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

• Endoscopic ultrasound
• Diagnosis
• Treatment
• Gastric varices

Gastric variceal bleeding is more severe and fatal than esophageal bleeding. Injection of cyanoacrylate into bleeding gastric varices is recommended, but prophylactic injection is debatable. Aim of this study is to evaluate prophylactic cyanoacrylate injection into gastric extension of esophageal varices type 2 (GOV2).

This randomized controlled trial included 75 patients (3 groups) with risky or bleeding esophageal varices and non-bleeding GOV2. Group A received a cyanoacrylate GOV2 injection, esophageal variceal band ligation (EBL), and β-blocker (BB); group B received EBL and BB; and group C received EBL. Follow-up for ≥ 24 weeks to check for bleeding or death was performed.

Baseline variables were comparable among the 3 groups. During follow-up (median, 37.5 weeks), increasing gastric extension and or bleeding risk signs were significantly lower in group A (0%) than B (12%) and C (32%) (p < 0.001). Bleeding occurred more in groups B (24%) and C (24%) than in A (8%) (p = 0.2). Gastric extension size was an independent predictor of bleeding (p = 0.03). Portal hypertensive gastropathy (PHG) decreased in groups A (24%) and B (24%) more than in C (8%) (p = 0.5). Mortality rates were 0.0% in group A, 8% in B, and 4% in C (p = 0.2).

Prophylactic cyanoacrylate injection into GOV2 before EBL significantly decreased the varix size and risk signs for bleeding with a statistically insignificant tendency to decrease the bleeding rate. A large gastric extension was an independent predictor of bleeding. Adding β-blockers can potentially decrease PHG and bleeding risk. An independent study with a larger sample size is recommended to confirm the rate of bleeding and test the mortality difference.

• cyanoacrylate
• gastric varices
• portal hypertension
• prophylaxis

Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.

• Upper gastrointestinal bleeding
• Portal hypertension
• Gastric varices
• Variceal band ligation
• Variceal obliteration
• Sclerotherapy
• Transjugular intrahepatic portosystemic shunt
• Balloon-occlusion retrograde transvenous obliteration

• Balloon-occluded retrograde transvenous obliteration
• Endoscopy
• Gastric varix
• Intervention
• Liver cirrhosis
• Prevention
• Prophylaxis
• Variceal bleeding
• Variceal hemorrhage
• Variceal obliteration

Situs inversus abdominus is a congenital abnormality characterized by the mirror image positioning of the abdominal organs, making it difficult to diagnosis and treatment of many diseases. Here, we report a rare case of gastric varices in situs inversus abdominus patient. A 55-year-old man was diagnosed with F2-shaped gastric varices associated with alcoholic cirrhosis. Abdominal dynamic computed tomography showed situs inversus abdominus, and gastric varices with a gastrorenal shunt. Due to the complex anatomy, emergency interventional radiology during bleeding was extremely difficult. Therefore, after thorough consultation, we decided to treat gastric varices prophylactically by balloon-occluded retrograde transvenous obliteration. After treatment, the patient’s clinical course was generally good, with no adverse events, and the gastric varices disappeared. It is important to assess anatomical positioning using three-dimensional reconstruction computed tomography images before treatment, to adequately prepare, including selecting appropriate devices (i.e., catheters and sheath). Although preventive treatment of gastric varices is controversial, in cases with anatomical complexity, preventive treatment with sufficient preparation would be recommended. To the best of our knowledge, there are no reports of treatment for gastric varices in situs inversus abdominus patient. This case will serve as a reference for successful treatment in future cases.

• Balloon-occluded retrograde transvenous obliteration
• Gastric varices
• Partial splenic embolization
• Polysplenia
• Situs inversus abdominus

Rebleeding of gastric varices (GVs) after endoscopic variceal obturation (EVO) can be fatal. This study was performed to evaluate the usefulness of computed tomography (CT) for the prediction of rebleeding after EVO GV bleeding.

Patients who were treated with EVO for GV bleeding and underwent CT before and after EVO were included. CT images of the portal phase showing pretreatment GVs and feeding vessels, and nonenhanced images showing posttreatment cyanoacrylate impaction were reviewed.

Fifty-three patients were included. Their mean age was 60.6±11.6 years, and 40 patients (75.5%) were men. Alcoholic liver disease was the most frequent underlying liver disease (45.3%). Complete impaction of cyanoacrylate in GVs and feeding vessels were achieved in 40 (75.5%) and 24 (45.3%) of patients, respectively. During the follow-up, GV rebleeding occurred in nine patients, and the cumulative incidences of GV rebleeding at 3, 6, and 12 months were 11.8%, 18.9%, and 18.9%, respectively. The GV rebleeding rate did not differ significantly according to the complete cyanoacrylate impaction in the GV, while it differed significantly according to complete cyanoacrylate impaction in the feeding vessels. The cumulative incidences of GV rebleeding at 3, 6, and 12 months were 22.3%, 35.2%, and 35.2%, respectively, in patients with incomplete impaction in feeding vessels, and there was no rebleeding during the follow-up period in patients with complete impaction in the feeding vessels (p=0.002).

Abdominal CT is useful in the evaluation of the treatment response after EVO for GV bleeding. Incomplete cyanoacrylate impaction in feeding vessels is a risk factor for GV rebleeding.

• Cyanoacrylates
• Esophageal and gastric varices
• Ethiodized oil
• Tomography
• X-ray computed

Background

The optimal management of gastric variceal bleeding in patients with non-cirrhotic portal hypertension (NCPH) is debatable due to the lack of data from large randomized controlled trials. Here we present our experience on proximal splenorenal shunt (PSRS) surgery in NCPH patients with bleeding gastric varices.

Methods

Over a five-year period, a total of 25 PSRS surgeries were performed and data was collected prospectively. Nineteen extrahepatic portal vein obstruction (EHPVO) and six non-cirrhotic portal fibrosis (NCPF) patients with bleeding fundic or isolated gastric varices and normal liver function were included. The collected data was analyzed retrospectively.

Results

Of the 25 patients who underwent PSRS five were lost to follow-up. Twenty patients (80%) were followed up for a median of 3.4 (1-5) years. Gastric variceal regression was noted in all 20 patients with the disappearance of varices in eight patients. On follow-up, shunt thrombosis was noted in four (20%) patients of whom, two had rebleeding between six months and three years after shunt surgery.

Conclusion

PSRS was effective in controlling gastric variceal hemorrhage in 92% (23 of 25) of patients with preserved liver function.

• gastric varices
• non cirrhotic portal hypertension
• proximal splenorenal shunt
• secondary prophylaxis

There are two types of esophageal varices (EVs): high-risk EVs (HEVs) and low-risk EVs, and HEVs pose a greater threat to patient life than low-risk EVs. The diagnosis of EVs is mainly conducted by gastroscopy, which can cause discomfort to patients, or by non-invasive prediction models. A number of non-invasive models for predicting EVs have been reported; however, those that are based on the formula for calculation of liver and spleen volume in HEVs have not been reported.

To establish a non-invasive prediction model based on the formula for liver and spleen volume for predicting HEVs in patients with viral cirrhosis.

Data from 86 EV patients with viral cirrhosis were collected. Actual liver and spleen volumes of the patients were determined by computed tomography, and their calculated liver and spleen volumes were calculated by standard formulas. Other imaging and biochemical data were determined. The impact of each parameter on HEVs was analyzed by univariate and multivariate analyses, the data from which were employed to establish a non-invasive prediction model. Then the established prediction model was compared with other previous prediction models. Finally, the discriminating ability, calibration ability, and clinical efficacy of the new model was verified in both the modeling group and the external validation group.

Data from univariate and multivariate analyses indicated that the liver-spleen volume ratio, spleen volume change rate, and aspartate aminotransferase were correlated with HEVs. These indexes were successfully used to establish the non-invasive prediction model. The comparison of the models showed that the established model could better predict HEVs compared with previous models. The discriminating ability, calibration ability, and clinical efficacy of the new model were affirmed.

The non-invasive prediction model for predicting HEVs in patients with viral cirrhosis was successfully established. The new model is reliable for predicting HEVs and has clinical applicability.

• Cirrhosis
• High-risk esophageal varices
• Non-invasive prediction model
• Liver volume
• Spleen volume

• Adult
• Aged
• Aspartate Aminotransferases/blood
• China/epidemiology
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/epidemiology
• Esophageal and Gastric Varices/etiology
• Esophageal and Gastric Varices/pathology
• Female
• Hepatitis B/complications
• Hepatitis B/diagnosis
• Hepatitis B/pathology
• Hepatitis B/virology
• Hepatitis C/complications
• Hepatitis C/diagnosis
• Hepatitis C/pathology
• Hepatitis C/virology
• Humans
• Liver/diagnostic imaging
• Liver/pathology
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/pathology
• Liver Cirrhosis/virology
• Male
• Middle Aged
• Multivariate Analysis
• Organ Size
• Platelet Count
• Predictive Value of Tests
• ROC Curve
• Reproducibility of Results
• Retrospective Studies
• Risk Assessment/methods
• Severity of Illness Index
• Spleen/diagnostic imaging
• Spleen/pathology
• Tomography, X-Ray Computed

• Cirrhosis
• Guideline
• Hepatic encephalopathy
• Varices

• Adrenergic beta-Antagonists/therapeutic use
• Ammonia/blood
• Anti-Bacterial Agents/therapeutic use
• Carvedilol/therapeutic use
• Disaccharides/therapeutic use
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/drug therapy
• Esophageal and Gastric Varices/pathology
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/prevention & control
• Hepatic Encephalopathy/diagnosis
• Hepatic Encephalopathy/drug therapy
• Hepatic Encephalopathy/pathology
• Humans
• Hypertension, Portal/diagnosis
• Hypertension, Portal/drug therapy
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnosis
• Propranolol/therapeutic use
• Quality of Life
• Vasoconstrictor Agents/therapeutic use

• TIPS
• hemorrhage
• interventional radiology
• portal hypertension
• varices

Varicose gastrointestinal bleeding is one of the major causes of morbidity and mortality in patients with chronic liver disease. Endoscopic treatment is the first therapeutic line for these patients, however, for those whom this therapeutic modality fail, a broad knowledge of alternative treatment options may improve the prognosis. We describe a case of a patient who were successfully embolized from gastroesophageal varices via transsplenic access.

Background and Aims: Gastric varices (GVs) occur in 20% of patients with portal hypertension. GVs are associated with a 65% risk of bleeding over the course of 2 years and have a mortality rate of up to 20%. The standard treatment for GVs is obliteration with cyanoacrylate (CYA). This study presents our experience with combined therapy (vascular coils and CYA) under endoscopic ultrasound (EUS) guidance. Methods: 16 patients (9 male and 7 female) were included into our study. Etiology of portal hypertension included: portal vein thrombosis (PVT) (31.0%), isolated splenic vein thrombosis (SVT) (25.0%), alcoholic cirrhosis (12.5%), hepatitis C cirrhosis (19.0%), and alcoholic cirrhosis with PVT (12.5%). Varices type GOV-2 were diagnosed in 8 patients, type IGV-1 and IGV-2 in 6 and 2 patients, respectively. Indications for treatment were based on endoscopic and endosonographic evaluations of GVs. Inclusion and exclusion criteria were also specified. Technique depended on the size of varices (different size of coils + CYA additionally). The results were based on the achievement of technical success, therapeutic effects, and number of adverse events. Average follow-up period was 327 days. Results: From January to August 2017, 16 patients were treated with EUS-guided obliteration of GVs using vascular coils only or coils with CYA injections. 6 (37.5%) and 10 (62.5%) patients underwent primary and secondary prophylaxis for hemorrhage, respectively. Technical success was achieved in 15 patients (94.0%). Mean numbers of implanted coils and CYA volume during one procedure were 1.7 and 2 mL, respectively. Therapeutic success was achieved in all patients treated with the combination. There were no serious complications such as embolization or death due to the procedure. Three patients (19.0%) had transient abdominal pain and two (12.5%) had transient fever. 1 patient had clinical symptoms of gastrointestinal bleeding. Conclusions: Based on our retrospective research we have concluded, that EUS-guided implantation of intravascular coils combined with cyanoacrylate injections is an effective method of treatment with an acceptable number of complications.

• coil
• cyanoacrylate
• endoscopic ultrasound
• gastric varices
• obliteration

• balloon-occluded retrograde transvenous obliteration (B-RTO)
• gastric varices
• portal hypertension
• selective B-RTO

• Aged
• Balloon Occlusion/methods
• Embolization, Therapeutic/methods
• Endosonography
• Esophageal and Gastric Varices/surgery
• Female
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Treatment Outcome

Gastric varices (GV) have different physiology and clinical characteristics compared to oesophageal varices (OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies’ recommendations are based are scrutinised in this review and areas of research are identified.

• Gastric varices
• Oesophageal varices
• Portal hypertension
• Cirrhosis

Gastric varices (GVs) are a major cause of upper gastrointestinal bleeding in patients with liver cirrhosis. The current treatments of choice are balloon-occluded retrograde transvenous obliteration (BRTO) and the placement of a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to compare the efficacy and outcomes of these two methods for the management of GV bleeding.

This retrospective study included consecutive patients who received BRTO (n=157) or TIPS (n=19) to control GV bleeding from January 2005 to December 2014 at a single tertiary hospital in Korea. The overall survival (OS), immediate bleeding control rate, rebleeding rate and complication rate were compared between patients in the BRTO and TIPS groups.

Patients in the BRTO group showed higher immediate bleeding control rates (p=0.059, odds ratio [OR]=4.72) and lower cumulative rebleeding rates (log-rank p=0.060) than those in the TIPS group, although the difference failed to reach statistical significance. There were no significant differences in the rates of complications, including pleural effusion, aggravation of esophageal varices, portal hypertensive gastropathy, and portosystemic encephalopathy, although the rate of the progression of ascites was significantly higher in the BRTO group (p=0.02, OR=7.93). After adjusting for several confounding factors using a multivariate Cox analysis, the BRTO group had a significantly longer OS (adjusted hazard ratio [aHR]=0.44, p=0.01) and a longer rebleeding-free survival (aHR=0.34, p=0.001) than the TIPS group.

BRTO provides better bleeding control, rebleeding-free survival, and OS than TIPS for patients with GV bleeding.

• Balloon-occluded retrograde transvenous obliteration
• Portasystemic shunt, transjugular intrahepatic
• Variceal bleeding

• Cyanoacrylate
• Endoscopic ultrasound
• Fine needle injection
• Gastric varices
• Variceal bleeding

• ascites
• encephalopathy
• esophageal varices
• hepatic venous pressure gradient
• portal hypertension

• balloon-occluded retrograde transvenous obliteration
• esophageal varices
• gastric varices
• transjugular intrahepatic portosystemic shunt
• variceal hemorrhage

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

• Cirrhosis
• Ligation
• Obliteration
• Obturation
• Portal hypertension

The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.

• Ascites
• Austria
• Billroth
• Cirrhosis
• Guidelines
• Portal hypertension
• TIPS
• Varices

• acute varices haemorrhage
• cirrhosis
• non-selective beta-blockers
• prophylaxis
• variceal band ligation
• varices

Endoscopy is an important means for the prevention and treatment of gastric variceal bleeding. With definite curative effects and mild side effects, endoscopic tissue adhesive injection has become a preferred first-line treatment for gastric variceal hemorrhage and is now widely used in clinical practice. However, it is still controversial regarding surgical technique, long-term efficacy, risk of complications, and the effect of secondary prevention of gastric variceal bleeding. This article makes a summary of the above points of dispute.

• Gastric varices
• Bleeding
• Tissue adhesive injection

• B-cell lymphoma
• Gastric variceal hemorrhage
• Portal hypertension

• gastric variceal bleeding
• somatostatin
• terlipressin

• Anatomy
• gastroesophageal varices
• portal hypertension
• transjugular intrahepatic portosystemic shunt

It is considered that gastric varices (GVs) which have the large form in endoscopic view should be treated because they are regarded as having high blood flow volume and the risky varices of hemorrhage. However, there is no data of the correlation among the endoscopic view, diameter of GV, and blood flow volume in GV. The aim of this study was to investigate whether GV diameter correlates to blood flow volume or not. In addition, the correlation between the endoscopic findings of GVs, patient status, and blood flow volume was assessed.

In this study, 24 patients were enrolled. Variceal form and its location were observed using flexible GI endoscopes. Assessment of variceal form and location was according to Japanese society of portal hypertension. Then, the GV diameter (the maximum short axis), the GV flow velocity, and the GV flow volume were measured by echo-endoscope with curved linear array or with electronic radial array.

Nineteen of 24 enrolled patients were analyzed. There was strong correlation between the GV diameter and the GV flow volume (rs = 0.85, P < 0.01). No significant difference in the GV diameter and the GV flow volume was found between each location. However, there was no significant difference in the GV diameter between each variceal form. In addition, no significant difference was found among Child–Pugh classifications, and in cases associated with or without hepatocelluer carcinoma.

Strong correlation was found between GV diameter and flow volume of GV, regardless of the location. However, since there was no significant difference in the GV diameter between each variceal form in endoscopic view, measuring GV diameter is important to understand its hemodynamics for further treatment.

• Endoscopic ultrasound
• flow volume
• gastric varices hemodynamics

• Cyanoacrylates
• Endoscopic
• Esophageal and gastric varices
• Hemostasis
• Proton pump inhibitors
• Treatment outcome

• Adult
• Aged
• Aged, 80 and over
• Chi-Square Distribution
• Enbucrilate/administration & dosage
• Enbucrilate/adverse effects
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/mortality
• Esophageal and Gastric Varices/therapy
• Female
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/mortality
• Gastrointestinal Hemorrhage/therapy
• Hemostasis, Endoscopic/adverse effects
• Hemostasis, Endoscopic/methods
• Hemostasis, Endoscopic/mortality
• Humans
• Logistic Models
• Male
• Middle Aged
• Multivariate Analysis
• Odds Ratio
• Proton Pump Inhibitors/adverse effects
• Proton Pump Inhibitors/therapeutic use
• Recurrence
• Retrospective Studies
• Risk Factors
• Sclerosing Solutions/administration & dosage
• Sclerosing Solutions/adverse effects
• Sclerotherapy/adverse effects
• Sclerotherapy/methods
• Sclerotherapy/mortality
• Time Factors
• Treatment Outcome
• Young Adult

• Cirrhosis
• Endoscopic band ligation
• Endoscopic sclerotherapy
• Endoscopic variceal obturation
• Endoscopy
• Esophageal varices
• Gastric varices
• Variceal hemorrhage

Portal hypertension (PH) plays an important role in the natural history of cirrhosis, and is associated with several clinical consequences. The introduction of transjugular intrahepatic portosystemic shunts (TIPS) in the 1980s has been regarded as a major technical advance in the management of the PH-related complications. At present, polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents. TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment. Recently, applying TIPS early (within 72 h after admission) has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding. In addition, TIPS is recommended as the second-line treatment for secondary prophylaxis. For bleeding gastric varices, applying TIPS was able to achieve hemostasis in more than 90% of patients. More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities, including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices. TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy. In patients with refractory ascites, there is growing evidence that TIPS not only results in better control of ascites, but also improves long-term survival in appropriately selected candidates. In addition, TIPS is a promising treatment for refractory hepatic hydrothorax. However, the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined. The advantage of TIPS is offset by a risk of developing hepatic encephalopathy, the most relevant post-procedural complication. Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome. This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.

• Transjugular intrahepatic portosystemic shunts
• Portal hypertension
• Cirrhosis
• Varices
• Ascites

• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/etiology
• Esophageal and Gastric Varices/mortality
• Esophageal and Gastric Varices/surgery
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/mortality
• Gastrointestinal Hemorrhage/surgery
• Humans
• Hypertension, Portal/diagnosis
• Hypertension, Portal/etiology
• Hypertension, Portal/mortality
• Hypertension, Portal/physiopathology
• Hypertension, Portal/surgery
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/mortality
• Metals
• Polytetrafluoroethylene
• Portal Pressure
• Portasystemic Shunt, Transjugular Intrahepatic/adverse effects
• Portasystemic Shunt, Transjugular Intrahepatic/instrumentation
• Portasystemic Shunt, Transjugular Intrahepatic/mortality
• Prosthesis Design
• Risk Factors
• Stents
• Treatment Outcome

• Acute-On-Chronic Liver Failure/complications
• Acute-On-Chronic Liver Failure/mortality
• Enbucrilate/therapeutic use
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/mortality
• Female
• Gastrointestinal Hemorrhage/mortality
• Gastrointestinal Hemorrhage/therapy
• Hemostatics/therapeutic use
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/mortality
• Male
• Middle Aged
• Multivariate Analysis
• Recurrence
• Renal Insufficiency/complications
• Renal Insufficiency/mortality
• Retrospective Studies
• Severity of Illness Index

• Bleeding
• Esophageal varices
• Ligation
• Prophylaxis
• Propranolol

• embolotherapy
• gastroesophageal varices
• hemorrhage
• interventional radiology
• transjugular intrahepatic portosystemic shunt

• Acute variceal bleeding
• Endoscopy
• Hemostasis

• Cyanoacrylates
• Endoscopy
• Esophageal and gastric varices
• Hemostasis
• Treatment outcome

• Adult
• Aged
• Aged, 80 and over
• Enbucrilate/adverse effects
• Enbucrilate/therapeutic use
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/mortality
• Esophageal and Gastric Varices/therapy
• Female
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/mortality
• Gastrointestinal Hemorrhage/therapy
• Hemostatic Techniques/adverse effects
• Hemostatic Techniques/mortality
• Humans
• Male
• Middle Aged
• Recurrence
• Retrospective Studies
• Time Factors
• Treatment Outcome
• Young Adult

• Cyanoacrylates
• Endoscopy
• Esophageal and gastric varices
• Hemostasis
• Treatment outcome

Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.

• Band ligation
• Beta-blockers
• Esophageal varices
• Primary prevention

AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.

METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.

RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.

CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

• Emergency balloon-occluded retrograde transvenous obliteration
• Gastric varices
• Bleeding
• Portal hypertension
• Ethanolamine oleate

• Adult
• Aged
• Balloon Occlusion/adverse effects
• Emergencies
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/diagnosis
• Female
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/therapy
• Hematemesis/etiology
• Humans
• Male
• Melena/etiology
• Middle Aged
• Recurrence
• Time Factors
• Tomography, X-Ray Computed
• Treatment Outcome

The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices.

In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied.

There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1±7.7 mm Hg vs 19.7±5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3±5.8 mm Hg vs 17.0±8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016).

Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.

• Cirrhosis
• Fundal varices
• Hepatic venous pressure gradient
• Hypertension, portal
• Portasystemic shunt, surgical

AIM: To compare the efficacy of modified percutaneous transhepatic variceal embolization (PTVE) with 2-octyl-cyanoacrylate (2-OCA) and endoscopic variceal obturation (EVO) with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding.

METHODS: In this retrospective study, the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA (EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed. Patient demographics, rebleeding rate, survival rate, and complications were compared between the two groups (PTVE and EVO). All results were expressed as mean ± SD, or as a percentage. Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or the χ² test (with Yates correction) where appropriate. A P value less than 0.05 was considered significant. Statistical computation was performed using SPSS 13.0 software.

RESULTS: A total of 77 patients were included; 45 patients who underwent EVO and 32 patients who received PTVE. During the follow-up (19.78 ± 7.70 mo in the EVO group, vs 21.53 ± 8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group (37.78% vs 12.5%, P = 0.028). The cumulative rebleeding-free rate was 75%, 59%, and 49% in 1, 2, and 3 years respectively for EVO, and 93%, 84%, and 84% for PTVE (P = 0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment. Variables including age, gender, cause, Child-Pugh classification, size of gastric varices (GV), location of GV, and treatment methods were analyzed. It was revealed that Child-Pugh classification [risk ratio (RR) 2.10, 95%CI: 1.03-4.28, P = 0.040], choice of treatment (RR 0.25, 95%CI: 0.08-0.80, P = 0.019), and size of GV (RR 2.14, 95%CI: 1.07-4.28, P = 0.032) were the independent factors for predicting rebleeding. Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up, eight patients in the EVO group and four patients in the PTVE group died. The cumulative survival rates at 1, 2, and 3 years were 93%, 84%, and 67% respectively in the EVO group, and 97%, 88%, and 74% respectively in the PTVE group. The survival rates were not significantly different between the two groups (P = 0.432). Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival (RR 2.77, 95%CI: 1.12-6.80, P = 0.027). The incidence of complications was similar in both groups.

CONCLUSION: With extensive and permanent obliteration of gastric varices and its feeding veins, PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.

• Gastric varices
• Endoscopic variceal obturation
• Percutaneous transhepatic variceal embolization
• 2-octyl-cyanoacrylate
• Bleeding

AIM: To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.

METHODS: Retrospective observational study in a Tertiary Referral Centre. Between January 1999-October 2005, we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices. Patient details including age, gender and aetiology of liver disease/segmental portal hypertension were documented. The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle. All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded. Initial haemostasis rates, rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy. The duration of follow up was also listed. The study was conducted according to the United Kingdom research ethics guidelines.

RESULTS: Thirty-seven patients were included. 33 patients (89%) had thrombin (250 U/mL) for gastric varices, 2 (5.4%) for duodenal varices, 1 for rectal varices and 1 for gastric and rectal varices. (1) Gastric varices, an average of 15.2 mL of thrombin was used per patient. Re-bleeding occurred in 4 patients (10.8%), managed in 2 by a transjugular intrahepatic portosystemic shunt (TIPSS) (one unsuccessfully who died) and in other 2 by a distal splenorenal shunt; (2) Duodenal varices (or type 2 isolated gastric varices), an average of 12.5 mL was used per patient over 2-3 endoscopy sessions. Re-bleeding occurred in one patient, which was treated by TIPSS; and (3) Rectal varices, an average of 18.3 mL was used per patient over 3 endoscopy sessions. No re-bleeding occurred in this group.

CONCLUSION: Human thrombin is a safe, easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.

• Variceal haemorrhage
• Ectopic Varices
• Gastric varices
• Portal hypertension
• Thrombin

• BRTO
• Gastric varices
• embolization
• liver cirrhosis
• portal hypertension
• portosystemic shunt

• BRTO
• Gastric varices
• TIPS
• cyanoacrylate
• liver cirrhosis
• portal hypertension
• splenorenal shunt

• BRTO
• Gastric varices
• liver cirrhosis
• portal hypertension
• portosystemic shunt