ENDOSCOPIC INJECTION SCLEROTHERAPY FOR ESOPHAGEAL VARICES IN TWO PATIENTS WITH IDIOPATHIC MYELOFIBROSIS

Case 1: A 75‐year‐old woman was admitted to our department in February 1996 with tarry stool. At 71 years of age, she had been diagnosed with idiopathic myelofibrosis (IMF) based upon laboratory data and a biopsy of iliac bone marrow. Fibergastroscopic examination on admission revealed esophageal varices graded as Ls, F2, Cb, and red color (RC)(+ +). Esophageal varices were considered the most likely cause of the bleeding. Computed tomography (CT) showed a markedly enlarged spleen and large collateral veins (left gastric vein, spleno‐renal shunt). We performed endoscopic injection sclerotherapy (EIS) twice weekly using 5% ethanolamine oleate with iopamidol (5% EOI), the total amount of sclerosant was 13 mL. No further variceal bleeding occurred until she died in June 1996. Case 2: A 67‐year‐old man was admitted to our hospital in February 1992 with anemia and leukocytosis after a health check. He was diagnosed with IMF based upon laboratory data and a biopsy of iliac bone marrow. Screening upper gastrointestinal endoscopy demonstrated esophageal varices graded as Ls, F3, Cb, and red color (RC)(+) and gastric varices graded as Lg–cf, F2, and RC(–). CT showed a markedly enlarged spleen and large collateral veins (left gastric vein, short gastric vein). We performed EIS four times weekly using 5% EOI, the total amount of sclerosant was 32 mL. Two weeks after EIS the varices were graded as F1, RC(–). This patient experienced esophageal varix recurrence up to 1 year later, and EIS was performed twice using 5% EOI.     

Observation of gastric variceal flow characteristics by endoscopic ultrasonography using color Doppler

OBJECTIVES: The aim of this study was to investigate the endoscopic color Doppler ultrasonography (ECDUS) findings of gastric varices and to determine the role of ECDUS in the diagnosis of gastric varices. METHODS: Using ECDUS, we evaluated 114 patients with gastric varices found consecutively by routine upper endoscopy. We monitored the color flow images of gastric varices and perigastric collateral veins. We measured the blood flow velocity of gastric varices and the thickness of the gastric wall to submucosal gastric varices with this technique, and investigated the usefulness of ECDUS in evaluating the hemodynamics of gastric varices. Endoscopic findings of gastric varices were evaluated according to the grading system of the Japanese Research Committee on Portal Hypertension. RESULTS: Color flow images of gastric varices and perigastric veins were delineated in all 114 patients with ECDUS. Evaluation of blood flow velocity in the 114 gastric varices revealed velocities of 7.7-35.7 cm/s (mean 18.2 +/- 5.9 cm/s). The velocities (23.7 +/- 6.4 cm/s, N = 21) of large, coil-shaped (F3)-type gastric varices were significantly higher than those (16.7 +/- 4.9 cm/s, N = 93) of enlarged tortuous (F2)-type varices (P < 0.0001). The 114 gastric varices were at 1.0-2.2 mm (1.6 +/- 0.3 mm) of gastric wall thickness. The thickness (1.2 +/- 0.1 mm, N = 22) for red color sign (RC)- or erosion-positive varices was significantly less than that (1.7 +/- 0.2 mm, N = 92) for the negative cases (P < 0.0001). The mean velocity was 28.0 +/- 6.1 cm/s in bleeding cases (N = 4) and 17.6 +/- 5.5 cm/s in nonbleeding cases (N = 110), and the velocities of the bleeding cases were significantly higher than those of the nonbleeding cases (P < 0.001). The mean thickness of the gastric wall was 1.2 +/- 0.2 mm for bleeding cases and 1.6 +/- 0.3 mm for nonbleeding cases, and the mean wall thickness in the bleeding cases was significantly less than in the nonbleeding cases (P < 0.001). CONCLUSIONS: ECDUS is a useful modality for diagnosis of the hemodynamics of gastric varices and may allow the prediction of a high risk for hemorrhage.     

Evaluation of the alternate blood FLow in esophageal variceal patients by endoscopic color Doppler ultrasonography

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color ?ow images of esophageal varices. The direction of blood ?ow in passageways is fundamentally hepatofugal ?ow according to ECDUS. The present study is designed to evaluate the alternate direction of color ?ow image of passageways via ECDUS in esophageal variceal patients. Methods: The study involved 125 patients with esophageal varices using ECDUS. The grades of red color (RC) were as follows: RC(+) in 79 cases, RC(+ +) in 35 cases, and RC(+ + +) in 11 cases. We investigated the alternate direction on color ?ow images of the left gastric vein, the palisade vein, and the perforating veins via ECDUS. Results: Color ?ow images of the esophageal varices and the left gastric vein were obtained in all 125 (100%) patients by ECDUS. Color ?ow images of the perforating veins were obtained in 90 (72.0%) of the 125 patients. Vessel images of the palisade veins were detected in 33 (26.4%) of the 125 patients. The alternate direction on color ?ow images was detected in seven (5.6%) of the 125 patients with ECDUS: in three patients, left gastric vein; in three patients, perforating veins; and in one patients, left gastric vein and palisade veins. This phenomenon was observed periodically at regular intervals. The endoscopic ?ndings were RC(+) in all seven patients. Conclusion: The alternate direction of blood ?ow in the passageways was observed in a few cases of RC(+) esophageal varices. We can observe the hemodynamics of esophageal varices non‐invasively and in real time with ECDUS, and clarify the frequencies of the alternate direction of blood ?ow in RC‐positive esophageal variceal patients.     

Endoscopic prediction of hepatocellular carcinoma by evaluation of bleeding esophageal varices

BACKGROUND: Prognostic indicators for patients with liver cirrhosis accompanied by esophageal varices are hemorrhage of the varices and development of hepatocellular carcinoma (HCC). Although predictors for HCC have been reported, few studies have investigated the correlation between carcinoma development and endoscopic findings of bleeding varices. We examined whether endoscopic variceal findings such as form (F factor), color (C factor) and red color sign (RC factor) predict development of HCC. METHODS: This study included 124 patients with liver cirrhosis who received treatment for bleeding esophageal varices. Patients were followed up with blood chemistries including alpha-fetoprotein and by abdominal ultrasonography and computed tomography. The primary outcome measure of this study was the cumulative incidence of HCC after the treatment for esophageal varices. The secondary measure was whether endoscopic factors predicted the HCC development, and if so, which factors. RESULTS: During follow-up, 32 of the 124 patients developed HCC. The cumulative carcinogenic rate after 3, 5 and 10 years was 11.8, 25.8 and 37.8%, respectively. Among the 32 patients who developed HCC, 29 (90.6%) had large esophageal varices (large F factor) prior to treatment of the varices. As the F factor increased, the percentage of patients who developed HCC also increased. In particular, independent predictors for HCC were: history of blood transfusion (p=0.037), presence of hepatitis C virus antibody (p=0.005), platelet count <7.5 x 10(4)/ml (p=0.004), alpha-fetoprotein level >10 ng/ml (p=0.030), and large F factor (F3) (p=0.002). Variceal RC and C factors were not independent predictors for carcinogenesis. CONCLUSION: The endoscopic F factor rating of bleeding esophageal varices can be a significant predictive factor for HCC in patients with liver cirrhosis.     

Color Doppler findings of gastric varices compared with findings on computed tomography

Background: Background: The aim of this study was to evaluate the hemodynamics of gastric varices. Methods: We evaluated the detection rates of gastric varices, inflowing vessels to gastric varices, and outflowing vessels from gastric varices in 24 patients with gastric varices, using color Doppler sonography, and compared these findings with computed tomography findings. Eighteen patients had F2-type varices and 6 had F3-type, classified according to the Japanese Research Society for Portal Hypertension. Fourteen patients had fundal varices, and 10 had cardiac and fundal varices. Results: The detection rates of collateral veins using color Doppler sonography were as follows: gastric varices were detected in all 24 patients (100%); inflowing vessels, in 21 of the 24 patients (87.5%); and outflowing vessels, in 18 of the 24 patients (75.0%). The detection rates of collateral veins, using computed tomography, were: gastric varices were detected in all 24 patients (100%); inflowing vessels, in all 24 patients (100%); and outflowing vessels, in 21 of the 24 patients (87.5%). The color Doppler findings agreed perfectly with the computed tomography findings in 13 of the 24 patients (54.2%). Conclusions: Although color Doppler sonography is a useful, noninvasive modality for evaluating the hemodynamics of gastric varices, it falls short in visualizing the detailed hemodynamics of the inflowing and outflowing vessels of gastric varices in half of the patients when compared with computed tomography. Received: September 13, 2001 / Accepted: December 14, 2001     

Perforating Veins in Recurrent Esophageal Varices after Endoscopic Therapy Visualized by Endoscopic Color Doppler Ultrasonography

This study was designed to evaluate the detection rate and the direction of blood flow of perforating veins using endoscopic color Doppler ultrasonography (EC-DUS) in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. Perforating veins were defined as vessels communicating between esophageal varices and paraesophageal veins. The study involved thirty patients with recurrent esophageal varices who had been followed up for more than one year. Seven of them had high risk intramucosal venous dilatation (IMVD) of the esophagus, and 23 had F₁ (small straight varices) red color (RC) positive varices. Color flow images of perforating veins were obtained in 18 patients (60.0%). The perforating veins were classified into three types according to flow direction. Type 1 had inflow from paraesophageal veins to esophageal varices, Type 2 had outflow type from esophageal varices to paraesophageal veins, and Type 3 was mixed, showing both inflow and outflow. Of the 18 patients in whom color flow images were obtained, 15 (83.3%) cases were Type 1, none were Type 2, and three (16.7%) were Type 3. All the color flow images in the perforating veins were demonstrated as a continuous wave. In conclusion, perforating veins can be detected at a high rate by ECDUS in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. (Dig Endosc 1999; 11: 236–240)     

Evaluation of arterial blood flow in esophageal varices via endoscopic color Doppler ultrasonography with a galactose-based contrast agent

Background We examined the usefulness of endoscopic color Doppler ultrasonography, using Levovist in evaluating the arterial blood flow, in patients with esophageal varices.Methods The study involved 110 patients with esophageal varices who were examined using endoscopic color Doppler ultrasonography (ECDUS). We compared vessel images detected by pre-contrast ECDUS with those detected by enhanced ECDUS. We evaluated the detection rate of the pulsatile wave, and measured systolic velocity and end-diastolic velocity. We calculated the resistance index (RI), which demonstrates the resistance of peripheral vessels in arterial flow.Results Color flow images of the pulsatile wave were obtained by pre-contrast ECDUS in 3 (2.7%) of the 110 patients. Color flow images of the pulsatile waves were obtained in 40 (36.4%) of the 110 patients by enhanced ECDUS using Levovist. That is, by using Levovist, a pulsatile wave could be delineated in 37 patients in whom pulsatile waves were previously undiagnosed via pre-contrast ECDUS. Color flow images of the pulsatile waves were detected in 37 (37.7%) of the 98 F2 varices and in 3 (25.0%) of the 12 F3 varices. Color flow images of the pulsatile wave were detected in 35 (40.2%) of the 87 red color (RC)(+) varices, and in 5 (21.7%) of the 23 RC(++) or RC (+++) varices. Next, we calculated the RI of the pulsatile wave, obtained by enhanced ECDUS using Levovist, in 40 patients. The RI ranged from 0.49 to 0.83 (mean, 0.67 ± 0.09); there were nine patients with RIs of less than 0.60, and all 9 of these patients had both F2 and RC(+) type varices (100%).Conclusions Levovist contrast in ECDUS examinations suggests that arterial flow is involved in the formation of esophageal varices.     

Hemodynamic assessment of the left gastric vein in patients with esophageal varices with color Doppler EUS: factors affecting development of esophageal varices

BACKGROUND: An understanding of the development of esophageal varices is important in the evaluation of risk of variceal hemorrhage. To clarify factors affecting the development of esophageal varices, the morphology and hemodynamics of the left gastric vein were analyzed with color Doppler EUS. METHODS: Sixty-seven patients with esophageal varices underwent color Doppler EUS. Seventeen had small varices (F1), 32 had medium varices (F2), and 18 had large varices (F3). RESULTS: Hepatofugal blood flow velocity in the left gastric vein trunk increased as the size of the varices increased (p < 0.0001), whereas the diameter did not increase. The left gastric vein bifurcates into anterior and posterior branches. As the size of the varices enlarged, the branch pattern was more likely to be anterior branch dominant (p = 0.041). There was no significant difference between the 3 size groups of esophageal varices with respect to the size of the paraesophageal collaterals. The detection rate and diameter of the perforating vein increased as the size of the varices increased (p = 0.032 and 0.012, respectively). CONCLUSION: Blood flow velocity in the left gastric vein trunk, branches, and perforating veins may regulate blood flow supplying the esophageal varices and contribute to their development. These findings are important to understanding the pathogenesis of esophageal varices.     

位置、直径、出血风险在食管胃底静脉曲张破裂出血患者分型中应用初探

目的 初步探讨应用静脉曲张位置、直径、出血风险对食管胃底静脉曲张破裂出血患者进行分型(LDRf分型)的可行性.方法 回顾分析381例因食管胃底静脉曲张破裂出血行内镜下急诊治疗患者,对静脉曲张位置、直径和出血危险因素进行分析,并尝试进行LDRf分型.结果 食管胃底静脉出血好发于食管中下段,不同直径的曲张静脉均有出血,曲张静脉多见有红色征.所有患者均可进行LDRf分型,食管静脉曲张破裂出血患者中,Rf1共计 133 例(45.4%),Rf2共计 160 例(54.6%);胃静脉曲张破裂出血患者中,Rf1共计47例(53.4%),Rf2共计41例(46.6%).结论 LDRf可用于食管胃静脉曲张的分类并对诊断治疗有一定指导意义.     

The clinical characteristics, endoscopic treatment, and prognosis for patients presenting with duodenal varices

BACKGROUND/AIMS: This study investigated the clinical characteristics, endoscopic appearances, usefulness of endoscopic treatments, and survival of patients with duodenal varices. METHODOLOGY: Twelve patients were evaluated in whom endoscopy confirmed duodenal varices (13 lesions), and patient data was retrospectively analyzed regarding underlying diseases, hepatic function, endoscopic appearance, previous treatment for other complicated varices, endoscopic treatment for hemorrhage from duodenal varices, and survival. RESULTS: Underlying diseases consisted of liver cirrhosis in 8 patients, and pancreatic cancer-related pylemphraxis in 4 patients. Endoscopic appearances of hemorrhage from duodenal varices revealed negative red color (RC) signs in all 6 lesions, and 5 of 6 lesions were F3 lesions. Three of 5 patients with hemorrhagic duodenal varices had received treatment for esophageal varices. Successful hemostasis and complete eradication by endoscopic treatments was achieved in all 5 patients (6 lesions). The 1, 3, and 5 year cumulative survival rates were 66.7%, 48.6%, and 36.5% in the patients with duodenal varices. CONCLUSIONS: The hemorrhagic factor of duodenal varices is F factor, but not RC sign. Changes of blood flow in the collateral circulatory pathway after treatment for esophageal varices may increase the risk of hemorrhage from duodenal varices. Endoscopic treatment is useful for hemorrhagic duodenal varices.     

Five Cases of Recurrent Varices Located in the Middle Esophagus

Recurrent varices located in the middle esophagus are considered to be rare. We could find no scientific reports on this type of recurrent varices. We report herein on five cases diagnosed by endoscopy and endoscopic color Doppler ultrasonography (ECDUS). Endoscopic findings revealed the disappearance of varices in the lower esophagus and F₂ type recurrent varices in the middle esophagus. Color flow images of the left gastric vein and the developed para‐esophageal vein, and the perforating vein of inflow type from para‐esophageal veins to esophageal varices in the middle esophagus were produced using ECDUS. One of the five cases had red color (RC)‐positive recurrent varices located in the middle esophagus and was admitted to our hospital with hematemesis. In such cases, where the recurrent varices show a high‐risk sign, rupture is probable.     

门静脉高压患者胃静脉曲张的内镜识别和分类

背景：肝硬化门静脉高压的出血原因中，食管和（或）胃静脉曲张破裂出血最为常见。胃静脉曲张的发生率较食管静脉曲张低，但再出血率高，出血量大，死亡率亦较高。尽管如此，胃静脉曲张在临床诊治过程中未受到应有的重视。目的：根据内镜下对食管和胃静脉曲张的识别和分类，了解食管和胃静脉曲张的比例。方法：根据Sarin分类，在内镜直视下将114例门静脉高压患者分为单纯食管静脉曲张、胃食管静脉曲张1型（GOV1型）、胃食管静脉曲张2型（GOV2型）、孤立性胃静脉曲张1型（IGV1型）和孤立性胃静脉曲张2型（IGV2型）五种类型。结果：本组患者中单纯食管静脉曲张42例（36．8％），GOV1型40例（35．1％），GOV2型20例（17．5％），IGV1型12例（10．5％），未见IGV2型。结论：半数门静脉高压患者存在胃静脉曲张，临床工作中仅处理食管静脉曲张是很片面的。须努力开展组织黏合剂、球囊闭塞下逆行经静脉栓塞术（B．RTO）或外科分流等治疗：对有条件的患者应鼓励开展肝移植治疗。     

Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices

BACKGROUND: Bleeding from gastric varices larger than 2 cm in diameter represents a major limitation for endoscopic hemostasis. METHODS: 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. RESULTS: 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. CONCLUSIONS: Endoscopic ligation therapy with large detachable snares and elastic bands is safe and effective for treatment of large bleeding gastric varices.     

Gastroesophageal endoscopic features in cirrhosis. Observer variability, interassociations, and relationship to hepatic dysfunction

Nowadays, gastroesophageal endoscopic features of portal hypertension are the recognized predictive factors for bleeding and consequently allow the selection of patients for prophylactic therapies. The aim of this prospective study was to investigate the interobserver agreement, the interassociations between these features, and the relationship between these signs and the degree of hepatic dysfunction. In 100 consecutive cirrhotic patients (84% with alcoholism) without history of digestive bleeding, gastroesophageal endoscopic examination was performed and recorded using a videoendoscope. Four independent observers evaluated the following endoscopic features: the size, extent, color, and red signs of esophageal varices, the mosaic pattern, congestive gastropathy, fundic varices, and associated lesions of the stomach. Agreement was assessed using kappa statistics (kappa) and a quantitative score. The size of esophageal varices was significantly associated with their extent and the presence of red signs, whereas no relation was found either between gastropathy or mosaic pattern and fundic varices, or between esophageal and gastric features. Agreement between observers was good for the size of esophageal varices (kappa = 0.59), the presence of red signs (kappa = 0.60), and of gastric-associated lesions (kappa = 0.68) and gastropathy (kappa = 0.50), while it was poor for the extent (kappa = 0.37) and the color (kappa = 0.28) of esophageal varices as well as for the mosaic pattern (kappa = 0.38). The Child-Pugh score significantly increased along with the presence or the size of esophageal varices as well as with the presence of red signs; no relationship could be shown between this score and the presence of gastric features. We conclude that (1) interobserver agreement was good for the main endoscopic features, especially for the size and the red signs of esophageal varices; (2) esophageal patterns were significantly associated between themselves and related to hepatic dysfunction; and (3) gastric patterns were related neither to esophageal features nor to hepatic dysfunction and were not associated between themselves.     

Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices.

Aim: Because the procedure of balloon-occluded retrograde transvenous obliteration (B-RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long-term outcome of B-RTO, including changes in esophageal varices. Methods: B-RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices (n = 7), F(1) varices (n = 11), and F(2) varices (n = 4). The outcome measures included the development/worsening of esophageal varices after B-RTO and survival rates. Results: The cumulative bleeding-free probability for all 22 patients at 3 years after B-RTO was 100%. The overall 3-year survival was 94.4%. Seven patients who had no esophageal varices prior to B-RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F(1) esophageal varices prior to B-RTO showed no changes in the varices after B-RTO, while two patients progressed to F(2) varices and two developed F(3) varices. The cumulative treatment-free probability of the esophageal varices at 24 months after B-RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre-existing F(1) varices, and 75% for those with pre-existing F(2) varices. Conclusion: Although the B-RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.     

门脉高压胃静脉曲张的内镜分类

目的 将234例门脉高压患者,根据内镜下静脉曲张的分布部位进行分类.方法 内镜直视下对食管静脉曲张以及食管贲门静脉曲张(GOV1型)、食管胃底静脉曲张(GOV2型)、无食管静脉曲张的孤立性胃底静脉曲张(IGV1型)及异位静脉曲张(IGV2型)作内镜分类.结果 234例门脉高压患者中,单纯食管静脉曲张67例(28.6%),食管静脉曲张伴贲门部静脉曲张98例(GOV1型,41.9%),食管静脉曲张经贲门延伸至胃底部46例(GOV2型,19.7%),内镜未见食管静脉曲张,仅有胃底静脉曲张者22例(IGV1型,9.4%),1例异位静脉曲张(IGV2型,0.4%).结论 门脉高压患者内镜检查表明半数以上患者存在胃静脉曲张,其中存在胃底静脉曲张的GOV2型和IGV1型68例,占全组患者的29.1%.应高度重视门脉高压患者胃静脉曲张的临床治疗,可选择内镜黏合剂、B-RTO术等方法.     

Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate

BACKGROUND: bleeding from gastric varices is a life-threatening complication of portal hypertension. Fundal and isolated gastric varices are at high risk for variceal bleeding. In this study, we report our experience with n-butyl-2-cyanoacrylate (BC) in patients with large gastric varices. STUDY: twenty-nine patients (15 male, 14 female) with large fundal varices (active bleed, 5; passive bleed after eradication of esophageal varices, 13; unbled fundal varices with red color sign, 11) underwent endoscopic sclerotherapy with BC. Cirrhosis was present in 13 patients; extrahepatic portal venous obstruction, in 13; and noncirrhotic portal fibrosis, in 3. N-Butyl-2-cyanoacrylate after mixing with lipiodol (1:1) was given to the initial 10 patients and was given in undiluted form to the remaining patients, followed by injection of 0.7 mL of distilled water to rinse the injection catheter. One to three injections (0.5-1 mL) were given until all gastric varices became hard. All patients were on long-term endoscopic sclerotherapy or variceal ligation programs for eradication of esophageal varices. RESULTS: acute variceal bleeding was controlled in all five patients with BC injections. Eradication of gastric varices was achieved in 27 (93.1%) patients (20 patients in 1 session, 4 patients in 2, and 3 patients in 3-6). Rebleeding occurred in three (10.3%) patients who responded to repeat BC injections. Complications related to the procedure occurred in two (6.9%) patients. In one patient, the needle became impacted into the tissue adhesive. This patient died 5 days later because of massive upper gastrointestinal bleeding. In the other patient, there was distal embolization. CONCLUSIONS: sclerotherapy of gastric varices with BC is a safe and an effective treatment for control of bleeding and eradication. The needle should be withdrawn immediately after the BC injection to prevent its impaction into the tissue adhesive.     

ENDOSCOPIC ULTRASONOGRAPHY FINDINGS AND CLINICAL BACKGROUNDS IN CASES WITH EARLY RECURRENCE OF ESOPHAGEAL VARICES AFTER ENDOSCOPIC INJECTION SCLEROTHERAPY

Aims: To investigate the factors affecting early recurrence of esophageal varices after endoscopic injection sclerotherapy (EIS). Subjects and Methods: Forty‐four cases with esophageal varices were examined by esophagogastroscopy and endoscopic ultrasonography (EUS) 2 months after EIS. Cases with and without red color (RC) signs evaluated within 1 year after EIS were classified as Early Recurrent Group (ERG) and Non‐Early Recurrent Group (N‐ERG), respectively, and compared with EUS images and clinical backgrounds. Results: Compared with ERG (17 cases), N‐ERG (27 cases) had significantly higher detection rates of cardiac intramural veins (CV) and esophageal intramural veins (EV), larger maximum diameters of CV and EV, and higher numbers of CV (P < 0.05). The detection rates of gastric perforating veins (GPV)—but not esophageal perforating veins (EPV), paragastric veins (PGV), or paraesophageal veins (PEV)—correlated with recurrence of varices (P < 0.05). ERG differed in age, gender, γ‐glutamyltranspeptidase (GTP), and detection rates of portosystemic (PS) shunts from N‐ERG (P < 0.05). Age, serum alanine aminotransferase (ALT) and γ‐GTP level, detection rates of PS shunt, maximum diameters of CV and EV, numbers of CV, and GPV‐positive case differed (P < 0.10) by univariate analysis, and maximum diameters (hazard ratio (HR)), 7.16: 95% CI [1.45–35.33]; P = 0.016) and numbers (HR, 1.96: 95% CI, [1.02–3.75]; P = 0.043) of CV differed significantly between the two groups by multivariate analysis. Conclusions: EUS is useful in predicting recurrence of esophageal varices after EIS, and the degree of the development of CV is the most important critical factor for early recurrences.     

Improvement of collateral vessels in the vicinity of gastric cardia after endoscopic variceal ligation therapy for esophageal varices.

BACKGROUND & AIMS: Endoscopic variceal ligation (EVL) therapy has been performed widely to treat or prevent variceal bleeding. We sought to examine the influence of EVL for esophageal varices on collateral vessels in the vicinity of gastric cardia. METHODS: In 42 patients with esophagogastric varices, conventional endoscopy and endoscopic ultrasonography with a 20-MHz probe (CUP-EUS) were performed before and at every 3 months after EVL for esophageal varices. By using conventional endoscopy, cardial variceal sizes were divided into 3 grades: F0, F1, and F2. The sizes of submucosal, perforating, and paracardial vessels at the cardia also were classified into 3 grades according to CUP-EUS findings. RESULTS: Conventional endoscopy showed cardial varices in 33 (79%) patients before and 23 (55%) patients at 3 months after the treatment (P < 0.05). CUP EUS showed that 29 (69%) patients had severe grade cardial submucosal vessels before EVL, but only 13 (31%) patients did after the treatment (P < 0.01). Nineteen (45%) patients had severe grade cardial perforating vessels before EVL, but only 4 (10%) patients did after the treatment (P < 0.001). Furthermore, patients with severe grade residual submucosal or perforating vessels at the cardia had shorter recurrence-free times of esophageal varices (P < 0.01, 0.05, respectively). CONCLUSIONS: Collateral vessels in the vicinity of gastric cardia were improved significantly after EVL, indicating that esophageal varices can be treated by EVL even though they connect with cardial varices. Furthermore, eradication of such collateral vessels by EVL may lead to longer recurrence-free status of esophageal varices.     

Prophylactic impact of endoscopic treatment for esophageal varices in liver resection: a prospective study

Background

Prophylactic treatment for esophageal varices has been performed without adequate supporting evidence. We assessed the feasibility of prophylactic and follow-up treatment for high-risk esophageal varices in patients with hepatocellular carcinoma (HCC).

Methods

Patients with HCC were screened prospectively and followed up for esophageal varices and gastroduodenal ulceration. High-risk esophageal varices (huge F3 varices or intermediate F2 varices positive for red color signs) were treated prophylactically. Follow-up endoscopy was performed to assess the impact of prophylaxis and changes in varices at 1 week, 1 month, and 6 months after operation. If high-risk varices were found during follow-up, secondary prophylaxis was performed according to the same criteria.

Results

Among 251 patients with HCC, 81 (32.3 %) had esophageal varices on screening endoscopy. Prophylactic endoscopic treatment was required by 13 patients (1 with F3 varices and 12 with F2 varices positive for red color signs). Ten varices worsened, and 4 varices progressed to high-risk varices requiring endoscopic treatment. No F0 or F1 varices at screening endoscopy progressed to high-risk varices, and no bleeding event occurred during 6 months of preplanned follow-up. A preoperative platelet count of less than 10 × 10⁴/μL (odds ratio: 4.21, 95 % confidence interval 3.11–10.6; p < 0.001), the presence of splenomegaly (2.87, 2.16–21.8; p = 0.011), and an indocyanine green retention rate at 15 min of greater than 30 % (2.31, 1.88–24.6; p = 0.026) were independent predictors of worsening varices.

Conclusions

Our protocol for prophylactic and follow-up treatment of high-risk esophageal varices was feasible in patients with HCC.