Hemostasis With Endoscopic Band Ligation for Rupture of Jejunal Varices

Diagnosis and management of ectopic varices in portal hypertension

Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.

Efficacy of early re-ligation after endoscopic gastric glue injection combined with endoscopic variceal ligation in preventing rebleeding of esophagogastric varices in patients with cirrhosis

BACKGROUND

The rate of rebleeding after successful hemostasis by endoscopic gastric glue injection (EGGI) combined with endoscopic variceal ligation (EVL) in ruptured esophagogastric varices (EHV) in cirrhosis is still high, and a second EVL is often required, but the optimal interval between the first and second EVL has not been determined.

AIM

To explore the effect of timing of the second EVL after EGGI combined with EVL in the prevention of rebleeding from esophagogastric varices in patients with liver cirrhosis.

METHODS

A total of 121 patients with cirrhosis and hemorrhage who were treated at our hospital from May 2017 to September 2019 were retrospectively selected and divided into 1 mo group (n = 27), 2 mo group (n = 32), 3 mo group (n = 37), and > 3 mo group (n = 25) based on the interval between the first and second EVL. The curative effect, rebleeding rate, fatality rate, rate of complications and portal hemodynamic changes (splenic vein, portal vein, and left gastric vein diameter and mean blood flow velocity) after the completion of the second EVL were compared among the groups.

RESULTS

The total effective rate in the 1 mo group was 100.00% (27/27), significantly higher than those of the 2 mo [78.13% (25/32)], 3 mo [75.68% (28/37)], and > 3 mo [68.00% (17/25)] groups (P < 0.05). The rebleeding rate in the 1 mo group [3.70% (1/27)] was significantly lower than those of the 2 mo [31.25% (10/32)], 3 mo [37.84% (14/32)], and > 3 mo [68.00% (17/25)] groups (P < 0.05); the rebleeding rate in the 2 mo group was significantly lower than that of the > 3 mo group (P < 0.05). The mortality rate in the 1 mo group (0) was significantly lower than that of the > 3 mo group [24.00% (6/25)] (P < 0.05). The average blood flow velocity of the splenic vein and portal vein after the second EVL in the 1 mo group [(32.42 ± 3.36) cm/s and (27.51 ± 2.79) cm/s, respectively] were significantly higher than those of the 2 mo [(30.02 ± 2.77) cm/s and (24.55 ± 2.61) cm/s, respectively], 3 mo [(29.11 ± 3.24) cm/s and (24.19 ± 2.38) cm/s, respectively], and > 3 mo [(29.04 ± 2.81) cm/s and (23.89 ± 2.11) cm/s, respectively] groups (P < 0.05).

CONCLUSION

Early re-ligation after EGGI combined with EVL can effectively, safely, and reliably improve the severity of varicose veins and reduce the rebleeding rate, and has a positive impact on the portal venous system.

Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review

INTRODUCTION

Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports.

METHODS

We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review.

RESULTS

We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07).

DISCUSSION

A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.