Practical approach to endoscopic management for bleeding gastric varices

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

Ендоскопічне лікування кровотеч із варикозно розширених вен шлунка

Кровотеча з варикозно розширених вен стравоходу та шлунка є найнебезпечнішим для життя ускладненням цирозу печінки та портальної гіпертензії. Кровотеча з варикозно розширених вен шлунка часто є серйознішою та може призвести до смерті. Для її зупинки спочатку проводиться ендоскопічне лікування. Зараз міжнародні консенсусні рекомендації щодо лікування кровотечі з варикозу шлунка відрізняються залежно від ендоскопічної класифікації. Варикозне розширення вен шлунка має іншу фізіологію та клінічні характеристики порівняно з варикозним розширенням вен стравоходу. Існує мало інформації про способи гемостазу при кровотечі зі шлункових вариксів. Незважаючи на те, що кілька нещодавніх розробок щодо препаратів і методів поліпшили результати при цій патології, консенсус щодо оптимального лікування не досягнутий. У цій статті розглядаються сучасні можливості ендоскопічного втручання при варикозній кровотечі зі шлунка за літературними даними з бази MedLine.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The “sandwich” method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report

BACKGROUND

Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections.

CASE SUMMARY

A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period.

CONCLUSION

EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Management Options for Gastric Variceal Hemorrhage

Importance

Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed.

Observations

Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension.

Conclusions and Relevance

Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

The role of divided injections of a sclerotic agent over two days in balloon-occluded retrograde transvenous obliteration for large gastric varices

Objective

To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension.

Materials and Methods

50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed.

Results

In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen.

Conclusion

When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.