Eradication of esophageal varices by sclerotherapy combined with argon plasma coagulation: Effect of portal hemodynamics and longitudinal clinical course

Evaluation and management of esophageal varices by through-the-scope endoscopic Doppler probe method

OBJECTIVES

Objective assessments of esophageal varices (EVs) are inadequate. The recurrence of variceal bleeding after endoscopic variceal ligation (EVL) is associated with residual blood flow underlying EVL or incomplete treatment of a perforating vein by EVL. We aimed to assess our novel through-the-scope endoscopic Doppler probe method (DOP) for the evaluation and management of EVs.

METHODS

This study included 20 patients (54 varices) with a history of esophageal variceal rupture from June 2019 to May 2021 who underwent DOP at a tertiary hospital. Variceal velocities were compared based on the size and endoscopic variceal findings. Additionally, we performed EVL assisted by DOP (EVL + DOP) in nine patients.

RESULTS

Doppler imaging of EVs was observed in all 20 patients. The velocity of varices was significantly higher in EVs with a larger size, greater form, blue color, and red color sign positive. Perforating veins connecting to the EVs were identified in six out of nine patients who underwent EVL + DOP. Eight out of nine patients underwent repeat EVL. Repeat EVL was performed until the variceal velocity reached absent. No recurrence of variceal bleeding occurred during the follow-up period (mean 8.7 ± 3.2 months). No adverse events associated with DOP were observed.

CONCLUSION

The evaluation of EVs using DOP is feasible and accurate. EV velocities are related to the variceal size, form, blue color, and red color sign. EVL + DOP may be a more reliable treatment for EVs. Further large-scale, long-term comparative studies are warranted.

Variceal Bleeding: Beyond Banding

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Role of argon plasma coagulation in treatment of esophageal varices

With the development of endoscopic therapy, argon plasma coagulation (APC) has been widely used by endoscopists. It has many advantages, such as simple to operate, low cost, and minimal invasiveness. Because of its capability of lesion ablation and hemostasis, APC has several indications in the gastrointestinal tract. One of them is esophageal varices. The aim of this review is to summarize the research on APC in this field to provide a reference for clinical practice.

The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study

Background

The recurrence of esophageal varices remains high in patients with hepatic portal hypertension after the endoscopic esophageal variceal eradication therapies, including endoscopic variceal band ligation (EVL), injection sclerotherapy (EIS) or EVL plus EIS. The aim of this study was to evaluate the endoscopic ultrasound probe examinations (EUP) findings in the prediction of recurrence following esophageal variceal eradication in a prospective cohort.

Methods

A total of 206 cirrhotic portal hypertension patients with esophageal variceal eradication, who underwent endoscopic variceal therapy (EVL or EIS or EVL plus EIS) were initially enrolled. All patients were scheduled for a follow-up every 6 months for up to 3 years. EUP was performed to evaluate peri-esophageal collateral veins (peri-ECVs), perforating veins (PFV) and para-esophageal collateral veins (para-ECVs). In addition, computed tomography (CT) were conducted to detect portal vein diameter, portal vein embolus, and major portosystemic collateral shunts. The relationship between esophageal variceal recurrence and EUP findings were analyzed.

Results

We found that as high as 93.5% of patients developed esophageal variceal recurrence in the 3-year follow-up. The time of esophageal variceal recurrence after variceal eradication was 13.4 months (13.4 ± 9.2 months). Furthermore, the median time of recurrence in patients who were undertaken EVL,EIS and EVL plus EIS was 10, 13 and 12 months, respectively. We identified that the risk factors, including EVL (OR 0.23, 95% CI 0.08–0.71, p < 0.01), Child-Pugh score (OR 3.32,95% CI 1.31–35.35, p < 0.05), large peri-ECVs (OR 4.56, 95% CI 2.17–9.58, p < 0.0001), and existence of PFV (OR 2.14, 95% CI 1.44–3.16, p < 0.001), were significantly associated with the recurrence of esophageal varices. The peri-ECVs and PFV showed better ability to predict esophageal variceal recurrence. When cut-off value of peri-ECVs diameter was 3.5 mm, the specificity of prediction 1-year variceal recurrence was 86% and the sensitivity was 45%.

Conclusions

The EUP appears to be very effective, convenient and economical examinations to predict esophageal varices recurrence after variceal eradication by endoscopic therapies. The high Child-pugh score, large peri-ECVs, and PFV are independent risk factors related to esophageal varices recurrence.

Thrombin combined with somatostatin for treatment of patients with upper gastrointestinal hemorrhage: Impact on inflammatory factors and coagulation function

AIM

To evaluate the effect of thrombin combined with somatostatin on inflammatory factors and coagulation function in patients with upper gastrointestinal hemorrhage.

METHODS

Seventy patients with upper gastrointestinal bleeding treated from July 2015 to June 2017 were divided into either an observation group or a control group. The control group was given octreotide alone, and the observation group was given thrombin combined with octreotide. After treatment, serum inflammatory factors, coagulation function, clinical efficacy, and adverse reactions were compared between the two groups.

RESULTS

Time to hemostasis was significantly shorter in the observation group than in the control group (16.75 h ± 3.12 h vs 25.46 h ± 3.45 h, t = 11.078, P < 0.01). The effective rate was significantly higher in the observation group than in the control group [94.29% (33/35) vs 77.14% (27/35), χ² = 4.200, P < 0.05]. Serum tumor necrosis factor α (5.32 ng/L ± 0.75 ng/L vs 8.02 ng/L ± 1.24 ng/L, t = 11.022, P < 0.01 ) and interleukin (IL)-6 levels (20.12 ng/L ± 3.45 ng/L vs 31.26 ng/L ± 4.12 ng/L, t = 12.264, P < 0.01) were significantly lower and serum IL-2 (6.75 ng/L ± 1.02 ng/L vs 4.68 ng/L ± 0.76 ng/L, t = 10.349, P < 0.01) was significantly higher in the observation group than in the control group. Prothrombin time (13.32 s ± 2.2 s vs 16.84 s ± 3.24 s, t = 5.249, P < 0.05) and activated partial thromboplastin time (33.12 s ± 4.56 s vs 40.18 s ± 5.35 s, t = 5.942, P < 0.05) were significantly lower, and platelets (67.82 × 10⁹/L ± 8.36 × 10⁹/L vs 58.75 × 10⁹/L ± 6.82 × 10⁹/L, t = 4.973, P < 0.05) and plasma fibrinogen (315.45 g/L ± 45.24 g/L vs 284.72 g/L ± 40.15 g/L, t = 3.006, P < 0.05) were significantly higher in the observation group than in the control group.

CONCLUSION

Thrombin combined with somatostatin can shorten hemostatic time and improve clinical efficacy in patients with upper gastrointestinal hemorrhage, which may be related to reducing inflammatory symptoms and improving coagulation function.

Dual red imaging (novel advanced endoscopy) can increase visibility and can predict the depth in diagnosing esophageal varices

BACKGROUND

Dual red imaging (DRI) is a new technology that can increase the visibility of deeper veins compared with narrow band imaging (NBI). As esophageal varices (EVs) are a vascular disease occurring in the submucosal layer, their visibility might be increased by DRI. We prospectively clarified whether the visibility of EVs with red color sign (RCS) can be increased by DRI, and clarified the relation between the visibility scores and the obtained endoscopic ultrasound (EUS) images.

METHODS

Forty patients were enrolled. The visibility of the EVs on DRI and NBI endoscopic images was evaluated by five observers in a blinded manner and was compared with a white light image (bad, 0; equal, 1; good, 2). The diameter of the lumen and the depth of the EVs and RCS from the epithelium were measured by EUS. The relation between the visibility scores and the EUS findings was investigated.

RESULTS

The DRI scores were 1.66 ± 0.34 for the EV substance and 1.79 ± 0.28 for the RCS, whereas the NBI scores were 0.68 ± 0.38 and 0.41 ± 0.28, respectively. A significant negative correlation was found between the depth and the visibility score (r = -0.505, p = 0.001 for EVs; r = -0.458, p = 0.003 for RCS).

CONCLUSIONS

DRI increased the visibility of the EVs and RCS. The visibility of the EVs or RCS in the shallower position was more enhanced by DRI. Visual recognition of the changing degrees of visibility by DRI enables the prediction of the depth of EVs.