How to Approach a Patient With Gastric Varices

[Trends in endovascular treatment and prevention of portal bleeding]

Bleeding from esophageal and gastric varices is a major factor of mortality in patients with portal hypertension. The gold standard for diagnosis of portal hypertension is hepatic venous pressure gradient determining the treatment algorithms and risk of recurrent bleeding. Combination of endoscopic methods and therapy is limited by varix localization and not always effective. In these cases, endovascular bypass and decoupling techniques are preferred. Early endovascular treatment of portal bleeding is effective for hemostasis and higher transplantation-free survival of patients. Early transjugular intrahepatic portosystemic bypass should be associated with 8-mm covered stents of controlled dilation. Combination of endovascular techniques reduces the complications of each technique and potentiates their positive effect. Endovascular treatment and prevention of portal bleeding should be determined by anatomical features of portal venous system.

Comparison of the management of gastric variceal bleeding techniques

Background and Aim

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

Methods

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

Results

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

Conclusion

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

Clinical outcomes related to portal pressures before and after embolization of large portosystemic shunts in cirrhosis

Objectives

Embolization of large portosystemic shunts effectively controls gastric variceal bleeding and prevents hepatic encephalopathy. The significance of dynamic changes in hepatic venous pressure gradient before and after embolization on clinical events and patient outcomes remains unknown.

Methods

In this retrospective single-center series, 46 patients with gastric variceal bleeding, hepatic encephalopathy, or both undergoing embolization (January 2018 to October 2020) were included, and dynamic changes in portal pressures were analyzed against patient outcomes.

Results

Males predominated. The most common portosystemic shunt syndrome was the lienorenal shunt. In all, 34 patients underwent embolization for hepatic encephalopathy and 11 for gastric variceal bleeding. The proportion of patients surviving at the end of 12 and 32 months was 86.96 and 54.35%, respectively. The hepatic venous pressure gradient before shunt embolization was 13.4 ± 3.2 and 16.9 ± 3.7 mm Hg after occlusion (p < 0.001). Bleeding from varices on overall follow-up was notable in five patients (10.9%), and overt hepatic encephalopathy in four (N = 42, 9.5%) patients at 6-12 months. The development of infections within 100 days and beyond the first year was associated with the risk of dying at the end of 12 and 32 months, respectively. Elevation of hepatic venous pressure gradient by >4 mm Hg from baseline and an absolute increase to >16 mm Hg immediately post-procedure significantly predicted the development of early- and late-onset ascites, respectively.

Conclusion

Close monitoring for the development of infections and optimization of beta-blockers and diuretics after shunt embolization may improve clinical outcomes and help identify patients who will benefit from liver transplantation pending prospective validation.

Non-invasive model for predicting esophageal varices based on liver and spleen volume

BACKGROUND

Upper endoscopy is the gold standard for predicting esophageal varices in China. Guidelines and consensus suggest that patients with liver cirrhosis should undergo periodic upper endoscopy, most patients undergo their first upper endoscopy when esophageal variceal bleeds. Therefore, it is important to develop a non-invasive model to early diagnose esophageal varices.

AIM

To develop a non-invasive predictive model for esophageal varices based on liver and spleen volume in viral cirrhosis patients.

METHODS

We conducted a cross-sectional study based on viral cirrhosis crowd in the Second Affiliated Hospital of Xi'an Jiaotong University. By collecting the basic information and clinical data of the participants, we derived the independent risk factors and established the prediction model of esophageal varices. The established model was compared with other models. Area under the receiver operating characteristic curve, calibration plot and decision curve analysis were used to test the discriminating ability, calibration ability and clinical practicability in both the internal and external validation.

RESULTS

The portal vein diameter, the liver and spleen volume, and volume change rate were the independent risk factors of esophageal varices. We successfully used the factors to establish the predictive model [area under the curve (AUC) 0.87, 95%CI: 0.80-0.95], which showed better predictive value than other models. The model showed good discriminating ability, calibration ability and the clinical practicability in both modelling group and external validation group.

CONCLUSION

The developed non-invasive predictive model can be used as an effective tool for predicting esophageal varices in viral cirrhosis patients.