Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts

BACKGROUND AND OBJECTIVES. There is no standard treatment for gastric varices. Transjugular retrograde obliteration (TJO) is one way of obliterating gastric varices with gastrorenal shunts, in which blood flow is abundant. Our aim was to examine our experience with TJO during an 8-year period and to determine the long-term effects of this treatment. METHODS. We performed TJO procedures in 52 patients to obliterate gastric varices. All the patients had liver cirrhosis. Sixteen had hepatocellular carcinoma (HCC) without vascular invasion. We inserted an angiographic catheter with an occlusive balloon through the right internal jugular vein into the gastrorenal shunt or the gastric varices. After controlling the other blood-draining routes with a microcoil or absolute ethanol, or both, we injected 5% ethanolamine oleate with iopamidol into the gastric varices under fluoroscopy. RESULTS. The gastric varices were successfully obliterated by TJO in all cases. The complications were all minor and transient. The mortality rate for TJO was 0%. There was no recurrence and no bleeding of gastric varices at all after TJO. Patient survival differed depending on the presence or absence of HCC (P <.05). The development of HCC in the cirrhotic liver was the most common cause of late death. Gastrointestinal bleeding was not a cause of death. The occurrence rate of esophageal varices after TJO was high, but these varices could be treated easily by endoscopic injection sclerotherapy before they bled. CONCLUSIONS. Portal blood flow through the gastrorenal shunt is diverted to the porto-azygos venous system after the gastrorenal shunt is obliterated by TJO. TJO is a safe option that we recommend for treating gastric varices with gastrorenal shunts, provided that the TJO is followed by endoscopic injection sclerotherapy.     

Variceal upper digestive bleeding--an ever new complication in liver cirrhosis

Variceal bleeding in liver cirrhosis is a medical emergency with a high mortality. The therapeutic options in patients with portal hypertension are: treatment of acute bleeding from varices, prevention of the first bleeding episode and prevention of rebleeding. Treatment of acute bleeding from varices includes: blood volume restitution, use of antibiotics for preventing bacterial infections, vasoactive drug therapy (terlipressin, somatostatin, vapreotide, octreotide), endoscopic band ligation for acute esophageal bleeding and endoscopic therapy with tissue adhesive (cyanoacrylate) for acute gastric variceal bleeding. Endoscopic treatments are best used in association with pharmacological therapy. In primary prophylaxis non-selective beta- blocker therapy and endoscopic band ligation are useful. Beta blockers, band ligation or both should be used for prevention of recurrent bleeding. In patients who fail endoscopic and pharmacological treatment for prevention of rebleeding TIPS and transplantation should be considered.     

Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices.

BACKGROUND/AIM: The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose. METHODS: Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43-71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes. RESULTS: We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 +/- 66 mm H(2)O, whereas in patients with isolated gastric varices it was 262 +/- 44 mm H(2)O (p < 0.01). CONCLUSION: We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.     

Gastrointestinal tract haemorrhage and ischaemia

Gastrointestinal (GI) bleeding, especially acute upper gastrointestinal bleeding, is a common medical emergency. Peptic ulcer, variceal bleeding and bleeding from stress ulceration in critically ill patients are all associated with significant morbidity and mortality. The Rockall score should be used to identify high-risk patients who need urgent treatment. Adequate resuscitation is essential before attempting endoscopy, which is used to establish the diagnosis and allow effective endoscopic therapies. Terlipressin, a vasopressin analogue, is indicated in patients with suspected variceal bleeding prior to endoscopy, whereas a proton pump inhibitor infusion is recommended in patients with peptic ulcer bleeding only after endoscopic treatment. Selective mesenteric embolization and surgery are reserved for patients with non-variceal bleeding refractory to therapeutic endoscopy. Transjugular intrahepatic portosystemic shunt stenting and shunt surgery are reserved for patients with refractory variceal bleeding in an acute setting or as a bridge therapy for prevention of acute variceal bleeding before liver transplantation. In critically ill patients, adequate resuscitation, cautious use of vasopressors, prophylactic use of gastric acid-suppressing agents and enteral nutrition are the cornerstones of treatment in prevention of stress ulcers. Lower GI investigations should be performed in patients with rectal bleeding after exclusion of upper GI bleeding. GI tract ischaemia plays an important role in the aetiology of stress ulcer disease and ischaemic colitis and is also a potential complication of mesenteric embolization in patients with GI bleeding refractory to therapeutic endoscopy.     

Duodenal varices as a cause of massive upper gastrointestinal bleeding

Duodenal varices are an uncommon but serious manifestation of portal hypertension. Our management of three patients with massive bleeding due to duodenal varices stimulated a review of this subject. Thirteen cases of this condition were previously reported. Endoscopic examination of the entire duodenal mucosa is essential to document bleeding from duodenal varices. Medical therapies, including vasopressin and endoscopic sclerotherapy, have had limited success in controlling active duodenal variceal bleeding. Duodenal varix suture ligation or resection also resulted in a high rate of rebleeding. End-to-side portocaval shunt was the most effective procedure in stopping acute and subsequent bleeding in patients with duodenal varices. Despite therapy with or without portosystemic shunt, mortality risk is high in Child's class C patients and in patients with emergency duodenal variceal bleeding.     

When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done?

BACKGROUND: Acute variceal bleeding is the major cause of death in patients with chronic liver disease. This justifies the search for a more effective therapy to achieve rapid and definitive hemostasis in every patient. At present, the recommended standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide together with early endoscopic band ligation or sclerotherapy. In the case of ectopic varices terlipressin and cyanoacrylate embolization (if varices can be reached by endoscope) are in use. FOCUS: The treatment is considered to have failed when bleeding continues or significant bleeding recurs within 48 h. This indicates the need for emergency transjugular intrahepatic portosystemic shunting (TIPS) which has been regarded as rescue treatment of choice when standard treatment fails. Although randomized studies against supportive treatment are lacking, the high efficacy and relatively low mortality after TIPS implantation are convincing. It is reasonable that smaller shunts should be preferred (probably 8 mm in diameter) since most patients have an increased risk of liver failure. To increase the effect of the shunt with respect to acute hemostasis it should be combined with transjugular embolization of the varices. CONCLUSION: Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding.     

不同治疗方式对门静脉高压症患者食管下段腔内外静脉的影响

目的 研究内镜结扎、脾切除加贲门周围血管离断术（断流术）、内镜结扎联合部分脾栓塞、内镜结扎加脾切除加贲门周围血管离断术（联合断流术）对食管下段腔内外静脉的影响。方法 将142例患者根据治疗方法的不同分为4组：内镜结扎组（54例）、断流手术组（23例）、结扎联合部分脾栓塞组（34例）、腔内外联合断流组（31例）。运用微探头超声检查食管下段静脉结构的情况,进行治疗前后对比研究。结果 治疗后内镜结扎组黏膜下曲张静脉消失,食管周围静脉丛仍然存在;结扎联合部分脾栓塞组黏膜下曲张静脉消失,食管周围静脉丛曲张较术前减轻;断流组黏膜下曲张静脉存在,程度较前减轻,食管周围静脉丛消失;腔内外联合断流组食管黏膜下和周围静脉丛均消失。后两组治疗后穿静脉的显示率也显著降低。结论 腔内外联合断流能更有效地闭塞食管下段壁内外静脉,阻断门静脉奇静脉分流,防治食管静脉曲张出血与复发。     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

Endoscopic band ligation of oesophageal varices

BACKGROUND: For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy. METHODS: All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included. RESULTS: After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone. CONCLUSION: EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.     

Hemodynamic Effects of Combined Therapy Using Partial Splenic Embolization and Transjugular Retrograde Obliteration for Gastric Varices with Gastrorenal Shunt

Background  

The purpose of the present study was to investigate the short-term effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the portal hemodynamics of gastric varices with a gastrorenal shunt.     

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.     

Digestive hemorrhage caused by rupture of esophageal varices. Analysis of 47 emergency surgeries

Between 1 January 1984 and 31 December 1986, 47 patients out of a total of 228 patients admitted to hospital with endoscopy-proven bleeding esophageal varices, underwent an emergency operation. The indications were massive hemorrhage in 29 patients, and rebleeding early after a first serious episode in 18 patients. Four patients underwent early reoperation for recurrent variceal bleeding. Thirty-seven porto-caval shunts, 10 esophageal transections, 3 proximal gastric resections and 1 exploratory laparotomy were performed. The early results were satisfactory in 53.2% of the patients; operative morbidity and mortality were 19.1% and 27.7% respectively. Four patients died from gastric variceal bleeding soon after esophageal transection. Operative mortality was greater when the patient was Child C or operated for massive hemorrhage. Survivors were followed for at least 12 months. Two patients died from shunt occlusion and recurrent variceal bleeding. No severe encephalopathy was reported. Analysis of the results suggest that porto-caval shunt is indicated in Child A or B patients, particularly with recurrent variceal bleeding soon after a first episode controlled medically.     

Short-term hemodynamic effects of transjugular retrograde obliteration of gastric varices with gastrorenal shunt

OBJECTIVES: The purpose of this study was to investigate the short-term effects on portal hemodynamics of transjugular retrograde obliteration (TJO) of gastric varices with gastrorenal shunt. METHODS: Thirty patients with gastric varices and a gastrorenal shunt were included in this study. The patients ranged in age from 42 to 75 years (16 men and 14 women), and according to Child's classification, class A, B and C cirrhosis was seen in 1, 13 and 16 patients, respectively. The portal blood flow was measured by an ultrasonic duplex Doppler system, and the wedged hepatic venous pressure was measured by hepatic venous catheterization, before and after TJO. RESULTS: Complete obliteration of the gastrorenal shunt and gastric varices was revealed by retrograde inferior phrenic venography and computed tomography after TJO in all cases. The wedged hepatic venous pressure was significantly increased the day after TJO compared with that before therapy (257 +/- 71 vs. 307 +/- 73 mm H(2)O, p < 0.01). The portal venous flow was significantly increased 1 week after TJO compared with that before therapy (744 +/- 190 vs. 946 +/- 166 ml/min, p < 0.01). The serum albumin levels before and after TJO were 3.0 +/- 0.4 and 3.1 +/- 0.5 g/dl, respectively, and the total bilirubin levels were 1.5 +/- 0.7 and 1. 5 +/- 0.8 mg/dl, respectively, neither of these parameters changing significantly. The plasma ammonia levels before and after TJO were 109 +/- 62 and 67 +/- 31 microg/dl, and the indocyanine green retention rates at 15 min were 31 +/- 13 and 24 +/- 13%, both showing a significant change (p < 0.01 and p < 0.05, respectively). CONCLUSIONS: We conclude that TJO increases portal blood flow which contributes to the decrease in plasma ammonia levels and the indocyanine green retention rate, although increasing the wedged hepatic venous pressure.     

What happens to esophageal varices after transection and devascularization?

In 14 patients who underwent endoscopic examination after esophageal transection and proximal gastric devascularization, varices disappeared in seven patients, were reduced in diameter or number in six patients, and were unchanged in one patient. No varices were present in any patient within 1 cm of the stapled anastomosis, and Doppler studies showed no flow in residual varices. During a mean follow-up of 20 months (range: 6 to 44 months), varices recurred in three patients and enlarged in five others. This study suggests that variceal obliteration, a reduction in variceal diameter, the removal of the bleeding zone in the esophagus, and undetectable blood flow in residual varices all contribute to the prevention of variceal rebleeding; although these changes are not always permanent, the return to the preoperative state may take many years.     

Emergency portacaval shunt for variceal hemorrhage. A prospective study.

Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.     

Portasystemic shunting remains the procedure of choice for control of variceal hemorrhage

We reviewed 108 patients (50% Child's C) who had been admitted with acutely bleeding esophageal varices to compare the efficacy of operative (portasystemic shunt) therapy with the reported efficacy of sclerotherapy. In the patients with shunts the early mortality (preoperative plus operative) was 13% and late mortality was 23%. Survival at five years was 50%. Recurrent variceal bleeding was seen in 4% of the patients. Procedure-related mortality and variceal rebleeding rates for the shunt group were respectively 50% and 8% of that reported for sclerotherapy. Variceal rebleeding in the sclerotherapy group required approximately 7 units of blood per episode. We concluded that immediate attempts at control of hemorrhage followed by portasystemic shunting remains the therapy of choice for these patients.     

Portal hypertension and bleeding esophageal varices

Summary Bleeding from esophageal varices exacts a high mortality and extraordinary societal costs. Prophylaxis—medication, sclerotherapy, or shunt surgery to prevent an initial bleeding episode—is ineffective. In patients who have bled from varices, endoscopic injection sclerotherapy can control acute bleeding in more than 90% of patients. Because recurrent bleeding frequently occurs and survival without definitive therapy is dismal, selection of a permanently effective treatment is mandatory once variceal bleeding has been controlled.Long-term injection sclerotherapy can be performed in compliant patients; it is relatively safe but is associated with a 30–50% rebleeding rate. Betablockers significantly reduce portal pressure and recurrent bleeding but have not been shown to diminish mortality from BEV. Portal decompressive surgery permanently halts bleeding in more than 90% of patients; the risk of operative mortality is high in decompensated cirrhotics, and long-term complications of encephalopathy and accelerated liver failure may limit indications for shunt surgery to good-risk cirrhotics who are not liver transplant candidates. Devascularization procedures have a low operative mortality and encephalopathy rate but unacceptably high rates of recurrent bleeding.Liver transplantation is curative therapy for bleeding esophageal varices and the associated underlying hepatic dysfunction; cost and availability of donor organs generally limit its use in this setting to variceal bleeders with end-stagè liver disease not associated with active alcoholism.     

Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices

OBJECTIVE: This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA: Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS: Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS: Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.     

The use of sclerotherapy for the management of oesophageal varices in portal hypertension

Summary Although sclerotherapy is currently the most widely used treatment for the management of both acute variceal bleeding and the long-term management of patients with varices, its definitive role in the treatment of these patients has yet to be finally proven. Sclerotherapy appears to be the most effective treatment for the majority of patients with acute variceal bleeding. Failures require either a shunt or a transection and/or devascularisation procedure. Current evidence favours simple staple gun transection or a shunt (either a portacaval shunt or a side-to-side narrow diameter polytetrafluoroethylene graft between the portal vein and vena cava). In long-term management of patients after a variceal bleed the currently favoured treatment is repeated sclerotherapy. However, failures should be identified early. We define failures as patients who present with varices that are either difficult to eradicate by sclerotherapy or who have repeated life-threatening variceal bleeds during the course of repeated injection sclerotherapy. Such patients should have either a portal-to-systemic shunt or a transection and devascularisation operation. Further controlled trials are required to define the specific indications for the individual forms of therapy. Prophylactic treatment for varices that have not yet bled is unjustified at present. Based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Balloon-occluded retrograde transvenous obliteration performed in a pediatric patient with isolated gastric fundal varices

Background

For giant gastric varices in association with portal hypertension, endoscopic treatment often is difficult. Although balloon-occluded retrograde transvenous obliteration (B-RTO) has been performed successfully in adult cirrhotic patients, there has been no report in pediatric patients.

Methods

A 10-year-old girl with biliary atresia (BA) who had been free of jaundice after hepatic portoenterostomy was detected to have isolated gastric fundal varices by routine endoscopy. They gradually enlarged up to 4 cm in diameter, showing a tense appearance, so prophylactic treatment was conducted. Magnetic resonance angiography showed the blood flow of the varices mainly drained by a large gastrorenal shunt. A balloon catheter was introduced into the gastrorenal shunt via the femoral vein and was inflated to occlude the outflow of the varices. Five percent ethanolamine oleate was injected into the varices, and the outflow occlusion was kept for more than 30 minutes. Extensive thrombosis was achieved by an additional embolotherapy after 17 months. Throughout the course, the patient has been doing well without bleeding or worsening of the liver function tests.

Conclusions

B-RTO for isolated gastric fundal varices has been performed safely in a pediatric patient and seems effective in reducing the variceal size and tension.