The role of endoscopy in the ligation of gastric varices (GV) remains controversial. This study aimed to evaluate the efficacy of endoscopic band ligation (EBL) using large-volume ligators for the management of non-bleeding GV in patients with cirrhosis.

One hundred fifty-eight patients with non-bleeding GV due to cirrhosis were divided randomly into 2 groups: the EBL group and the endoscopic variceal obturation (EVO) group. The EBL group underwent EBL with large-volume ligators and the EVO group underwent tissue glue injection for the treatment of GV. Follow-up endoscopy was performed 3 to 4 weeks after endoscopic treatment. Patients were followed up for ≥6 months after treatment. Eradication, complication, and recurrence rates were evaluated and compared between groups.

The type and size of GV were similar in both groups. No significant difference was found in the mean number of treatment sessions or eradication and recurrence rates after 6 months. Ulcer bleeding occurred in 2 EBL patients (2.50%) after ligation, whereas 8 EVO patients (10.25%) experienced bleeding due to glue extrusion. The bleeding rate after endoscopic treatment significantly differed between the groups. In the EVO group, 1 patient developed renal embolism after injection and 2 patients developed sepsis. The prevalence of postoperative fever was significantly higher in the EVO group than in the EBL group.

Large-volume band ligators have similar efficacy to tissue glue for eradicating GV, however, the former is safer. Nevertheless, multicenter studies are needed to further confirm these results.

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

The modalities to treat bleeding polyps include electrocautery snare polypectomy, adrenaline injection, clipping, argon plasma coagulation and surgery. We hereby describe an endoscopic banding ligation method for the management of bleeding gastric polyp in a patient receiving antiplatelet therapy. A 66-year-old man presented with a five month-history of intermittent tarry stool passage, nausea and fatigue. He had a past history of peripheral arterial occlusive disease and non-insulin dependent diabetes mellitus with end stage renal disease, and regularly took antiplatelet agent (ticlopidine 100 mg thrice daily) for cardiovascular prophylaxis. On examination, the patient was grossly pale, ill in appearance, with a pulse of 110/min and blood pressure of 108/76 mmHg. Laboratory examination revealed hemoglobin of 7.8 g/dl. Endoscopic examination revealed a bleeding sessile polyp over the posterior wall of the antrum. Endoscopic banding ligation was carried out by a pneumoactivated esophageal variceal ligation device set. Bleeding stopped immediately following the procedure, and the patient recovered uneventfully. It is suggested that endoscopic banding ligation is a safe and effective technique for the treatment of bleeding gastrointestinal polyps in patients receiving antiplatelet therapy.

The evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14-17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.

In people with portal hypertension, gastric varices are less prevalent than oesophageal varices. The risk of bleeding from gastric varices seems to be lower than from oesophageal varices; however, when gastric varices bleed, it is often severe and associated with higher mortality. Endoscopic sclerotherapy of bleeding gastric varices with N-butyl-2-cyanoacrylate glue (cyanoacrylate) is considered the best haemostasis with a lower risk of re-bleeding compared with other endoscopic methods. However, there are some inconsistencies between trials regarding mortality, incidence of re-bleeding, and adverse effects.

To assess the benefits and harms of sclerotherapy using cyanoacrylate compared with other endoscopic sclerotherapy procedures or with variceal band ligation for treating acute gastric variceal bleeding with or without vasoactive drugs in people with portal hypertension and to assess the best dosage of cyanoacrylate.

We searched the Cochrane Hepato-Biliary Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded from inception to September 2014 and reference lists of articles. We included trials irrespective of trial setting, language, publication status, or date of publication.

Randomised clinical trials comparing sclerotherapy using cyanoacrylate versus other endoscopic methods (sclerotherapy using alcohol-based compounds or endoscopy band ligation) for acute gastric variceal bleeding in people with portal hypertension.

We performed the review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Hepato-Biliary Module.We presented results as risk ratios (RR) with 95% confidence intervals (CI), with I(2) statistic values as a measure of intertrial heterogeneity. We analysed data with both fixed-effect and random-effects models, and reported the results with random-effects models. We performed subgroup, sensitivity, and trial sequential analyses to evaluate the robustness of the overall results, risk of bias, sources of intertrial heterogeneity, and risk of random errors.

We included six randomised clinical trials with three different comparisons: one trial compared two different doses of cyanoacrylate in 91 adults, bleeding actively from all types of gastric varices; one trial compared cyanoacrylate versus alcohol-based compounds in 37 adults with active or acute bleeding from isolated gastric varices only; and four trials compared cyanoacrylate versus endoscopic band ligation in 365 adults, with active or acute bleeding from all types of gastric varices. Main outcomes in the included trials were bleeding-related mortality, failure of intervention, re-bleeding, adverse events, and control of bleeding. Follow-up varied from six to 26 months. The participants included in these trials had chronic liver disease of different severities, were predominantly men, and most were from Eastern countries. We judged all trials at high risk of bias. Application of quality criteria for all outcomes yielded very low quality grade of the evidence in the three analyses, except for the low quality evidence rated for the re-bleeding outcome in the cyanoacrylate versus endoscopic band ligation comparison. Two different doses of cyanoacrylate: we found very low quality evidence from one trial for the effect of 0.5 mL compared with 1.0 mL of cyanoacrylate on all-cause mortality (20/44 (45.5%) with 0.5 mL versus 21/47 (45%) with 1.0 mL; RR 1.02; 95% CI 0.65 to 1.60), 30-day mortality (RR 1.07; 95% CI 0.41 to 2.80), failure of intervention (RR 1.07; 95% CI 0.56 to 2.05), prevention of re-bleeding (RR 1.30; 95% CI 0.73 to 2.31), adverse events reported as fever (RR 0.56; 95% CI 0.32 to 0.98), and control of bleeding (RR 1.04; 95% CI 0.78 to 1.38). Cyanoacrylate versus alcohol-based compounds: we found very low quality evidence from one trial for the effect of cyanoacrylate versus alcohol-based compounds on 30-day mortality (2/20 (10%) with cyanoacrylate versus 4/17 (23.5%) with alcohol-based compound; RR 0.43; 95% CI 0.09 to 2.04), failure of intervention (RR 0.36; 95% CI 0.09 to 1.35), prevention of re-bleeding (RR 0.85; 95% CI 0.30 to 2.45), adverse events reported as fever (RR 0.43; 95% CI 0.22 to 0.80), and control of bleeding (RR 1.79; 95% CI 1.13 to 2.84). Cyanoacrylate versus endoscopic band ligation: we found very low quality evidence for the effect of cyanoacrylate versus endoscopic band ligation on bleeding-related mortality (44/185 (23.7%) with cyanoacrylate versus 50/181 (27.6%) with endoscopic band ligation; RR 0.83; 95% CI 0.52 to 1.31), failure of intervention (RR 1.13; 95% CI 0.23 to 5.69), complications (RR 2.81; 95% CI 0.69 to 11.49), and control of bleeding (RR 1.07; 95% CI 0.90 to 1.27). There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). Trial sequential analysis showed that the analyses were underpowered (diversity-adjusted required information size was 5290 participants for bleeding-related mortality).

This review suggests that endoscopic sclerotherapy using cyanoacrylate may be more effective than endoscopic band ligation in terms of preventing re-bleeding from gastric varices. However, due to the very low quality of the evidence, we are very uncertain about our estimates on all-cause and bleeding-related mortality, failure of intervention, adverse events, and control of bleeding. The trials were at high risk of bias; the number of the included randomised clinical trials and number of participants included in each trial was small; and there was evidence of internal heterogeneity across trials, indirectness of evidence in terms of population, and possible publication bias.The effectiveness of different doses of cyanoacrylate and the comparison of cyanoacrylate versus alcohol compounds to treat variceal bleeding in people with portal hypertension is uncertain due to the very low quality of the evidence.The shortcomings mentioned call for more evidence from larger trials that need to be conducted according to the SPIRIT statement and reported according to CONSORT guidelines.

Gastric varices (GVs) are known to bleed massively and often difficult to manage with conventional techniques. This article aims to overview the endoscopic methods for the management of acute gastric variceal bleeding, especially the advantages and limits of GV obliteration with tissue adhesives, by comparison with band ligation and other direct endoscopic techniques of approach. The results of indirect radiological and surgical techniques of GV treatment are shortly discussed. A special attention is payed to the emerging role of endoscopic ultrasound in the therapy of bleeding GV, in the confirmation of its eradication and in follow-up strategies.

Esophagogastric varices are the most common complication in patients with portal hypertension, and endoscopy plays an important role in their diagnosis and in the prevention of acute bleeding from these structures. Recently, new modalities such as endoscopic ultrasonography (EUS) and narrow-band imaging have been introduced for the diagnosis of esophagogastric varices. In Japan, endoscopic therapy has become the first choice for the treatment of acutely bleeding esophageal or gastric varices. The two principal methods used to treat esophageal varices are endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). Recently, combinations of EIS plus EVL and EVL plus argon plasma coagulation were reported to be more effective than EVL or EIS alone. Additionally, endoscopic cyanoacrylate injection is superior to EIS and EVL for the treatment of acutely bleeding gastric varices.

Acute variceal bleeding could be a fatal complication in patients with liver cirrhosis. In patients with decompensated liver cirrhosis accompanied by ascites or hepatic encephalopathy, acute variceal bleeding is associated with a high mortality rate. Therefore, timely endoscopic hemostasis and prevention of relapse of bleeding are most important. The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital. Furthermore, to obtain hemodynamic stability, the hemoglobin level should be maintained at >8 g/dL, systolic blood pressure >90 to 100 mm Hg, heart rate <100/min, and the central venous pressure from 1 to 5 mm Hg. When the patient becomes hemodynamically stable, hemostasis should be achieved by performing endoscopy as soon as possible. For esophageal variceal bleeding, endoscopic variceal ligation is usually performed, and for gastric variceal bleeding, endoscopic variceal obturation is performed primarily. If it is considered difficult to achieve hemostasis through endoscopy, salvage therapy may be carried out while keeping the patient hemodynamically stable.

BACKGROUND. Treatment of gastric varices (GV) implies a number of several difficulties and sometimes entails complications. The best endoscopic success rate was attributed until now to the use of tissue adhesives(N-Butyl-2-Cyanoacrylate) and band ligation. AIM. To assess the therapeutic efficacy and safety of cyanoacrylate injection compared to band ligation in patients with acute GV hemorrhage. MATERIAL AND METHODS. Thirty-seven patients with upper gastrointestinal bleeding from GV were included in the study, treated with cyanoacrylate injection (GVO)-19 patients or band ligations (GVL)-18 patients. They were followed up for overall results, complications and survival rate. RESULTS. The mean age of the study group was 60.22 ± 9.34 years, with a male/female ratio of 21:16. The mean follow-up period was 427.26 ± 214.16 days in the GVO group and 406.21 ± 213.23 days in the GVL group (p = 0.76). Initial hemostasis was achieved in all patients treated with cyanoacrylate and in 88.88% from the GVL group (p = 0.43). Rebleeding occurred in 72.22% of the GVL group and in 31.57% of the GVO patients (p = 0.03). Patients in the GVO group had a significantly larger rebleeding-free period(p = 0.006). No difference was found in survival rates(p = 0.75). The Child Class (p = 0.003 for Class C) and treatment method (p = 0.01) were independently associated with the rate of rebleeding. No differences were found regarding the rate of complications. CONCLUSION. The use of cyanoacrylate in acute GV bleeding had better results when compared with band ligation in terms of controlling the hemorrhage and recurrence of bleeding. The overall survival rate was not influenced by the method used for the treatment of complicated GV.

This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.

Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.

Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.

There is a relative dearth of literature on the definitive endoscopic management of bleeding gastric varices. Variceal ligation with bands and detachable snares, sclerosants, cyanoacrylate glue, and thrombin injections have been used with variable success.

To report our experience with bovine thrombin injection for the treatment of bleeding gastric varices.

A retrospective review.

Tertiary-referral hospital.

Forty-two cases of gastric varices were identified from our endoscopy database between July 1998 and July 2003. Thirteen patients had thrombin injection.

Thrombin injection therapy for bleeding gastric varices.

Control of hemorrhage, risk of rebleeding, and mortality.

Of the 13 patients who underwent thrombin injections, hemostasis in the acute setting was successful in 92% of cases. Patients received 1 to 4 sessions of thrombin, with a mean total dose of 10.8 mL for variceal eradication. One patient continued to bleed and needed a transjugular intrahepatic portosystemic shunt as a rescue procedure. The patient with hepatocellular carcinoma died within 30 days, and 4 more patients died after a median follow-up of 22 months; none died because of bleeding. There was no rebleeding in the remaining patients at a median follow-up of 25 months.

The retrospective nature and small number.

In our series, injection with thrombin proved to be an effective endoscopic treatment in the majority of patients with bleeding gastric varices. The overall mortality, after controlling bleeding, was 38% (5/13), subsequent to a median follow-up of 22 months.

Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices.

Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary.

Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27).

This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.

There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy.

A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis.

Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death).

Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.

Over the last 20 years, endoscopic hemostasis has become the primary method of controlling acute, overt upper gastrointestinal hemorrhage (UGIH) and prevent rebleeding. Although uncommon, procedure-related complications may occur. This article reviews the risks attributable to endoscopic hemostasis in acute UGIH and how to help prevent these complications.

Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension.

Detachable mini-loop ligation is useful for endoscopic management of esophageal varices. This study evaluated the treatment of gastroduodenal angiodysplasia by detachable mini-loop ligation.

Eleven patients (9 women, 2 men; mean age 61 [18] years) with bleeding gastroduodenal angiodysplasia were treated endoscopically by detachable mini-loop ligation. At endoscopy, two patients had actively bleeding lesions. By using a ligating device, a detachable nylon ring was inserted through the accessory channel of an endoscope and opened at the rim of a transparent ligation chamber attached to the tip of the instrument. The angiodysplasia was aspirated into the chamber, and the mini-loop was closed and detached.

Initial ligation therapy was successful in all patients without inducing uncontrollable bleeding. In one patient, two mini-loops were applied to the same angiodysplastic lesion. The only significant complication was severe GI bleeding from a duodenal ulcer that developed at the ligation site in one patient. This was successfully treated by endoscopic placement of hemoclips.

Detachable mini-loop ligation is an effective and safe modality for endoscopic treatment of bleeding gastroduodenal angiodysplasia.

Bleeding and perforation are the major and serious complications associated with endoscopic polypectomy. To develop a safe and effective method to resect hyperplastic polyps of the stomach, we employed rubber bands to strangulate hyperplastic polyps and to determine the possibility of inducing avascular necrosis in these lesions.

Forty-seven patients with 72 hyperplastic polyps were treated with endoscopic banding ligation (EBL). On 14 days after endoscopic ligation, follow-up endoscopies were performed to assess the outcomes of the strangulated polyps.

After being strangulated by the rubber bands, all of the polyps immediately became congested (100%), and then developed cyanotic changes (100%) approximately 4 minutes later. On follow-up endoscopy 2 weeks later, all the polyps except one had dropped off. The only one residual polyp shrank with a rubber band in its base, and it also dropped off spontaneously during subsequent follow-up. No complications occurred during or following the ligation procedures.

Gastric polyps develop avascular necrosis following ligation by rubber bands. Employing suction equipment, EBL can easily capture sessile polyps. It is an easy, safe and effective method to eradicate hyperplastic polyps of the stomach.

Optimal treatment for gastric variceal bleeding remains to be determined. The use of conventional sclerosing agents is associated with high rates of recurrent bleeding. Other agents, such as cyanoacrylate, have significant complication rates and can damage endoscopic equipment. The risk of prior-associated disease has caused concern regarding the use of bovine thrombin.

Beriplast-P (human thrombin) forms a fibrin clot at the needle tip immediately upon injection through a double lumen needle. In 10 patients with gastric variceal bleeding, a median dose of 6 mL of Beriplast-P was injected into gastric varices.

Immediate hemostasis was achieved in 7 of 10 patients (70%) with a single injection. At a median follow-up of 8 months, there was no recorded episode of recurrent bleeding from gastric varices.

These results suggest that Beriplast-P is useful in the treatment of gastric variceal bleeding. Refinements in the design of the injection needle may improve the efficacy of this novel therapy.

Bleeding from gastric varices larger than 2 cm in diameter represents a major limitation for endoscopic hemostasis.

Endoscopic ligation of gastric varices was performed with detachable snares and elastic bands in 41 patients who had recent bleeding from gastric varices larger than 2 cm in diameter. Gastric varices larger than 2 cm were ligated with detachable snares, and then adjacent small gastric varices were ligated with elastic bands.

Among the 41 patients, 10 of 12 patients with active bleeding and 28 of 29 patients with red color signs at initial endoscopy were successfully treated by endoscopic ligation by using detachable snares and elastic bands. Bleeding recurred early (before variceal eradication) in 4 of 38 patients (10.5%). The overall hemostatic rate for endoscopic ligation was 82.9% (34/41). In 33 of 36 patients (91.7%) who underwent repeated ligation treatments, variceal eradication was nearly complete. Mean follow-up in 30 of 33 patients after eradication of varices was 16.4 months (3-32 months), and 29 of 30 did not have recurrent bleeding. During and after ligation there were no serious complications.

Endoscopic ligation therapy with large detachable snares and elastic bands is safe and effective for treatment of large bleeding gastric varices.

The purpose of this study was to evaluate the accuracy and reproducibility of measurements obtained with a new 3-dimensional stereoscopic endoscopy system in vitro and in vivo.

The system includes an electronic stereoscopic endoscope and a personal computer. After correction of barrel distortion by an image-processing technique, 3-dimensional data are computed with triangulation. Initially, graph paper and models of gastric lesions, both elevated and depressed, were used as objects. For evaluating accuracy and reproducibility, the absolute error (/E/) and the coefficient of variation (CV) were calculated: /E/ = average value of absolute value (measured value minus sign true value)/true value. Then, the sizes of 50 gastric lesions were measured by 2 endoscopists, one experienced and the other inexperienced, and the findings were compared with measurements made radiographically.

The maximum for /E/ and for the CV for the distance on the graph paper were, respectively, 5.6% and 7.0%. The /E/ and CV for the diameter and for the height of the elevated model were, respectively, 5.9% and 5.7% for the former and, respectively, 16.8% and 16.5% for the latter. The /E/ and CV for the area of the depressed model were, respectively, 9.0% and 1.6%. The correlation coefficients between the sizes of lesions measured by stereoscopic endoscopy and radiographically were 0.91: 99% CI [0.81, 1.00], and 0.98: 99% CI [0.85, 1.00], respectively, for the experienced and inexperienced endoscopists.

The new stereoscopic endoscopy system is useful for measuring gastric lesion size in clinical practice.

The long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated as the initial treatment for bleeding gastric varices.

Fifty-two patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis over a 10-year period. Histoacryl was injected intravariceally. Among these 52 patients, 32 had active bleeding and 20 had recent bleeding. Most of the varices were large (F2 or F3, 48 cases). After Histoacryl injection, the patients were followed endoscopically with retreatment administered as necessary. The patients were followed for a mean 28.1 months.

The rate of initial hemostasis (no bleeding occurred for 48 hours after sclerotherapy) was 96.2%. Cumulative nonbleeding rates were 64.7%, 52.7%, and 48.2% at 1, 5, and 10 years, respectively. When rebleeding occurred, 80.0% was within 1 year after initial injection. Recurrent bleeding was easily stopped with the reinjection of Histoacryl in most patients. The treatment failure-related mortality rate was 4.0% (2 of 52). The cumulative survival rates were 66.9%, 60.4%, and 55.5% at 1, 5, and 10 years, respectively. The mortality depended on either malignancy or liver function (Child-Pugh classification).

These results suggest that Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices, with rare complications occurring both acutely and long-term. Therefore, Histoacryl injection sclerotherapy is considered to be the first choice of treatment for bleeding gastric varices, but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.

Gastric varices and portal hypertensive gastropathy (PHG) are an important complication of both generalized and segmental portal hypertension. The natural history and risk factors for bleed from GV are not extensively studied as that for esophageal varices. Recently, effective therapy for gastric variceal bleed in form of tissue adhesives, balloon-occluded retrograde transvenous obliteration of gastric varices (BRTO) has been developed. Further advances are still needed regarding natural history, risk factors, bleeding, and mechanism of GV rupture.

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.

The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.

The treatment of esophageal variceal hemorrhage is still the subject of some controversy. The main causes of portal hypertension in children are portal vein thrombosis or cirrhosis, most commonly caused by biliary atresia. Many treatment options are available including endoscopic, radiographic, and surgical strategies. In general, children with presinusoidal obstructions have preserved hepatic synthetic function, and, therefore, treatment options include endoscopic strategies or portosystemic shunts, each with advocates. For children with advanced liver disease, liver transplantation offers the only chance for cure, so primary treatment of variceal bleeding should be by endoscopic means or transjugular intrahepatic portosystemic shunt (TIPS). Each modality has specific advantages and disadvantages, and treatment recommendations must therefore be tailored to the individual on a case-by-case basis, largely dependent on the expertise and experience of the health care team.