1
|
Haddad S, Haddad S, Swaid K, Martini N, Mansour M, Alkouri L. Portal vein thrombosis in a 10-month-old infant as a complication of neonatal umbilical catheterization: a case report. Ann Med Surg (Lond) 2023; 85:5158-5162. [PMID: 37811093 PMCID: PMC10553039 DOI: 10.1097/ms9.0000000000001173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Esophageal varices bleeding after portal hypertension is a rare condition in children but is associated with significant morbidity and mortality. Neonatal umbilical catheterization is one of the risk factors for the development of portal vein thrombosis (PVT) and portal hypertension. Case presentation Neonatal umbilical catheterization was used here to provide appropriate treatment for postpartum sepsis. Color Doppler revealed an approximate total obstruction of the portal vein, and endoscopy showed esophageal varices. The patient was sequentially managed with endoscopic sclerotherapy. Discussion The manifestations associated with PVT (like splenomegaly and bleeding esophageal varices) have been detected in a 10-month-old, which is considered a relatively young age according to the medical literature review. Conclusion Using umbilical vein catheterization in neonates may be associated with several complications, including PVT. This case report describes a rare instance of portal hypertension complicated by bleeding esophageal varices in a 10-month-old infant who had undergone newborn umbilical catheterization.
Collapse
Affiliation(s)
| | | | | | - Nafiza Martini
- Faculty of Medicine, Damascus University
- Stemosis for Scientific Research
| | - Marah Mansour
- Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lina Alkouri
- Damascus University, Pediatric University Hospital, Damascus
| |
Collapse
|
2
|
Kiran HS, Karkra R, Laghima VN, Venkatesh CR. Chronic Extrahepatic Portal Vein Occlusion in a Young Patient. Cureus 2023; 15:e40806. [PMID: 37485108 PMCID: PMC10362884 DOI: 10.7759/cureus.40806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Extrahepatic portal vein obstruction (EHPVO) is a rare condition characterized by the occlusion or narrowing of the portal vein outside the liver. We present a case report of a patient with EHPVO secondary to combined protein C and S deficiency and pancytopenia secondary to hypersplenism, highlighting the clinical presentation, diagnostic challenges, and management strategies. Early recognition of this condition and prompt initiation of appropriate treatment can prevent life-threatening complications such as variceal bleeding and portal hypertension. This case underscores the need for a high index of suspicion for inherited thrombophilias in patients presenting with portal vein thrombosis, particularly in the absence of traditional risk factors.
Collapse
Affiliation(s)
- H S Kiran
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - Rohan Karkra
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - V N Laghima
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| | - C R Venkatesh
- Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education & Research (JSSAHER), Mysuru, IND
| |
Collapse
|
3
|
Ahmed Z, Farooq U, Faiza Arif S, Aziz M, Iqbal U, Nawaz A, Lee-Smith W, Badal J, Mahmood A, Kobeissy A, Nawras A, Hassan M, Saab S. Transjugular Intrahepatic Portosystemic Shunt Outcomes in the Elderly Population: A Systematic Review and Meta-Analysis. Gastroenterology Res 2022; 15:325-333. [PMID: 36660467 PMCID: PMC9822662 DOI: 10.14740/gr1571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure typically utilized to treat refractory ascites and variceal bleeding. However, TIPS can lead to significant complications, most commonly hepatic encephalopathy (HE). Advanced age has been described as a risk factor for HE, as the elderly population tends to have decreased cognitive reserve and increased sarcopenia. We conducted a systematic review and meta-analysis of the available literature to summarize the association between advanced age and risk of adverse events after undergoing TIPS. Methods A comprehensive search strategy to identify reports of specific outcomes (HE, 30-day and 90-day mortality, and 30-day readmission due to HE) in elderly patients after undergoing TIPS was developed in Embase (Embase.com, Elsevier). We compared outcomes and performed separate data analyses for patients aged < 70 vs. > 70 years and patients aged < 65 vs. > 65 years. Results Six studies with a total of 1,591 patients met our inclusion criteria and were included in the final meta-analysis. Three studies divided patients by age < 65 vs. > 65 years, with a total of 816 patients who were 54% male. The remaining three studies divided patients by age < 70 vs. > 70 years, with a total of 775 patients who were 63% male. Results demonstrated a significantly lower risk of post-TIPS HE (risk ratio (RR): 0.42, confidence interval (CI): 0.185 - 0.953, P = 0.03, I2 = 49%), 30-day mortality (RR: 0.37, CI: 0.188 - 0.74, P = 0.005, I2 = 0%), and 90-day mortality (RR: 0.35, CI: 0.24 - 0.49, P = 0.001, I2 = 0%) in patients aged > 70 vs. < 70 years, as well as a trend towards lower risk of 30-day readmission due to HE. There was no significant difference in post-TIPS HE, 30-day or 90-day mortality, or 30-day readmission due to HE between patients aged < 65 vs. > 65 years. Conclusion Age > 70 years is associated with significantly higher rates of HE and 30-day and 90-day mortality rates in patients after undergoing TIPS, as well as a trend towards higher 30-day readmission due to HE.
Collapse
Affiliation(s)
- Zohaib Ahmed
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA,Corresponding Author: Zohaib Ahmed, Department of Internal Medicine, University of Toledo, Toledo, Oh, USA.
| | - Umer Farooq
- Department of Internal Medicine, Loyola Medicine/MacNeal Hospital, Chicago, IL, USA
| | | | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Umair Iqbal
- Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Ahmad Nawaz
- Division of Internal Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Joyce Badal
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Abdallah Kobeissy
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Sammy Saab
- Department of Medicine and Surgery at the David Geffen School of Medicine at UCLA (University of California Los Angeles), Los Angeles, CA, USA
| |
Collapse
|
4
|
Zhang Q, Jin J, Zhang F, Xiang Y, Wu W, Wang Z, Kong D. Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study. Surg Endosc 2022; 36:7839-7847. [PMID: 35879573 PMCID: PMC9485182 DOI: 10.1007/s00464-022-09412-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/24/2022] [Indexed: 11/30/2022]
Abstract
Background Herein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs. Methods Ninety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding. Results The mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed. Conclusion The bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09412-6.
Collapse
Affiliation(s)
- Qianqian Zhang
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Yi Xiang
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Wenyue Wu
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - ZeXue Wang
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, Key Laboratory of Digestive Diseases of Anhui Province, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China. .,Fuyang Hospital of Anhui Medical University, Fuyang, Anhui, 236000, People's Republic of China.
| |
Collapse
|
5
|
Feiner R, Johns E, Antman-Passig M, Khan D, Witek L, Berisha N, Irie T, Oved H, White RM, Heller DA. Drug-Eluting Rubber Bands for Tissue Ligation. ACS APPLIED MATERIALS & INTERFACES 2022; 14:27675-27685. [PMID: 35670525 PMCID: PMC10015968 DOI: 10.1021/acsami.2c06175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Rubber band ligation is a commonly used method for the removal of tissue abnormalities. Most often, rubber band ligation is performed to remove internal hemorrhoids unresponsive to first line treatments to avoid surgery. While the procedure is considered safe, patients experience mild to significant pain and discomfort until the tissue sloughs off. As patients often require multiple bandings and sessions, reducing these side effects can have a considerable effect on patient adherence and quality of life. To reduce pain and discomfort, we developed drug-eluting rubber bands for ligation procedures. We investigated the potential for a band to elute anesthetics and drug combinations to durably manage pain for a period of up to 5 days while exhibiting similar mechanical properties to conventional rubber bands. We show that the rubber bands retain their mechanical properties despite significant drug loading. Lidocaine, released from the bands, successfully altered the calcium dynamics of cardiomyocytes in vitro and modulated heart rate in zebrafish embryos, while the bands exhibited lower cytotoxicity than conventional bands. Ex vivo studies demonstrated substantial local drug release in enteric tissues. These latex-free bands exhibited sufficient mechanical and drug-eluting properties to serve both ligation and local analgesic functions, potentially enabling pain reduction for multiple indications.
Collapse
Affiliation(s)
- Ron Feiner
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA
| | - Eleanor Johns
- Cancer Biology and Genetics Program, Memorial Sloan Kettering Cancer Center, New York, 10065, USA; Gerstner Sloan Kettering Graduate School of Biomedical Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA
| | - Merav Antman-Passig
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA
| | - Doha Khan
- Division of Biomaterials – Department of Molecular Pathobiology, NYU College of Dentistry, New York, NY, 10010, USA
| | - Lukasz Witek
- Division of Biomaterials – Department of Molecular Pathobiology, NYU College of Dentistry, New York, NY, 10010, USA; Department of Biomedical Engineering, NYU Tandon School of Engineering, Brooklyn, NY, 11201, USA
| | - Naxhije Berisha
- The Graduate Center of the City University of New York, New York, NY, 10016, USA; Department of Nanotechnology, Advanced Science Research Center (ASRC) at the Graduate Center of the City University of New York, New York, NY, 10031, USA; Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA
| | - Takeshi Irie
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA; Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA
| | - Hadas Oved
- Shmunis School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Richard M. White
- Cancer Biology and Genetics Program, Memorial Sloan Kettering Cancer Center, New York, NY, 10065 USA; Weill Cornell Medical College, New York, New York 10065, United States
| | | |
Collapse
|
6
|
Vidili G, Arru M. Non-invasive tools for the prediction of esophageal varices in cirrhosis: Can advanced ultrasound techniques spare endoscopy? JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:364-366. [PMID: 35277979 PMCID: PMC9314588 DOI: 10.1002/jcu.23176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Gianpaolo Vidili
- Department of Medical, Surgical and Experimental SciencesUniversity of SassariSassariItaly
| | - Marco Arru
- Department of Medical, Surgical and Experimental SciencesUniversity of SassariSassariItaly
| |
Collapse
|
7
|
Efficacy of Endoscopic Band Ligation in the Treatment of Acute Esophageal Varicose Bleeding. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1015238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
8
|
CT hepatic arterial perfusion index does not allow stratification of the degree of esophageal varices and bleeding risk in cirrhotic patients in Child-Pugh classes A and B. Abdom Radiol (NY) 2021; 46:5586-5597. [PMID: 34453180 PMCID: PMC8590679 DOI: 10.1007/s00261-021-03259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
Purpose To evaluate if the hepatic arterial perfusion index (HPI) in liver parenchyma of cirrhotic patients can serve as a surrogate parameter for stratifying the degree of esophageal varices and related bleeding risks. Methods CT image data of sixty-six patients (59 men; mean age 68 years ± 10 years) with liver cirrhosis (Child–Pugh class A (35/66, 53%), B (25/66, 38%), and C (6/66, 9%) who underwent perfusion CT (PCT) for hepatocellular carcinoma (HCC) screening between April 2010 and January 2019 were retrospectively identified. HPI, a parameter calculated by a commercially available CT liver perfusion analysis software that is based on the double maximum slope model, using time attenuation curve to determine perfusion, was correlated with the degree of esophageal varices diagnosed at endoscopy and the number of bleeding events. Results Eta correlation coefficient for HPI/presence of esophageal varices was very weak (0.083). Spearman-Rho for HPI/grading of esophageal varices was very weak (0.037 (p = 0.804)). Kendall-Tau-b for HPI/grading of esophageal varices was very weak (0.027 (p = 0.807)). ANOVA and Bonferroni post-hoc-tests showed no significant difference of HPI between different grades of esophageal varices (F (3, 62) = 1.676, p = 0.186). Eta correlation coefficient for HPI/bleeding event was very weak (0.126). Conclusion The stratification of the degree of esophageal varices and the related bleeding risk by correlation with the HPI as a surrogate parameter for portal venous hypertension was not possible for patients with liver cirrhosis in Child–Pugh class A and B. Graphic abstract ![]()
Collapse
|
9
|
Zia HA, Aby ES, Rabiee A. An Update on the Management of Esophageal Variceal Hemorrhage. Clin Liver Dis (Hoboken) 2021; 18:179-183. [PMID: 34745574 PMCID: PMC8549718 DOI: 10.1002/cld.1108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Audio Recording.
Collapse
Affiliation(s)
- Hassaan A. Zia
- Division of Gastroenterology, Hepatology and NutritionUniversity of ChicagoChicagoIL
| | - Elizabeth S. Aby
- Division of Gastroenterology, Hepatology, and NutritionUniversity of MinnesotaMinneapolisMN
| | - Atoosa Rabiee
- Division of Gastroenterology and HepatologyWashington DC Veterans Affairs Medical CenterWashingtonDC
| |
Collapse
|
10
|
Abstract
Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.
Collapse
|
11
|
Schluckebier D, Afzal NA, Thomson M. Therapeutic Upper Gastrointestinal Endoscopy in Pediatric Gastroenterology. Front Pediatr 2021; 9:715912. [PMID: 35280448 PMCID: PMC8913901 DOI: 10.3389/fped.2021.715912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
This paper seeks to give a broad overview of pediatric upper gastrointestinal (GI) pathologies that we are now able to treat endoscopically, acquired or congenital, and we hope this delivers the reader an impression of what is increasingly available to pediatric endoscopists and their patients.
Collapse
Affiliation(s)
- Dominique Schluckebier
- Pediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, United Kingdom
| | - Nadeem Ahmad Afzal
- Department of Paediatrics, Southampton Children's Hospital, Southampton, United Kingdom
| | - Mike Thomson
- Pediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, United Kingdom
| |
Collapse
|
12
|
Simonetti RG, Perricone G, Robbins HL, Battula NR, Weickert MO, Sutton R, Khan S. Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis. Cochrane Database Syst Rev 2020; 10:CD000553. [PMID: 33089892 PMCID: PMC8095029 DOI: 10.1002/14651858.cd000553.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis. SEARCH METHODS We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers. SELECTION CRITERIA Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities. AUTHORS' CONCLUSIONS Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.
Collapse
Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Giovanni Perricone
- S.C. Epatologia e Gastroenterologia, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Helen L Robbins
- Department of Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Narendra R Battula
- Division of Hepatobiliary and Abdominal Transplant surgery, University of Florida, Gainesville, Florida, USA
| | - Martin O Weickert
- The ARDEN NET Centre, ENETS Centre of Excellence, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Robert Sutton
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saboor Khan
- Surgery, University Hosptial Coventry and Warwickshire, Coventry, UK
| |
Collapse
|
13
|
Barrett's adenocarcinoma with esophageal varices successfully treated by endoscopic submucosal dissection with direct varices coagulation. Clin J Gastroenterol 2019; 13:178-181. [PMID: 31559540 DOI: 10.1007/s12328-019-01048-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/17/2019] [Indexed: 12/27/2022]
Abstract
A 67-year-old Japanese man with alcoholic cirrhosis underwent esophagogastroduodenoscopy (EGD), which revealed a 15-mm elevated lesion on the esophagogastric junction (EGJ). Endoscopic findings suggested that the lesion was an intramucosal cancer present on the esophageal varices. The location of the lesion at EGJ caused difficulties in endoscopic injection sclerotherapy and endoscopic variceal ligation for esophageal varices before esophageal endoscopic submucosal dissection (ESD). Direct varices coagulation treatment was therefore selected during ESD. Coagulation of bared varices with hemostatic forceps after mucosal incision enabled performing ESD without serious bleeding. 2 months afterwards, the patient underwent EGD, with no esophageal varices or carcinoma recurrence. Direct varices coagulation was effective for ESD of Barrett adenocarcinoma with esophageal varices.
Collapse
|
14
|
Song JE, Kim BS. Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding. Clin Endosc 2019; 52:407-415. [PMID: 31591278 PMCID: PMC6785426 DOI: 10.5946/ce.2019.178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/19/2019] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jeong Eun Song
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Byung Seok Kim
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| |
Collapse
|
15
|
Arasu S, Liaquat H, Suri J, Ehrlich AC, Friedenberg FK. Incidence and risk factors of dysphagia after variceal band ligation. Clin Mol Hepatol 2019; 25:374-380. [PMID: 31315388 PMCID: PMC6933116 DOI: 10.3350/cmh.2019.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/12/2019] [Indexed: 01/08/2023] Open
Abstract
Background/Aims There is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL. Methods We identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved “complete eradication” of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded. Results Of the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0–4.0) with a median of 9.0 bands placed (IQR, 3.0–14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all p>0.05). No strictures were identified on subsequent esophageal evaluation. Conclusions Approximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.
Collapse
Affiliation(s)
- Saraswathi Arasu
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Hammad Liaquat
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Jaspreet Suri
- Internal Medicine, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Frank K Friedenberg
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
16
|
Parsi MA, Schulman AR, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos). VideoGIE 2019; 4:285-299. [PMID: 31334417 PMCID: PMC6616320 DOI: 10.1016/j.vgie.2019.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data. Methods In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use. Results Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays). Conclusions Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.
Collapse
Key Words
- ABS, Ankaferd blood stopper
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- CPT, Current Procedural Terminology
- CSEMS, covered self-expandable metallic stent
- EBL, endoscopic band ligation
- EDP, endoscopic Doppler probe
- GAVE, gastric antral vascular ectasia
- HP, heater probe
- LGIB, lower GI bleeding
- MPEC, multipolar electrocoagulation
- OTSC, over-the-scope clip
- PTFE, polytetrafluoroethylene
- RCT, randomized controlled trial
- TTS, through-the-scope
- U.S. FDA, United States Food and Drug Administration
- UGIB, upper GI bleeding
Collapse
Affiliation(s)
| | - Mansour A Parsi
- Section for Gastroenterology & Hepatology, Tulane University Health Sciences Center, New Orleans, LA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, CT
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kuman Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | | | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | |
Collapse
|
17
|
Butt N, Abbasi A, Ali Khan M, Butt S, Ahmad SM. Esophageal Variceal Band Ligation Interval and Number Required for the Obliteration of Varices: A Multi-center Study from Karachi, Pakistan. Cureus 2019; 11:e4993. [PMID: 31497424 PMCID: PMC6707816 DOI: 10.7759/cureus.4993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction Esophageal variceal band ligation (EVBL) is the best form of treatment for variceal bleeding. The frequency of EVBL for the eradication of esophageal varices has no consensus. We evaluated the number and interval of EVBL sessions required for the obliteration of esophageal varices. Methods Esophagogastric varices were treated endoscopically with band ligation on initial presentation and then every after three weeks till the obliteration of the varices. Endoscopic band ligation consists of placing rubber elastic bands on large varices. Frequencies were calculated for qualitative variables and mean ± standard deviations for continuous variables. Results A total of 107 cases with esophagogastric varices were enrolled. Out of them, seven patients with small esophageal varices and large fundal varices were excluded. The remaining 100 with large esophageal varices had EVBL performed. The second session of EVBL was done in 46 patients with large esophageal varices. The third session of EVBL for the obliteration of esophageal varices required in 20 patients with large esophageal varices and the fourth session was required in only two patients. The total sessions required for the complete obliteration for esophageal varices were 2±1. Only one patient developed post-EVBL bleeding one week after band ligation. Conclusion Esophageal variceal ligation was a safe and well-tolerated procedure performed at three-week intervals in patients with large esophageal varices. On average, two to three sessions of EVBL are required for the complete obliteration of esophageal varices.
Collapse
Affiliation(s)
- Nazish Butt
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Amanullah Abbasi
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - M Ali Khan
- Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Sehrish Butt
- Biomedical and Biological Sciences, Dow University of Health Sciences, Karachi, PAK
| | | |
Collapse
|
18
|
Sobotka LA, Ramsey ML, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019; 11:292-297. [PMID: 31040890 PMCID: PMC6475704 DOI: 10.4253/wjge.v11.i4.292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus non-selective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal.
CASE SUMMARY An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis, measuring 8 mm in diameter by 1 cm in length, which was dilated.
CONCLUSION Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.
Collapse
Affiliation(s)
- Lindsay A Sobotka
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Mitchell L Ramsey
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Michael Wellner
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sean G Kelly
- Department of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| |
Collapse
|
19
|
Sobotka LA, Ramsey M, Wellner M, Kelly SG. Rare cause of dysphagia after esophageal variceal banding: A case report. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
20
|
Nett A, Binmoeller KF. Endoscopic Management of Portal Hypertension-related Bleeding. Gastrointest Endosc Clin N Am 2019; 29:321-337. [PMID: 30846156 DOI: 10.1016/j.giec.2018.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal bleeding as a sequela of portal hypertension can be catastrophic and fatal. Endoscopic and endosonographic therapy play a critical role in management of such bleeding- both for hemostasis of active bleeding and bleeding prophylaxis. Variceal band ligation is established as the standard intervention for esophageal varices. For other sources of portal hypertension-related bleeding, or for salvage therapy for esophageal varices, a variety of endoscopic techniques are available. Endoscopic ultrasound may be used to enhance endoscopic management, particularly for gastric and ectopic varices.
Collapse
Affiliation(s)
- Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA.
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor Suite 600, San Francisco, CA 94115, USA
| |
Collapse
|
21
|
Kotzev A, Chernev N. Esophageal obstruction after endoscopic variceal ligation. Presse Med 2018; 47:1013-1015. [PMID: 30348479 DOI: 10.1016/j.lpm.2018.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/02/2018] [Accepted: 09/17/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrey Kotzev
- Medical university, university hospital "Alexandrovska", clinic of gastroenterology, Sofia, Bulgaria.
| | - Nikolay Chernev
- Medical University, department of diagnostic imaging, Sofia, Bulgaria
| |
Collapse
|
22
|
Amer MIM, Ahmed ME, Hassan DA. Hysteroscopic tubal occlusion using iso-amyl-2-cyanoacrylate in patients with hydrosalpinx. J Obstet Gynaecol Res 2018; 44:2174-2180. [PMID: 30058273 DOI: 10.1111/jog.13769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/04/2018] [Indexed: 11/29/2022]
Abstract
AIM The aim of this work is to assess the effectiveness of hysteroscopic tubal occlusion using iso-amyl-2-cyanoacrylate, among infertile women with hydrosalpinx prior to in vitro fertilization (IVF). METHODS Hysteroscopic injection of fallopian tubes with hydrosalpinx by 0.5 mL iso-amyl-2-cyanoacrylate was done in 40 infertile women planning for IVF. The patients were then followed-up after 1 and 3 months, with hysterosalpingography (HSG) to confirm complete tubal occlusion. Reinjection with iso-amyl-2-cyanoacrylate was done in these patients with incomplete tubal occlusion after 1 month of the first injection, followed by HSG 2 months later to confirm complete tubal occlusion. Data were prescribed as range, mean and standard deviation (for parametric variables) and range, number and percentage (for categorical variables). RESULTS The total number of tubes injected in this study was 54, 42 (77.8%) of which were completely occluded after one injection while 12 (22.2%) were partially occluded. Reinjection of the partially occluded tubes was done, and (HSG) of all patients after 3 months of the primary injection confirmed 48 (88.9%) of the tubes completely occluded while 6 (11.1%) remained partially occluded. Thirty-two (80%) patients underwent one cycle of IVF/ET (embryo transfer), while 8 (20%) patients did not appear for follow-up. Among the patients who underwent IVF/ET, 24 (75%) got pregnant, while 8 (25%) failed to conceive. Among the pregnant patients, 8 (33.3%) delivered at term, 3 (12.5%) had first trimester abortion, while the remaining 13 (54.2%) did not deliver yet. CONCLUSION Iso-amyl-2-cyanoacrylate used for hysteroscopic tubal occlusion in patients with hydrosalpinx prior to IVF is safe and effective.
Collapse
Affiliation(s)
- Mohamed I M Amer
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mortada E Ahmed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dalal A Hassan
- Department of Obstetrics and Gynecology, El-Galaa Maternity Teaching Hospital, Cairo, Egypt
| |
Collapse
|
23
|
Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
Collapse
Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
| |
Collapse
|
24
|
Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial. Indian J Gastroenterol 2018; 37:313-320. [PMID: 30132224 DOI: 10.1007/s12664-018-0871-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 07/22/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension. METHODS Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n = 43) or intravenous boluses of terlipressin (Group B, n = 43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission. RESULTS Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p = 0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p = 0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis. CONCLUSIONS Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure.
Collapse
|
25
|
Primary Prophylaxis for Gastrointestinal Bleeding in Children With Biliary Atresia and Portal Hypertension Candidates for Liver Transplantation: A Single-Center Experience. Transplant Proc 2018; 51:171-178. [PMID: 30655149 DOI: 10.1016/j.transproceed.2018.04.074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cirrhosis for biliary atresia (BA) is associated with risk of gastrointestinal bleeding (GB) from gastroesophageal varices due to portal hypertension. Primary prophylaxis of GB is controversial in children who are candidates for liver transplantation (LT). The aim of the study was to define the management of gastroesophageal varices and to identify the benefit of primary prophylaxis for GB in BA children waiting for LT. METHODS A retrospective single-center study including all BA children listed for LT in 2008-2016. Clinical, endoscopical, and biochemical data were analyzed. RESULTS Of 82 children, 50 (61%) did not receive primary prophylaxis and did not present any episode of bleeding, 16 (19.5%) underwent primary prophylaxis, and 16 (19.5%) presented spontaneous GB and received secondary prophylaxis. Children without primary prophylaxis and GB were younger than patients with primary prophylaxis and those with GB (7.7 years [range, 4.1-37.9 years] vs 11.2 years [range, 5.1-43 years]; P = .03 vs 10.7 years [range, 6.9-39.9 years], respectively; P = .004). Seventy-five percent of GB occurred in children older than 8 months. Fifteen (93.8%) children with GB presented esophageal varices (grade III = 10 [62.5%]) and 10 (62.5%) required endoscopic treatments, consisting mainly of sclerotherapy. Median time to LT was similar for children with or without bleeding (2 months [range, 0-17.7 months] vs 2.2 months [0-17.9 months], respectively; P = .89). After 45.5 months (range, 13.7-105.5 months) of follow-up, the overall patient survival was 97.6%. At the intention-to-treat analysis, the survival rate was 100% for patients without bleeding episode and 87.5% for children with GB (P = .16). CONCLUSIONS Despite the risk of GB being not clinically predictable in children with BA waiting for LT, our experience suggests that primary prophylaxis of GB might be unnecessary in children younger than 6 months, while it should be considered in older children. Thus, the occurrence of GB does not delay the timing of transplantation.
Collapse
|
26
|
Ibrahim M, Mostafa I, Devière J. New Developments in Managing Variceal Bleeding. Gastroenterology 2018; 154:1964-1969. [PMID: 29481777 DOI: 10.1053/j.gastro.2018.02.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 12/14/2022]
Abstract
Liver cirrhosis is the end stage of chronic liver disease, independent of etiology, and is characterized by accumulation of fibrotic tissue and conversion of the normal liver parenchyma into abnormal regenerative nodules. Complications include portal hypertension (PH) with gastroesophageal varices, ascites, hepatorenal syndrome, hepatic encephalopathy, bacteremia, and hypersplenism. The most life-threatening complication of liver cirrhosis is acute variceal bleeding (AVB) which is associated with increased mortality that, despite recent progress in management, is still around 20% at 6 weeks. Combined treatment with vasoactive drugs, prophylactic antibiotics, and endoscopic techniques is the recommended standard of care for patients with acute variceal bleeding. There are many promising new modalities including the combination of coil and glue injection for management of bleeding or non-bleeding gastric varices and hemostatic powder application, that requires minimal expertise, when performed early after admission of a cirrhotic patient with AVB and overt hematemesis acting as a bridge therapy till definitive endoscopic therapy can be performed in hemodynamically stable conditions and without acute bleeding.
Collapse
Affiliation(s)
- Mostafa Ibrahim
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt.
| | - Ibrahim Mostafa
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
27
|
Role of noninvasive markers to predict the presence of esophageal varices in cirrhosis: Pilot study. Indian J Gastroenterol 2018; 37:74-75. [PMID: 29455439 DOI: 10.1007/s12664-018-0834-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
28
|
Guo YW, Miao HB, Wen ZF, Xuan JY, Zhou HX. Procedure-related complications in gastric variceal obturation with tissue glue. World J Gastroenterol 2017; 23:7746-7755. [PMID: 29209115 PMCID: PMC5703934 DOI: 10.3748/wjg.v23.i43.7746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/12/2017] [Accepted: 10/28/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To focus on procedure-related complications, evaluate their incidence, analyze the reasons and discuss the solutions.
METHODS Overall, 628 endoscopic gastric variceal obturation (EGVO) procedures (case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.
RESULTS In the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.
CONCLUSION Although EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.
Collapse
Affiliation(s)
- Yun-Wei Guo
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Hui-Biao Miao
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Zhuo-Fu Wen
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Jie-Ying Xuan
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Hao-Xiong Zhou
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| |
Collapse
|
29
|
A. L, A.E. E, M. A, A. Y, Fathy T. Thoracic complications of upper gastrointestinal endoscopy in Zagazig University Hospitals. A cross-sectional single center study. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2017.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
30
|
Mansour L, El-Kalla F, El-Bassat H, Abd-Elsalam S, El-Bedewy M, Kobtan A, Badawi R, Elhendawy M. Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices. Gastrointest Endosc 2017; 86:307-315. [PMID: 28082116 DOI: 10.1016/j.gie.2016.12.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).
Collapse
Affiliation(s)
- Loai Mansour
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Ferial El-Kalla
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Hanan El-Bassat
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | | | - Abdelrahman Kobtan
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Rehab Badawi
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Mohamed Elhendawy
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| |
Collapse
|
31
|
Tsou YK, Liu CY, Fu KI, Lin CH, Lee MS, Su MY, Ohata K, Chiu CT. Endoscopic Submucosal Dissection of Superficial Esophageal Neoplasms Is Feasible and Not Riskier for Patients with Liver Cirrhosis. Dig Dis Sci 2016; 61:3565-3571. [PMID: 27770376 PMCID: PMC5104793 DOI: 10.1007/s10620-016-4342-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/05/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Esophageal endoscopic submucosal dissection (ESD) has rarely been reported for the treatment of cirrhotic patients. AIM To report the results of ESD treatment of superficial esophageal neoplasms (SENs) for cirrhotic patients. METHODS Forty patients with 50 consecutive SENs undergoing 46 sessions of ESD were retrospectively reviewed. The cirrhotic group included eight patients (11 SENs) with liver cirrhosis consisting of six patients classified as Child-Pugh class A liver cirrhosis and two patients classified as class B liver cirrhosis. Four patients (6 SENs) had coexisting esophageal varices. Parameters were compared between the cirrhotic patients and the non-cirrhotic controls (32 patients, 39 SENs). RESULTS Platelet counts of the cirrhotic group were significantly lower, while international normalized ratio was significantly higher. When the cirrhotic group and non-cirrhotic group were compared, the mean tumor length (4 vs. 3.7 cm, p = 0.56) and median procedure time (15.1 vs. 11.5 min/cm2, p = 0.30) were similar. The en bloc resection rates were 81.8 and 89.7 % (p = 0.60). Within the cirrhotic group, both lesions without en bloc resection were patients with esophageal varices. The rates of submucosal disease for the cirrhotic group and non-cirrhotic groups were 54.5 and 25.6 % (p = 0.064), respectively, while the R0 resection rates were 77.8 and 94.3 % (p = 0.16), respectively. The two lesions without R0 resection in cirrhotic group had positive vertical but not horizontal margins due to submucosal invasion. Intraprocedural bleeding occurred more frequently in cirrhotic patients than non-cirrhotic patients (18.2 vs. 0 %, p = 0.045). None of the patients suffered from esophageal perforation, postoperative bleeding, or death that was related to the ESD. CONCLUSION Esophageal ESD seems to be safely and can be effectively performed on cirrhotic patients, particularly those without severe liver dysfunction.
Collapse
Affiliation(s)
- Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Yuan Liu
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Department of Medicine, Mackay Medical College, New Taipei, Taiwan
| | - Kuang-I Fu
- Department of Gastroenterology, Kanma Memorial Hospital, Nasushiobara, Japan
| | - Cheng-Hui Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mu-Shien Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, 5-9-22 Higashi-gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| |
Collapse
|
32
|
Ali SM, Wu S, Xu H, Liu H, Hao J, Qin C. A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices. J Laparoendosc Adv Surg Tech A 2016; 27:333-341. [PMID: 28221819 DOI: 10.1089/lap.2016.0436] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB). PATIENTS AND METHODS In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival. RESULTS Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02). CONCLUSIONS Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.
Collapse
Affiliation(s)
- Syed Mohsin Ali
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Shanbin Wu
- 2 Qianfoshan Hospital Affiliated to Shandong University , Jinan, China
| | - Hongwei Xu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Hui Liu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Jinghua Hao
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Chengyong Qin
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| |
Collapse
|
33
|
Abstract
AIM: To evaluate the therapeutics effects of precision endoscopic treatment of gastroesophageal varices and observe the disappearance of blood vessels and side effects.
METHODS: One hundred and four patients with esophagogastric variceal bleeding who underwent precision endoscopic treatment were divided into three treatment groups: treatment above the cardia (n = 68), below the cardia (n = 15) and the combination of both (n = 21). The total effective rate, rate of improvement, rate of significant improvement, rebleeding rate and rate of complications were compared among the three groups.
RESULTS: The total effective rates, improvement rates and significant improve rates were 63.2%, 23.5% and 39.7%, respectively, for the group treated above the cardia; the corresponding percentages were 80.0%, 20.0% and 60.0% for the group treated below the cardia, and 90.5%, 28.6% and 61.9% for the combination group. There were significant differences in the total effective rate (χ2 = 6.444, P = 0.039) as well as the improvment rate and significant improvement rate (χ2 = 6.235, P = 0.044). The rebleeding rates at 2 wk and 3 mo after treatment were 11.8% and 19.1% for the group treated above the cardia, 6.7% and 13.3% for that below the cardia, and 9.5% and 14.3% for the combination group. There were no statistical differences in the rebleeding rates among the three groups (P > 0.05). No serious complications occurred in all the three groups. The incidence rates of complications in the three groups were 30.9%, 33.3% and 38.1%, respectively, and there was no statistical difference among them (P > 0.05).
CONCLUSION: The combination group had the best curative effect.
Collapse
|
34
|
Ertel AE, Chang AL, Kim Y, Shah SA. Management of gastrointestinal bleeding in patients with cirrhosis. Curr Probl Surg 2016; 53:366-95. [PMID: 27585818 DOI: 10.1067/j.cpsurg.2016.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/21/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Audrey E Ertel
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Young Kim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
| |
Collapse
|
35
|
Shaish H, Gilet A, Gerard P. 'It's all foreign to me': how to decipher gastrointestinal intraluminal foreign bodies. ABDOMINAL IMAGING 2015; 40:2173-2192. [PMID: 25952573 DOI: 10.1007/s00261-015-0434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In evaluating the gastrointestinal tract, whether in the emergency room setting, the inpatient setting or the outpatient setting, the radiologist may encounter a myriad of intraluminal radio-opaque, non-anatomic entities. It is the radiologist's role to distinguish between true foreign bodies and medical paraphernalia. Further, the later must be evaluated for proper positioning vs. improper, potentially detrimental positioning. While many foreign bodies from the community may be distinctly familiar to the radiologist, the large variety of medical tools in existence may not be. Furthermore, many medical devices are designed to transiently traverse, or interact with the gastrointestinal tract, requiring the radiologist to become familiar with their natural history. We explore a select group of common and uncommon intraluminal foreign bodies and will divide them into medical paraphernalia that are properly positioned; medical paraphernalia that are in abnormal locations and miscellaneous foreign bodies from the community. For each medical tool, we will discuss its development and medical utility, natural history as it relates to the gastrointestinal tract, optimal positioning as assessed radiologically, malpositioning, and subsequent complications. A small selection of unusual foreign bodies from the community will be presented. Finally, a selection of medical conditions which produce symptoms due to acquired intraluminal objects will be reviewed.
Collapse
Affiliation(s)
- Hiram Shaish
- Department of Radiology, Westchester Medical Center, 100 Woods Rd., Valhalla, NY, 10595, USA.
| | - Anthony Gilet
- Department of Radiology, Westchester Medical Center, 100 Woods Rd., Valhalla, NY, 10595, USA
| | - Perry Gerard
- Department of Radiology, Westchester Medical Center, 100 Woods Rd., Valhalla, NY, 10595, USA
| |
Collapse
|
36
|
Propranolol associated with endoscopic band ligation reduces recurrence of esophageal varices for primary prophylaxis of variceal bleeding: a randomized-controlled trial. Eur J Gastroenterol Hepatol 2015; 27:84-90. [PMID: 25397691 DOI: 10.1097/meg.0000000000000227] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to compare the recurrence of esophageal varices (EVs) after endoscopic band ligation (EBL) associated with propranolol (PP) versus EBL alone. PATIENTS AND METHODS Sixty-six cirrhotic outpatients (EBL group, n=32 and EBL+PP group, n=34) with high-risk EVs without previous bleeding were studied. MAIN OUTCOME MEASUREMENTS The primary outcome was recurrence of EV. The secondary outcomes were EV eradication, bleeding before EV eradication, mortality, and adverse events. RESULTS Demographic characteristics and the initial endoscopic findings were similar. EV eradication was achieved in all patients. Three patients presented gastrointestinal bleeding before variceal eradication, two in the EBL group and one in the EBL+PP group (P=0.13). Six patients died (liver failure), two in the EBL group and four in the EBL+PP group (P=0.27). Twelve (38%) patients in the EBL group and three (9%) patients in the EBL+PP group had variceal recurrence. The risk of recurrence of EVs after eradication was significantly higher among patients in the EBL group (P=0.003). CONCLUSION EBL alone and EBL+PP were effective in the primary prophylaxis of bleeding from EVs in cirrhotic patients (EV eradication, bleeding before EV eradication, mortality, and adverse events were similar in both groups). However, variceal recurrence was lower in the EBL+PP group than band ligation alone.
Collapse
|
37
|
Debernardi Venon W, Elia C, Stradella D, Bruno M, Fadda M, DeAngelis C, Rizzetto M, Saracco G, Marzano A. Prospective randomized trial: endoscopic follow up 3 vs 6 months after esophageal variceal eradication by band ligation in cirrhosis. Eur J Intern Med 2014; 25:674-9. [PMID: 25018142 DOI: 10.1016/j.ejim.2014.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/09/2014] [Accepted: 06/13/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Endoscopic variceal ligation (EVL) is recommended to treat esophageal varices (EV) in cirrhosis and portal hypertension. A program of endoscopic surveillance is not clearly established. The aim of this prospective randomized trial was to assess the most effective timing of endoscopic monitoring after variceal eradication and its impact on the patient's outcome and on the costs. METHODS A hundred and two cirrhotic patients with esophageal varices treated by EVL were evaluated. After variceal eradication patients were randomized to receive first endoscopic control at 3 (Group 1) and 6 (Group 2) months respectively. RESULTS Variceal obliteration was achieved in all patients. Variceal recurrence was observed in 28 cases at the first control (29.1%) without difference between the two groups (32% vs 29% in group 1 and 2 respectively, p=0.75). The incidence of large varices is similar in the two groups (33% vs 38% respectively). Using a multivariate analysis, medical therapy with B blockers was the only independent predictor of lowest risk of variceal recurrence [OR 2.30, 95% CI (1.68-3.26)]. Bleeding related to recurrent varices occurred in 3.1% of cases and was associated with portal thrombosis. Child Pugh score ≥8 was the only predictor of mortality (p=0.0002). CONCLUSIONS Recurrence of varices after banding ligation is not rare but it is associated with a low risk of variceal progression and bleeding. Accordingly, a first endoscopic control at 6 months after variceal eradication associated with a good risk stratification might be a cost-effective strategy of monitoring.
Collapse
Affiliation(s)
| | - Chiara Elia
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Davide Stradella
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Mauro Bruno
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Maurizio Fadda
- Clinical Nutrition and Dietetics Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Claudio DeAngelis
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Mario Rizzetto
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| | - Giorgio Saracco
- Gastroenterology Unit, San Luigi Gonzaga Hospital, University of Turin, Italy.
| | - Alfredo Marzano
- Gastro-Hepatology Unit, San Giovanni Battista Hospital, University of Turin, Italy.
| |
Collapse
|
38
|
Wang HM, Lo GH, Chen WC, Chan HH, Tsai WL, Yu HC, Tsay FW, Hsu PI. Randomized controlled trial of monthly versus biweekly endoscopic variceal ligation for the prevention of esophageal variceal rebleeding. J Gastroenterol Hepatol 2014; 29:1229-36. [PMID: 24955452 DOI: 10.1111/jgh.12538] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic variceal ligation (EVL) is effective in preventing esophageal variceal rebleeding. However, the optimal EVL interval remains unclear. AIM To investigate the effectiveness and safety of EVL using two intersession intervals. methods: From January 2009 to October 2012, 214 patients with acute esophageal variceal bleeding were screened. Emergency ligation was performed for patients with acute variceal bleeding. After achieving hemodynamic stability, eligible patients (n = 70) were randomized to either the monthly group or the biweekly group. RESULTS Median time from randomization to variceal obliteration was 2.7 months in the monthly group and 1.7 months in the biweekly group, at a mean of 2.3 ± 2.0 and 3.0 ± 1.8 sessions, respectively. After a median follow up of 23 months, six patients (17%) in the monthly group and nine patients (26%) in the biweekly group developed upper gastrointestinal rebleeding (P = 0.382). Esophageal variceal rebleeding occurred in six patients (17%) in the monthly group and in seven patients (20%) in the biweekly group (P = 0.759). No rebleeding from EVL ulcers occurred in the monthly group and was 5.7% (n = 2) for the biweekly group. Both treatment groups had similar rates of esophageal variceal recurrence and mortality. Notably, the incidence of post-EVL ulcers in the monthly group was lower than that in the biweekly group (11% vs 57%, P < 0.001). CONCLUSIONS Patients receiving EVL monthly had similar rebleeding rate, variceal recurrence, and mortality to those receiving EVL biweekly for secondary prophylaxis of variceal bleeding; however, the monthly interval was associated with fewer post-EVL ulcers found at follow-up endoscopies.
Collapse
|
39
|
Yang L, Yuan LJ, Dong R, Yin JK, Wang Q, Li T, Li JB, Du XL, Lu JG. Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension. World J Gastroenterol 2013; 19:9418-9424. [PMID: 24409071 PMCID: PMC3882417 DOI: 10.3748/wjg.v19.i48.9418] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/16/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.
METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed.
RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05).
CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.
Collapse
|
40
|
Kim SJ, Oh SH, Jo JM, Kim KM. Experiences with endoscopic interventions for variceal bleeding in children with portal hypertension: a single center study. Pediatr Gastroenterol Hepatol Nutr 2013; 16:248-53. [PMID: 24511521 PMCID: PMC3915733 DOI: 10.5223/pghn.2013.16.4.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/04/2013] [Accepted: 10/08/2013] [Indexed: 01/06/2023] Open
Abstract
PURPOSE The aim of this study was to compare the efficacy and safety of band ligation and injection sclerotherapy in the endoscopic treatment of children with variceal bleeding. METHODS The study population included 55 children, all of whom were treated at the time of endoscopic diagnosis of esophageal varices at Asan Medical Center, Seoul, Korea, between January 1994 and January 2011. The primary outcomes included initial success rates and duration of hemostasis after endoscopic management (band ligation vs. injectionsclerotherapy). RESULTS The mean age was 6.7±5.2 years and the mean follow-up time was 5.4±3.7 years. The most common cause of esophageal varices was biliary atresia. Of 55 children with acute variceal bleeding, 39 had band ligation and 16 had injection sclerotherapy. No differences between groups were observed in terms of the size, location, and presence of red color sign. The success rates of band ligation and sclerotherapy in the control of acute bleeding episodes were 89.7% and 87.5%. The mean duration of hemostasis after endoscopic intervention was 13.2±25.1 months. After one year, 19 of 39 patients (48.7%) treated with band ligation and 7 of 16 patients (43.8%) with injection sclerotherapy had experienced rebleeding episodes. Complications after the procedures were observed in 10.3% and 18.8% of children treated with band ligation and injection sclerotherapy. CONCLUSION The results of our current study suggest that band ligation and injection sclerotherapy are equally efficient treatments for the control of acute variceal bleeding and prevention of rebleeding.
Collapse
Affiliation(s)
- Seung Jin Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Min Jo
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
41
|
Ohmiya N, Nakamura M, Funasaka K, Miyahara R, Ohno E, Kawashima H, Itoh A, Hirooka Y, Toyota H, Goto H. Intestinal Phlebectasias Treated by Endoscopic Injection Sclerotherapy at Double-Balloon Endoscopy. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/s2212-0971(13)70105-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
42
|
MIRANDA MAC, FERRAZ ÁAB, DOMINGUES ALC, CHAVES RCM, JUCÁ N, MOTA DLD. IMPROVEMENT OF SCHISTOSOMAL PORTAL HYPERTENSIVE COLOPATHY AFTER SURGICAL TREATMENT. ARQUIVOS DE GASTROENTEROLOGIA 2013; 50:153-6. [DOI: 10.1590/s0004-28032013000200026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 03/28/2013] [Indexed: 11/22/2022]
Abstract
Context Data on vascular alterations in patients with hepatosplenic schistosomiasis and portal hypertensive colopathy and changes in these after surgery to decrease portal hypertension are limited. Objective The purpose of this study was to analyse the alterations of portal hypertensive colopathy previously and 6-12 months after splenectomy and gastric devascularization. Methods Twelve patients with hepatosplenic schistosomiasis who also had upper gastrointestinal bleeding were studied prospectively. Their endoscopic findings before and 6-12 months after the surgery were analysed. In addition, mucosal biopsies from ascending colon, sigmoid colon and rectum at these time points were subjected to histological and histomorphometric assessment. It was used a control group due to lack of normal pattern of the histomorphometric measures of vessels in individuals without portal hypertension. The critical level of significance adopted in all tests was of a maximum probability error of 5%. Results Surgery did not lead to significant improvement in histological and endoscopic findings. However, on histomorphometry, there was a significant decrease in the area, diameter and thickness of the vessels in mucosa at all colonic sites. Conclusion Surgery for decompression of schistosomal portal hypertension has a beneficial effect on the associated colopathy, being best indicated in patients with gastrointestinal bleeding and esophageal varices.
Collapse
|
43
|
Kim SJ, Kim KM. Recent trends in the endoscopic management of variceal bleeding in children. Pediatr Gastroenterol Hepatol Nutr 2013; 16:1-9. [PMID: 24010099 PMCID: PMC3746041 DOI: 10.5223/pghn.2013.16.1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 02/23/2013] [Accepted: 02/25/2013] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding results in significant morbidity and mortality in both children and adults. The guidelines for the management of variceal bleeding are well established in adults but not in children as there have been insufficient pediatric studies of this disorder. In addition, the adult guidelines for treatment of variceal bleeding cannot be applied directly to children as the etiology and natural course of this disease differs between children and adults. Examples of recommended treatments in children include endoscopic variceal ligation as secondary prophylaxis for biliary atresia whereas a meso-Rex shunt operation for extrahepatic portal vein obstruction. In this review, we discuss prophylaxis options and some technical aspects of endoscopic management for variceal bleeding in children.
Collapse
Affiliation(s)
- Seung Jin Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | | |
Collapse
|
44
|
Carlson DS, Pfadt E. Bleeding esophageal varices. Nursing 2012; 42:72. [PMID: 23172073 DOI: 10.1097/01.nurse.0000422664.70404.af] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|