 (40.6%) patients had at least one potential contra-indication for transplant. LT was performed in 3 (2.1%) patients (among 5 listed). Overall, 34 (23.8%) and 62 (43.4%) patients died at 6 weeks and 2 years post hospital admission, respectively. Following adjustment for confounders, referral for LT was associated with lower 2-year mortality (aHR (95% CI) = 0.20 (0.05-0.85)).

CONCLUSION

In a multicenter cohort of cirrhosis patients with AVB, less than a quarter underwent formal LT evaluation. Improved referral for LT following AVB may benefit cirrhosis patients' longer-term mortality.

Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding

BACKGROUND

Esophageal-gastric variceal bleeding (EGVB) represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes. Interventional therapy, a rapidly developing treatment modality over the past few years, has found widespread application in clinical practice due to its minimally invasive characteristics. However, whether transjugular intrahepatic portosystemic shunt (TIPS) treatment has an impact on patient prognosis remains controversial.

AIM

To probing the efficacy of TIPS for treating cirrhotic EGVB and its influence on the prognosis of patients afflicted by this disease.

METHODS

A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. Based on the different modes of treatment, the patients were assigned to the study group (TIPS received, n = 50) or the control group (percutaneous transhepatic varices embolization received, n = 42). Comparative analyses were performed between the two groups preoperatively and one month postoperatively for the following parameters: Varicosity status; hemodynamic parameters [portal vein flow velocity (PVV) and portal vein diameter (PVD); platelet count (PLT); red blood cell count; white blood cell count (WBC); and hepatic function [albumin (ALB), total bilirubin (TBIL), and aspartate transaminase (AST)]. The Generic Quality of Life Inventory-74 was utilized to assess quality of life in the two groups, and the 1-year postoperative rebleeding and survival rates were compared.

RESULTS

Following surgical intervention, there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts. Notably, the study group exhibited more pronounced enhancements than did the control group (P < 0.05). PVV increased, and PVD decreased compared to the preoperative values, with the study cohort achieving better outcomes (P < 0.05). PLT and WBC counts were elevated postoperatively in the two groups, with the study cohort displaying higher PLT and WBC counts (P < 0.05). No differences were detected between the two groups in terms of serum ALB, TBIL, or AST levels either preoperatively or postoperatively (P < 0.05). Postoperative scores across all dimensions of life quality surpassed preoperative scores, with the study cohort achieving higher scores (P < 0.05). At 22.00%, the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group (42.86%; P < 0.05); conversely, no marked difference was observed in the 1-year postoperative survival rate between the two cohorts (P > 0.05).

CONCLUSION

TIPS, which has demonstrated robust efficacy in managing cirrhotic EGVB, remarkably alleviates varicosity and improves hemodynamics in patients. This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.

Endoscopic procedures in hepatology: Current trends and new developments

Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.

MELD-Na score may underestimate disease severity and risk of death in patients with metabolic dysfunction-associated steatotic liver disease (MASLD)

Portal hypertension often precedes the development of advanced fibrosis in patients with Metabolic dysfunction-associated steatotic liver disease (MASLD) and may accelerate disease progression to cirrhosis. We aimed to evaluate whether prioritization tools accurately predict survival in patients with MASLD and clinically significant portal hypertension (CSPH). We retrospectively identified patients diagnosed with esophageal or gastric varices (EGV). Laboratory results, endoscopy reports and outcomes of patients with MASLD were compared to patients with advanced stage chronic liver disease (CLD) of other etiologies. During the study period 326 patients were diagnosed with EGV. 88 (26.9%) had MASLD, 113 (34.6%) viral hepatitis (VH), 63 (19.3%) alcoholic liver disease (ALD) and 62 (19%) both VH and ALD (VHALD). EGV bleeding events were significantly more frequent in patients with MASLD (36.3%), compared to VH (28.3%), ALD (30.1%) and VHALD (25.8%), respectively (p < 0.01). Mean Model for End-Stage Liver Disease (MELD)-Na score surrounding 1 year of first event of EGV bleeding was significantly lower in MASLD patients compared to all other etiologies (p = 0.02). At a MELD-Na score of 11-20, cumulative survival rate was significantly lower in MASLD patients compared to all other etiologies (log rank p < 0.01). MASLD patients present with EGV bleeding at lower MELD-Na scores compared to other etiologies of CLD. MELD-Na score may therefore underestimate disease severity and risk of death in patients with MASLD and CSPH.

Association of polycythemia vera with non‑cirrhotic portal hypertension in five patients: A case series

Polycythemia vera (PV) and non-cirrhotic portal hypertension (NCPH) are relatively independent diseases, and few studies have linked them. However, in clinical settings, there may be a causal relationship. The aim of the present study was to analyze the clinical data of five patients with portal hypertension caused by PV and summarize the characteristics of PV with portal hypertension, to enhance the knowledge of this disease. The clinical data of five patients with PV and portal hypertension treated at Beijing You'an Hospital (Beijing, China) from January 2010 to March 2022 were retrospectively collected. The characteristics of these patients were then summarized and analyzed, including general information, laboratory tests, imaging and gastroscopy data. Overall, four patients were diagnosed with PV earlier compared with those with NCPH (ranging between days and years), whereas one patient was diagnosed with NCPH at the time of PV diagnosis. These four patients had blood cell elevations of 2-3 categories (red blood cells, white blood cells or platelets). The Child classification of liver functions in all five patients were found to be grades A-B. All five patients had splenomegaly, where three patients had portal vein thrombosis and cavernous degeneration. In addition, four patients had moderate or severe esophageal varices. In conclusion, to the best of our knowledge, this was the first case series of NCPH caused by PV. Among the patients, it was revealed that: i) NCPH caused by PV had milder liver function damage compared with cirrhosis-induced portal hypertension; ii) splenomegaly, ascites and esophageal varicose veins were prominent symptoms of NCPH caused by PV; iii) If PV is diagnosed, esophagogastroduodenoscopy should be performed as early as possible and regularly, where primary prevention measures for esophageal variceal hemorrhage are recommended; and iv) patients with PV with portal hypertension are at risk of thrombosis and bleeding, but it remains to be determined whether early antithrombotic therapy can reduce complications.

Diagnosis and Management of Esophagogastric Varices

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.

Anticoagulation therapy early is safe in portal vein thrombosis patients with acute variceal bleeding: a multi-centric randomized controlled trial

Portal vein thrombosis (PVT) and acute variceal bleeding (AVB) are frequent complications of cirrhosis. The efficacy, safety, and timing of anticoagulant treatment in cirrhotic patients with PVT and AVB are contentious issues. We aimed to establish the safety and efficacy of initiating nadroparin calcium-warfarin sequential (NWS) anticoagulation therapy early after esophageal variceal band ligation within PVT patients having cirrhosis and AVB. Cirrhotic patients having AVB and PVT who underwent EVL were included and randomly allocated to either the NWS therapy group (1-month nadroparin calcium by subcutaneous injection following 5-month warfarin through oral administration, n = 43) or the control group (without any anticoagulation therapy, n = 43). The primary endpoint was the rate of PVT recanalization. Secondary endpoints included major bleeding events mainly referring to variceal rebleeding (5-day failure, 14-day, 4-week, 6-week, and 6-month rebleeding rates) and mortality after EVL. The overall recanalization (complete and partial) rate in the NWS therapy group was significantly higher than that in the control group (67.4% vs. 39.5%, P = 0.009). Low Child-Pugh score (P = 0.039, OR: 0.692, 95% CI 0.488-0.982), D-dimer < 2.00 ug/mL (P = 0.030, OR: 3.600, 95% CI 1.134-11.430), and NWS anticoagulation therapy (P = 0.002, OR: 4.189, 95% CI 1.660-10.568) were the predictors of PVT recanalization through univariate analysis of binary logistic regression. NWS anticoagulation therapy (P = 0.003, OR: 4.506, 95% CI 1.687-12.037) was the independent factor of recanalization through multivariate analysis. Nobody bled except for variceal rebleeding. Five-day failure and 14-day rebleeding were zero. There were no significantly different in 4-week (2.3% vs. 4.7%, P = 1.000), 6-week (4.7% vs. 9.3%, P = 0.672) and 6-month rebleeding (18.6% vs. 20.9%, P = 0.787) between the two groups. There was no mortality during six months follow-up. Low serum albumin (P = 0.011, OR: 0.844, 95% CI 0.741-0.962), high MELD score (P = 0.003, OR: 1.564, 95% CI 1.167-2.097) and Child-Pugh score (P = 0.006, OR: 1.950, 95% CI 1.206-3.155) were predictors of rebleeding by univariate analysis of binary logistic regression analysis. The Child-Pugh score (7 [6-8] vs. 6 [5-7], P = 0.003) and albumin levels (33.93 ± 5.30 vs. 37.28 ± 4.32, P = 0.002) were improved in the NWS therapy group at six months. In PVT patients with cirrhosis and AVB, starting NWS anticoagulation therapy early after EVL was safe and effective. It has the potential to raise albumin levels and improve liver function.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.

Evaluation of transjugular intrahepatic portosystemic shunt and modified sclerotherapy in preventing rebleeding of esophageal and gastric varices

Esophageal and gastric varices are complications of decompensated portal hypertension due to cirrhosis, and gastrointestinal bleeding and can seriously trigger major bleeding and crisis life. Seriously endangers patients' physical and mental health and attracts great attention in the clinic. To compare the efficacy and safety of MES (combined with lauromacrogol and tissue adhesive) and TIPS in the treatment of esophageal and gastric varices. The 62 cases of esophageal and gastric variceal bleeding in our hospital were retrospectively analyzed. They were divided into the MES group and TIPS group according to the treatment method. The rebleeding rate, complications, 2-year birth rate, treatment cost, and hospitalization time within 2 years after operation were compared between the two groups. Among the 62 patients, there were 32 in the MES group and 30 in the TIPS group. The rebleeding rate within 1 year after operation in the MES group was higher than that in the TIPS group, but the difference was not statistically significant. The rebleeding rate within 2 years after operation in the MES group was 40.63%, significantly higher than 13.33% in the TIPS group (P < 0. 05). In the MES group, the incidence of hepatic encephalopathy after the operation was 9.38%, significantly lower than 33.33% in TIPS group (P < 0. 05). The survival rate within 2 years after operation in MES group (81.25%) and TIPS group (83.33), the difference was not statistically significant (P > 0.05). There was no significant difference in hospital stay between the MES group and TIPS group (P > 0.05). The treatment cost of the MES group was lower than that of the TIPS group (P < 0.05). MES is more suitable for development and promotion in grass-roots hospitals, but TIPS treatment should be carried out as soon as possible for patients with poor efficacy of endoscopic treatment.

Shear Wave Dispersion Slope Measured with Shear Wave Dispersion Imaging Is Associated with Variceal Hemorrhage in Cirrhotic Patients

Background and Objectives: Portal hypertension (PH), as the main consequence of cirrhosis, leads to the development of gastroesophageal varices (GEVs). Variceal hemorrhage (VH) caused by the rupture of GEVs is a life-threatening emergency. Thus, the prediction of VH risk is considerably important. Our pilot study aimed to identify the risk factors of variceal hemorrhage (VH) in cirrhosis. Materials and Methods: Cirrhotic patients were prospectively included and divided into two groups according to the presence or absence of VH. Conventional ultrasound and shear wave dispersion (SWD) imaging were conducted to detect the portal vein diameter, spleen diameter, ascites, liver stiffness (LS) and shear wave dispersion slope (SWDS). The laboratory tests were recorded, including platelets (PLT), alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin (ALB). The risk factors of VH were screened using univariate analyses and identified using multivariate logistic regression. The ROC curves were used to assess diagnostic accuracy. Comparisons between AUCs were performed using the Delong method. Results: Sixty-five patients with 22 VHs were finally included. The SWDS, spleen diameter and ascites were identified as independent risk factors for VH. The SWDS showed good performance for diagnosing VH (AUC = 0.768, 95% CI: 0.647−0.864), and sensitively identified 95.5% (95% CI: 77.2%−99.9%) of patients with VH. Including the three risk factors in multivariate logistic regression, we obtained a formula for diagnosing VH: −20.749 + 0.804 × SWDS + 0.449 × spleen diameter + 1.803 × ascites (no ascites = 0, ascites = 1). Comparison of AUCs revealed that the formula (AUC = 0.900, 95% CI: 0.800−0.961) performed better than LS, SWDS, and spleen diameter in diagnosing VH (p < 0.001; p < 0.05; p < 0.05). Conclusions: SWDS is a sensitive parameter for assessing the risk of VH. Combining the SWDS, spleen diameter and ascites resulted in good diagnostic accuracy.

Managing gastric varices

Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.

Computed Tomography Images of Spontaneous Portosystemic Shunt in Liver Cirrhosis

Spontaneous portosystemic shunt (SPSS) refers to collateral vessels that communicate between the portal vein system and systemic circulation. SPSS mainly includes esophageal varices, gastric varices, left gastric vein, recanalized paraumbilical vein, abdominal wall varices, and spontaneous splenorenal shunt. SPSS contributes to the development of hepatic encephalopathy caused by portal vein inflow bypassing and carries a higher risk of death in liver cirrhosis. Abdominal contrast-enhanced computed tomography is a major imaging approach to establish a diagnosis of SPSS and evaluate its location and feature. This review primarily describes the main contrast-enhanced CT features of SPSS in liver cirrhosis.

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

Genome-wide association and Mendelian randomization study of blood copper levels and 213 deep phenotypes in humans

Metal elements are present in the human body, and their levels in the blood have important impacts on health. In this study, 2488 Chinese individuals were included in a genome-wide association study of 21 serum metal levels, with approximately 179,000 East Asian individuals in a bidirectional two-sample Mendelian randomization (MR) analysis, and 628,000 Europeans in a two-sample MR analysis. We identified two single nucleotide polymorphisms (SNPs) rs35691438 and rs671 that were significantly associated with serum copper levels (SCLs). The bidirectional two-sample MR analysis in the East Asian population showed that gamma-glutamyl transpeptidase levels have a causal effect on SCLs. SCLs have causal effects on six outcomes, namely risks of esophageal varix, glaucoma, sleep apnea syndrome, and systemic lupus erythematosus, white blood cell count, and usage of drugs affecting bone structure and mineralization. The two-sample MR analyses in the European population showed causal effects of erythrocyte copper levels on risks of carpal tunnel syndrome and compression fracture. Our results provide original insights into the causal relationship between blood metal levels and multiple human phenotypes.

A genome-wide association study in a Chinese population identifies SNPs associated with serum copper levels. Mendelian randomization analysis reveals causal effects on multiple human phenotypes in East Asian and European populations.

UPLC-MS/MS-Based Serum Metabolomics Signature as Biomarkers of Esophagogastric Variceal Bleeding in Patients With Cirrhosis

Background: Esophagogastric variceal bleeding (EVB) is a common and ominous complication of cirrhosis and represents the degree of portal hypertension progression and cirrhosis decompensation, desiderating the investigation into sensitive and specific markers for early detection and prediction. The purpose of this study is to characterize unique metabolites in serum of cirrhotic EVB patients and identify potential noninvasive biomarkers for detecting and assessing risk of variceal bleeding and cirrhosis progression through metabolomics-based approaches and explore possible pathophysiological mechanisms.

Methods: We used ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS) to profile serum metabolomes. In one discovery cohort (n = 26, 13 cases of EVB), univariate and multivariate statistical analyses were performed to demonstrate separation between the two groups and identify differentially expressed metabolites. Potential biomarkers were screened by Boruta and logistic regression analyses, further evaluated by receiver operating characteristic analysis, and tested in two validation cohorts (n = 34, 17 cases and n = 10, 5 cases).

Results: Bioinformatics analyses demonstrated that EVB patients possessed distinct metabolic phenotypes compared with nEVB controls, characterized by seven elevated and six downregulated metabolites, indicating that EVB-related metabolic disturbance might be associated with vitamin metabolism and fatty acid metabolism. Eight potential biomarkers were selected among which citrulline and alpha-aminobutyric acid with moderate AUC values, tested in the validation cohorts, were identified as specific biomarkers of EVB.

Conclusion: Our metabolomic study provides an overview of serum metabolic profiles in EVB patients, highlighting the potential utility of UPLC-MS/MS-based serum fingerprint as a feasible avenue for early detection of EVB.

Endoscopic Treatment of Esophageal Varices

Acute variceal bleeding is a complication of portal hypertension, usually due to cirrhosis, with high morbidity and mortality. There are 3 scenarios for endoscopic treatment of esophageal varices: prevention of first variceal bleed, treatment of active variceal bleed, and prevention of rebleeding. Patients with cirrhosis should be screened for esophageal varices. Recommended endoscopic therapy for acute variceal bleeding is endoscopic variceal banding. Although banding is the first-choice treatment, sclerotherapy may have a role. Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy.

[Value of purple sign for predicting rebleeding events in cirrhotic patients following endoscopic selective varices devascularization]

OBJECTIVE

To assess the value of the purple sign for predicting long-term rebleeding events in cirrhotic patients following endoscopic selective varices devascularization.

METHODS

We retrospectively analyzed the clinical data of 97 patients with liver cirrhosis, who had a history of gastroesophageal variceal bleeding and underwent endoscopic selective varices devascularization. Thirty-two of the patients showed purple sign after endoscopic treatment. We used propensity score matching (PSM) to minimize the selection bias of the patients (purple sign vs no purple sign) and reduce the intergroup differences of clinical characteristics. The primary outcome measure of this study was cumulative rebleeding events after endoscopic selective varices devascularization.

RESULTS

The 1-year rebleeding rate (27.0% vs 36.7%) or 6-month rebleeding rate (10.9% vs 26.9%) following endoscopic treatment was not significantly different between the purple sign group and no purple sign group before PSM (P=0.2385). But after PSM, the 1-year rebleeding rate (28.2% vs 56.4%) and 6-month rebleeding rate (5.0% vs 37.0%) were significantly lower in the purple sign group than in the no purple sign group (P=0.0304).

CONCLUSIONS

The presence of purple sign indicates a lower risk of rebleeding after endoscopic treatment of cirrhotic gastroesophageal varices and a potentially favorable treatment response after endoscopic therapy, thus providing a clinical indicator for stratification of the patients for sequential endoscopic sessions.

Self-expandable metallic stents (SEMS) in esophageal varices post-band ulcer refractory bleeding: a retrospective study

Background

Post-variceal band ligation bleeding ulcer is a severe complication with considerable mortality. We tried evaluating self-expandable metallic stent (SEMS) with concern to the ulcer morphology not well studied.

Results

We did a retrospective analysis of patients with bleeding post-band ulcers and treated by SEMS with concern to control bleeding and 6 weeks survival. Twenty-eight patients studied had their age (mean ± S.D.) 57.8 ± 8.6 years, and 85.7% were males. The Child-Pugh score range was 5–12]. Control of bleeding by SEMS was achieved in 23 (82.1%) patients, and overall, 6-week survival was 75%. Both post-band ulcer types B (oozing blood and type C (active spurted) were a risk for 6 weeks mortality (P = 0.04, OR 1.58, CI 95% 1.12–2.23).

Conclusion

SEMS is considered an excellent choice to control esophageal post-banding ulcer bleeding and a definite treatment bridge.

Additional Benefits Conferred by Endoscopic Sclerotherapy to Liver Cirrhosis Patients Receiving Endoscopic Variceal Ligation

Objective

Gastroesophageal varices are a direct consequence of portal hypertension in cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in reduced mortality and morbidity rates. The study was aimed to analyze the short-term and long-term efficacy of different endoscopic methods in the treatment of gastric varices in cirrhotic patients.

Methods

From January 2016 to December 2019, 135 patients with liver cirrhosis and gastric varices undergoing different endoscopic treatment protocols were retrospectively analyzed. The patients were divided into three groups according to endoscopic variceal ligation, endoscopic sclerotherapy, and a combination of both, respectively. Main outcomes including the overall response rate, hemostasis, short- and long-term rebleeding (3 months before and after treatment), complication, blood pressure, heart rate, portal venous pressure (PVP), portal vein diameter (PVD), portal vein velocity (PVV), portal vein blood flow (PVF) detected by ultrasound, recurrence rate, and mortality were analyzed after treatments.

Results

The overall response rate in the combined group was higher than that in the ligation group and the sclerotherapy group (P < 0.05). The incidence rate of complications in the combined group and the ligation group was lower than that in the sclerotherapy group (P < 0.05). After treatment, the PVP, PVD, and PVF were reduced in the combined group compared with the ligation group and the sclerotherapy group, while the PVV was not (P < 0.05). Lower rates of long-term rebleeding, recurrence, and mortality were noted in the combined group compared to the ligation group and the sclerotherapy group (P < 0.05).

Conclusion

Endoscopic variceal ligation combined with endoscopic sclerotherapy is more effective than both alone in treating liver cirrhosis and gastric varices. The combined therapy contributed to reduced short-term and long-term rebleeding rate, decreased long-term recurrence rate, and mortality.

Percutaneous Transhepatic Embolization of Ectopic Varices in a Patient With Portal Hypertension Presenting With Hemorrhagic Shock

Varices secondary to portal hypertension in the setting of liver cirrhosis typically occur in the gastroesophageal region. Management guidelines for bleeding gastroesophageal varices are well established in the literature. Ectopic varices that occur outside of this typical location are an uncommon complication of portal hypertension. Rarely, these varices can result in life-threatening hemorrhage. Management guidelines of ectopic variceal bleeds are not yet standardized as cases are rare and treatment approach in the literature has historically varied. We present an interesting case of a 37-year-old patient with alcoholic liver disease and cirrhosis who developed spontaneous hemorrhage and shock from bleeding ectopic varices. This report exemplifies how coil embolization via a percutaneous transhepatic approach can be used to manage ectopic variceal bleeds in the setting of hemorrhagic shock.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case-control study

BACKGROUND AND AIMS

The association between prognosis of variceal bleeding and portal vein thrombosis (PVT) is unclear. In this multicentre study, we determined the effect of PVT on rebleeding and mortality in patients with acute variceal bleeding (AVB) after oesophageal variceal band ligation (EVL).

METHODS

Cirrhotic patients with AVB who had undergone EVL were included. The patients were allocated to either the PVT group or the control cirrhotic group (CCG) based on the presence or absence of PVT. One-year rebleeding episodes and mortality after EVL were recorded.

RESULTS

A total of 218 cirrhotic patients with AVB from 3 centres were included. Patients with PVT had a higher rate of 14-day and 6-week rebleeding than those without PVT (14-day: 8.26% vs. 1.83%, p = 0.03; 6-week: 11.92% vs. 1.83%, p = 0.003). The rates of 5-day failure (3.67% vs. 0.92%, p = 0.175), 1-year rebleeding (21.10% vs. 20.18%, p = 0.867), and 14-day, 6-week, and 1-year mortality were similar between the groups (14-day: 3.67% vs. 0.92%, p = 0.175; 6-week: 3.67% vs. 0.92%, p = 0.175; 1-year: 3.67% vs. 1.83%, p = 0.408). The Child-Pugh class [p = 0.022, hazard ratio (HR): 1.453; 95% confidence interval (CI) 1.056-1.998], PVT (p = 0.050, HR: 4.622, 95% CI 0.999-21.395), albumin < 30 g/L (p = 0.023, HR: 5.886, 95% CI 1.272-27.245), and number of bands (p = 0.010, HR: 1.207, 95% CI 1.046-1.393) were identified as the predictors for 14-day rebleeding; the multivariate analysis revealed only the number of bands (p = 0.009, HR: 1.247, 95% CI 1.056-1.473) as the independent factor. PVT (p = 0.012, HR: 6.732, 95% CI 1.519-29.835) and albumin < 30 g/L (p = 0.027, HR: 3.643, 95% CI 1.160-11.441) were identified as predictors for 6-week rebleeding; however, only PVT (p = 0.015, HR: 6.380, 95% CI 1.427-28.515) was found to be the independent factor in the multivariate analysis. Further analysis showed that superior mesenteric vein (SMV) thrombosis is the only risk factor predicting 6-week rebleeding in patients with PVT (p = 0.032, HR: 3.405, 95% CI 1.112-10.429).

CONCLUSIONS

PVT was associated with high 14-day and 6-week rebleeding in patients after EVL. SMV thrombosis was the only risk factor for 6-week rebleeding in patients with PVT. High albumin levels may serve as a protective factor for the 14-day and 6-week rebleeding risk. PVT was not responsible for mortality after EVL during 1-year follow-up.

Self-expandable metallic stents (SEMS) in esophageal varices post-band ulcer refractory bleeding: a retrospective study

Background

Post-variceal band ligation bleeding ulcer is a severe complication with considerable mortality. We tried evaluating self-expandable metallic stent (SEMS) with concern to the ulcer morphology not well studied.

Results

We did a retrospective analysis of patients with bleeding post-band ulcers and treated by SEMS with concern to control bleeding and 6 weeks survival. Twenty-eight patients studied had their age (mean ± S.D.) 57.8 ± 8.6 years, and 85.7% were males. The Child-Pugh score range was 5–12]. Control of bleeding by SEMS was achieved in 23 (82.1%) patients, and overall, 6-week survival was 75%. Both post-band ulcer types B (oozing blood and type C (active spurted) were a risk for 6 weeks mortality (P = 0.04, OR 1.58, CI 95% 1.12–2.23).

Conclusion

SEMS is considered an excellent choice to control esophageal post-banding ulcer bleeding and a definite treatment bridge.

Complications and management of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices

OBJECTIVE

To report the complications and evaluate the risk factors of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices in cirrhotic patients.

METHODS

A total of 583 elective endoscopic tissue adhesives procedures were performed in 439 patients in our hospital from January 2015 to December 2016. The clinical characteristics and complications were retrospectively collected and evaluated.

RESULTS

The median age was 56 ± 11 years, and 290 (66.1%) patients were male. The main etiology of liver cirrhosis was hepatitis virus (63.3%). Two hundred fifty-nine (59.0%) patients were classified as Child-Pugh Class A. Bleeding occurred in 44 patients (7.5%) during procedures. Two patients developed distant embolism (0.5%; one pulmonary, one cerebra). In perioperative period, fever was a common complication; however, only 16 cases had high fever and one case had sepsis. Bleeding was observed in 7 (1.2%) patients. Overall incidence of the major perioperative complication was 3.8%. The major postoperative complication rate was 10.4% (60/582, 26 rebleeds, 27 ascites increase, 12 new-onset portal vein thrombosis). The complication-related death was 1.6% (one death from embolism, five deaths from rebleeding, one death from refractory ascites). Injection point was the only factor related to the major perioperative complications [odds ratio (OR) = 1.581, 95% CI, 1.086-2.301; P < 0.05]. Etiology of cirrhosis and injection point were independent risk factors of major postoperative complications (OR = 1.830, 95% CI, 1.005-3.331, P = 0.048; OR = 1.373, 95% CI, 1.089-1.731, P = 0.007).

CONCLUSION

The incidence of complications after elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices was low. The injection point was the risk factor for both perioperative and postoperative complications.

Application of artificial intelligence to endoscopy on common gastrointestinal benign diseases

Artificial intelligence (AI) has been widely involved in every aspect of healthcare in the preclinical stage. In the digestive system, AI has been trained to assist auxiliary examinations including histopathology, endoscopy, ultrasonography, computerized tomography, and magnetic resonance imaging in detection, diagnosis, classification, differentiation, prognosis, and quality control. In the field of endoscopy, the application of AI, such as automatic detection, diagnosis, classification, and invasion depth, in early gastrointestinal (GI) cancers has received wide attention. There is a paucity of studies of AI application on common GI benign diseases based on endoscopy. In the review, we provide an overview of AI applications to endoscopy on common GI benign diseases including in the esophagus, stomach, intestine, and colon. It indicates that AI will gradually become an indispensable part of normal endoscopic detection and diagnosis of common GI benign diseases as clinical data, algorithms, and other related work are constantly repeated and improved.

Ectopic variceal bleeding after hepatobiliary surgery: A case report

RATIONALE

Jejunal varices are rare in portal hypertension and are often difficult to diagnose and treat. Herein, we present a case of gastrointestinal bleeding due to jejunal varices after hepatobiliary surgery.

PATIENT CONCERNS

A 69-year-old man presented with recurrent massive gastrointestinal bleeding. He underwent partial right hepatectomy and cholangiojejunostomy 2 years prior to the first onset of bleeding. Two sessions of endoscopic vessel ligation for esophageal varices were performed afterwards, and hematemesis resolved completely, but massive melena still recurred during the following 5 years.

DIAGNOSIS

The patient was diagnosed with jejunal varices caused by portal venous stenosis after hepatobiliary surgery.

INTERVENTION

Portal venous angioplasty using balloon dilation and stent implantation was performed.

OUTCOMES

After the intervention procedure, the patient did not experience any onset of gastrointestinal bleeding during follow-up.

LESSONS

Hepatopancreatobiliary could lead to the formation of jejunal varices. The combined use of capsule endoscopy, contrast-enhanced computed tomography, and sometimes portal venography is a promising strategy to search for jejunal varices. Transcatheter angioplasty appears to be a safe and effective method for treatment of jejunal varices in certain appropriate cases.

Fluoroscopy-guided endoscopic sclerotherapy: a novel hybrid approach for symptomatic rectosigmoidal venous malformation (with video)

BACKGROUND AND AIMS

Recommendations for the treatment of lower GI bleeding do not include bleeding from venous malformations (VMs). The aim of this study was to delineate the usefulness of a novel hybrid intervention (fluoroscopy-guided endoscopic sclerotherapy) for the treatment of symptomatic VMs in the rectosigmoidal colon with bleeding.

METHODS

The magnetic resonance images of 421 patients with VM, referred to multicenter vascular anomaly centers from 2009 to 2017, were analyzed retrospectively. Treatment was performed for all patients who experienced bleeding from rectosigmoidal VMs using fluoroscopy-guided endoscopic sclerotherapy with polidocanol foam as a novel approach.

RESULTS

A total of 27 patients displayed VM in the rectosigmoidal area. Eleven of these presented with acute or previous bleeding and received treatment. Active bleeding was observed in 8 patients (72.7%), whereas 3 patients (27.3%) had signs of previous bleeding. Six of the 11 patients had anemia (54.5%). There were no adverse events within 24 hours of the intervention. In a 2-year follow-up period, only 1 patient (9.1%) presented with recurrent bleeding after 13 months and was successfully treated again with fluoroscopy-guided endoscopic sclerotherapy.

CONCLUSIONS

Fluoroscopy-guided endoscopic sclerotherapy was shown to be a safe and effective treatment of symptomatic VMs of the rectosigmoidal area. Thus, fluoroscopy-guided endoscopic sclerotherapy should be considered for patients with bleeding from VMs of the rectosigmoid after a comprehensive workup and interdisciplinary case discussion.

Validation of albumin, bilirubin, and platelet criteria for avoiding screening endoscopy in patients with advanced fibrosis

AIM

The albumin, bilirubin, and platelet (ABP) criteria was proposed to avoid screening endoscopy for detecting high-risk varices (HRV) and it has high diagnostic accuracy. We carried out a retrospective cross-sectional study to verify the diagnostic accuracy.

METHODS

A total of 610 patients with advanced fibrosis were enrolled in the study. ABP criteria are defined as follows: albumin >4.0 g/dL, bilirubin <22 μmol/L, and platelets >114 000/μL.

RESULTS

Background liver disease were hepatitis C/hepatitis B/non-alcoholic fatty liver disease/others:405 (66.4%)/67 (10.5%)/78 (12.8%)/60 (10.3%). A total of 105 patients (17.2%) had HRV. In multivariate analysis, serum bilirubin <22 μmol/L (HR 2.00, 95% CI 1.2-3.4), albumin >4.0 g/dL (HR 2.56, 95% CI 1.7-3.8), and platelets >114 000/μL (HR 3.52, 95% CI 2.1-5.8) levels were independently associated with no presence of HRV. When the ABP criteria were examined, 200 patients (32.8%) fulfilled the criteria, and 194 patients had no HRV (positive predictive value 97.0%) When classified by etiologies (hepatitis C/hepatitis B/non-alcoholic fatty liver disease), positive predictive value were 97.7/100/92.0%, respectively.

CONCLUSIONS

The ABP criteria are easy to examine, because they use only standard laboratory tests, and they are available for screening patients who might avoid endoscopy regardless of etiologies.