Influence of endoscopic variceal ligation on oesophageal motility

BACKGROUND: To determine the change of oesophageal manometry in patients with oesophageal varices before and after oesophageal variceal ligation (EVL). METHODS: Forty-five patients who had liver cirrhosis and oesophageal varices with high risk of bleeding were managed by EVL. Oesophageal manometry was performed just prior to the ligation and 4-6 weeks after obliteration of varices. Another 45 age- and sex-matched patients without hepatic, oesophageal or systemic disease served as the control group. RESULTS: At 5 cm above the lower oesophageal sphincter (LES), the amplitude of the contractive wave was significantly lower in patients before EVL (56.9 +/- 31.8 vs 80.1 +/- 30.1, P< 1.05) and returned to the level of control subjects after EVL (76.5 +/- 37.0 vs 80.1 +/- 30.1, P> 0.05). At 10 cm above LES, the amplitude of the contractive wave was significantly lower in patients before and after EVL than the control group (54.3 +/- 29.2 vs 68.1 +/- 29.5, 54.2 +/- 26.0 vs 68.1 +/- 29.5, respectively, P< 0.05). The percentage of tertiary waves was significantly higher in patients before and after EVL than in the control group (31.4 +/- 36.6 vs 5.8 +/- 15.1, 26.9 +/- 32.9 vs 5.8 +/- 15.1, respectively, P< 0.05). However, no significant swallowing disturbance was noted in patients after EVL. There was significantly greater LES length in patients before EVL (4.0 +/- 0.9 vs 3.4 +/- 0.7, P<0.05) but there was no significant difference in the LES length after EVL as compared with the control group. Eighty-six per cent (39/45) of patients developed paraoesophageal varices and 31% (14/45) developed new varices 6 months after variceal obliteration. However, there was no significant difference in manometry at the time of variceal obliteration between patients with variceal recurrence and those without. CONCLUSIONS: The presence of varices affected oesophageal motility. However, such abnormality had little clinical significance. Endoscopic variceal ligation normalized oesophageal motility and may not induce abnormal oesophageal motility. The manometric change can not be used to predict the recurrence of varices in cirrhotic patients after variceal obliteration.     

Endoscopic variceal ligation is a sufficient procedure for the treatment of oesophageal varices in patients with hepatitis C liver cirrhosis: comparison with injection sclerotherapy

AIMS: Endoscopic variceal ligation (EVL) is a recently developed alternative to endoscopic injection sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic variceal ligation and EIS were compared in an attempt to clarify the efficacy and safety of EVL for patients with cirrhosis due to hepatitis C. METHODS: Endoscopic variceal ligation was performed in 60 patients and EIS in 30. Varices were eradicated in all patients by EVL and 87% (26 out of 30) by EIS. RESULTS: There was no significant difference between EVL and EIS in relation to the incidence of bleeding and the 5 year survival rate after treatment. There were no severe complications except mild substernal pain after EVL, while pulmonary embolism occurred in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation is a safe and effective technique for eradicating oesophageal varices in patients with hepatitis C cirrhosis.     

Therapeutic results of endoscopic variceal ligation for acute bleeding of oesophageal and gastric varices

Endoscopic variceal ligation (EVL) using 'O' rings is widely accepted as a treatment of oesophageal varices that is at least as effective as endoscopic injection sclerotherapy but which produces fewer complications. Endoscopic variceal ligation using detachable snares has attracted attention as a safe and easy method of endoscopic treatment for gastric varices. Nineteen patients with acute bleeding from oesophageal or gastric varices were treated in the present study. Of these, 14 patients were treated with EVL using 'O' rings and five patients were treated with EVL using detachable snares and the treatment results were evaluated. Haemostasis was achieved in all patients. No serious complications of the procedures were observed. However, recurrences and rebleeding were observed in some patients during the maximum follow-up period of 24 months. Endoscopic variceal ligation using 'O' rings and detachable snares is useful for achieving haemostasis in cases of acute bleeding from oesophageal or gastric varices. However, additional endoscopic sclerotherapy may be needed to eliminate the variceal feeding vessels to further improve the long-term prognosis of these patients.     

Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy

BACKGROUND: To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy. METHODS: Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy. RESULTS: During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%). CONCLUSIONS: This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.     

Duodenal Perforation by a Linton-Nachlas Balloon Tube

In a patient with bleeding esophageal varices, inadvertent inflation of a Linton-Nachlas balloon in the third portion of the duodenum led to bowel perforation and death. This complication emphasizes a potential problem in passing a balloon catheter as far as possible down the nares, a technique that has been suggested to prevent balloon catheter inflation in the esophagus. To the best of our knowledge, this is the first reported case of duodenal rupture from attempted balloon tamponade for variceal hemorrhage.     

Esophageal perforation--associated risk with balloon tamponade after endoscopic therapy. Myth or reality?

BACKGROUND/AIMS: Variceal bleeding is still associated with high mortality and balloon tamponade may be a lifesaving measure when endoscopic therapy is not available or feasible. The risk of esophageal perforation with balloon tamponade after endoscopic therapy is still uncertain. The aims of the study were to investigate balloon tamponade effectiveness and safety after endoscopic therapy. METHODOLOGY: Retrospective analysis of 100 consecutive episodes of acute variceal bleeding treated with the Sengstaken-Blakemore tube. RESULTS: Balloon tamponade had an overall effectiveness of 61%. The Child-Pugh score was significantly higher in patients who failed balloon tamponade. In 48 cases balloon tamponade was preceded by failure of endoscopic therapy. Balloon tamponade was more effective if a previous attempt to perform endoscopic therapy happened (75% vs. 48%; p = 0.006). Aspiration was the most frequent complication. No cases of esophageal perforation were registered. CONCLUSIONS: Currently balloon tamponade is only used as a temporary bridge to other strategies, when other forms of hemostatic therapies do not succeed. Balloon tamponade was more effective in patients with less severe hepatic dysfunction. Previous attempts to perform endoscopic therapy may augment tamponade effectiveness without increasing the risk of esophageal perforation.     

Emergency Placement of Platinum Coils to Prevent Cardiac Tamponade After Wire Perforation of an Occluded Venous Coronary Bypass Graft

A case is reported of a patient with impending cardiac tamponade due to vessel perforation following balloon angioplasty of an occluded venous bypass graft. Prolonged balloon inflation failed to seal the perforation. Leakage was controlled immediately by the delivery of two platinum coils into the perforation. In case of a vessel perforation during an attempt to recanalize an occluded coronary artery bypass, placement of intracoronary platinum coils to seal the perforation may prevent the development of cardiac tamponade.     

Balloon tamponade and vasoactive drugs in the control of acute variceal haemorrhage

Successful pharmacological arrest of haemorrhage might avoid the risk of aspiration associated with tamponade and early studies have suggested that the vasoactive agent somatostatin may be as effective and perhaps safer than tamponade in controlling variceal haemorrhage. In our view, vasopressin has not established a role in management but we retain an open mind regarding the potential use of terlipressin in combination with nitroglycerin. It is unlikely that any of these agents can improve significantly our ability to control variceal haemorrhage when compared to balloon tamponade but they may reduce the incidence of pulmonary complications and thereby reduce subsequent mortality.Tamponade has proved successful in controlling acute haemorrhage from oesophageal varices in our hands. Late complications continue to give cause for concern but until effective safe alternatives to tamponade are developed, we continue to advocate its use for emergency control of acute variceal haemorrhage. Our own studies have shown that the high mortality seen in this patient population may reflect the severity of the underlying liver disease rather than failure of a management policy employing oesophageal tamponade for the initial control of acute variceal haemorrhage.     

The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding

Background and study aimsThe well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL.Patients and methodsThis study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention.Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6 months to evaluate variceal recurrence (F1 or more).ResultsBoth groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6 months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding.ConclusionAlthough, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.     

Challenges of banding jejunal varices in an 8-year-old child

Endoscoic variceal ligation(EVL) by the application of bands on small bowel varices is a relatively rare procedure in gastroenterology and hepatology. There are no previously reported paediatric cases of EVL for jejunal varices. We report a case of an eight-yearold male patient with a complex surgical background leading to jejunal varices and short bowel syndrome, presenting with obscure but profound acute gastrointestinal bleeding. Wireless capsule endoscopy and double balloon enteroscopy(DBE) confirmed jejunal varices as the source of bleeding. The commercially available variceal banding devices are not long enough to be used either with DBE or with push enteroscopes. With the use of an operating gastroscope, four bands were placed successfully on the afferent and efferent ends of the leads of the 2 of the varices. Initial hemostasis was achieved with obliteration of the varices after three separate applications. This case illustrates the feasibility of achieving initial hemostasis in the pediatric population.     

Severe bleeding following endoscopic variceal ligation: should EVL be avoided in Child C patients?

In the last decade there has been an evolution in the treatment of bleeding oesophageal varices. Endoscopic variceal ligation (EVL) is one of those new techniques that not only has shown to be more effective than sclerotherapy, but also causes less side effects, resulting in less episodes of rebleeding and improving survival. We describe severe bleeding in 3 patients after EVL, occurring between 5 and 10 days after the initial ligation. Two Child C patients could not be resuscitated and died shortly after this event. Severely impaired clotting function as a result of the liver disease and the greater size of the ulcers induced by EVL may contribute to this dramatic complication. Severe bleeding due to postligation ulceration may lead to death, which occurred in 2 of our Child C patients. Since more and more endoscopists are using EVL in the treatment of oesophageal variceal bleeding, they should be aware of the possible complications caused by this rather new technique.     

Emergency intrahepatic shunt via transjugular approach]

We report the case of a cirrhotic 65 year-old woman presenting with persistent and recurrent variceal hemorrhage in spite of endoscopic sclerotherapy with bucrylate, glypressin infusion and balloon tamponade. At the time of intrahepatic shunt placement via the transjugular route, Child-Pugh score was 14 (Child C category) and surgical variceal decompression or liver transplantation were contraindicated. At the end of the procedure, which included the placement of two Palmaz stents, varices were no more opacified and the wedge hepatic venous pressure gradient had decreased from 70%. Evolution of the patient was excellent with a permeable shunt after one month. Emergency placement of intrahepatic shunt with metallic stent has certainly a place in case of failure of initial management of variceal bleeding with pharmacotherapy, sclerotherapy or balloon tamponade.     

Endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleed: preliminary report of a randomized controlled trial

BACKGROUND: Prevention of variceal bleeding, a major cause of morbidity and mortality, is an important goal in the management of patients with portal hypertension (PHT). Although propranolol has been found useful in preventing the first episode of variceal bleeding (primary prophylaxis) in cirrhotic PHT, it has limitations which include side effects, contraindications, non-compliance and failure in some patients. Endoscopic variceal ligation (EVL) has not been used for primary prophylaxis. METHODS: Thirty cirrhotic patients with PHT, grade III to IV oesophageal varices, hepatic venous pressure gradient > or = 12 mmHg and no prior history of upper gastrointestinal bleeding were randomized to receive propranolol (to reduce their pulse rate by 25% from baseline, n = 15) and EVL (weekly to fortnightly until variceal eradication, n = 15). The two groups were comparable. All the patients in EVL group had variceal eradication during 3.8 +/- 2.2 sessions. RESULTS: There was no major complication or interval bleeding. During a follow-up period of 17.6 +/- 4.7 months, varices recurred in three, two of which bled (successfully treated by EVL). In contrast, during this period of follow up one patient in the propranolol group had variceal bleeding (P=NS). Side effects of propranolol included symptomatic bradycardia requiring reduction of dose in one of 15 patients. CONCLUSIONS: Although sample size in this study is small, it seems that EVL may be a good option for primary prophylaxis for variceal bleeding in patients with cirrhotic PHT; further studies on a larger number of patients and longer follow up are required.     

Portale Hypertension: Varizen

Background

Variceal hemorrhage is a major cause of morbidity and mortality in patients with cirrhosis. However, mortality rates have been substantially reduced in recent years due to improved diagnostic and therapeutic workup.

Therapy

Patients who present with active variceal hemorrhage require immediate hemodynamic resuscitation and early upper gastrointestinal endoscopy. Endoscopic variceal ligation (EVL) is the treatment of choice for esophageal varices, whereas cyanoacrylate injection is preferably used for the treatment of gastric varices. If endoscopic therapy fails to control bleeding, balloon tamponade or stent placement may be required. Emergency transjugular intrahepatic portosystemic shunt (TIPS) placement is a more definite option, when available.

Prophylaxis

For primary prophylaxis of variceal hemorrhage, treatment with a nonselective beta blocker or EVL is recommended whereas a combination of the two is recommended for secondary prophylaxis.

     

Endoscopic esophageal varix ligation: preliminary clinical experience

Endoscopic variceal ligation (EVL) was performed in 14 consecutive patients who had recently bled from esophageal varices. None was actively bleeding at initial treatment. Ligations were accomplished using an endoscopic ligating device and an overtube. There were no procedural complications. 132 varix ligations were performed during 44 separate EVL sessions. Two patients were lost to follow-up and two died; neither death resulted from hemorrhage or treatment complications. Variceal rebleeding occurred in 2 noncompliant patients (14.3%) and was successfully controlled with emergent EVL. Ten patients achieved complete variceal eradication with from 1 to 6 (mean, 3.9) EVL sessions. No major complications (perforation, secondary bleeding, deep ulceration) resulted and there were no treatment failures. Follow-up of 10 surviving patients ranged from 240 to 370 (mean, 280) days. Endoscopic observation suggested that varices were obliterated by a process of mechanical strangulation, ischemia, superficial ulceration, and scar formation. Preliminary data indicate that EVL is a safe and effective treatment for esophageal varices.     

Successful collapse vessel treatment with a syringe for thrombus-aspiration after the guidewire-induced coronary artery perforation

Coronary artery perforation is a rare however potentially life-threatening complication of percutaneous coronary intervention that could cause cardiac tamponade. It requires emergent surgery unless an appropriate procedure is performed immediately. In distal coronary artery perforations with guidewires, several procedures were reported to be effective in refractory cases after prolonged balloon inflation and reversal of heparin by protamine sulfate to induce hemostasis. We describe a case of successful collapse distal coronary artery treatment with a syringe for thrombus-aspiration without materials for an embolization after guidewire-induced coronary artery perforation.     

Oesophageal varices in cirrhotic patients: from variceal screening to primary prophylaxis of the first oesophageal variceal bleeding

Bleeding from oesophageal varices is still a lethal complication in cirrhotic patients with portal hypertension. Approximately 5–10% of patients with cirrhosis will develop oesophageal varices per year, and about 25–30% of cirrhotic patients with oesophageal varices and without previous variceal haemorrhage will bleed from ruptured varices. To date, data on preventing the formation/growth of oesophageal varices (preprimary prophylaxis) are conflicting, with insufficient evidence to use β‐blockers. There is evidence for the need for primary prophylaxis, and both β‐blockers and endoscopic variceal ligation have shown the same efficacy in preventing first bleeding, but which one to prefer is still controversial. The present article reviews the established and potential therapeutic strategies for preventing the development and rupture of oesophageal varices.     

Predictors and management of post-banding ulcer bleeding in cirrhosis: A systematic review and meta-analysis

Background and Aims

Post-banding ulcer bleeding (PBUB) is an understudied complication of oesophageal varices endoscopic band ligation (EBL). This systematic review with meta-analysis aimed at: (a) evaluating the incidence of PBUB in patients with cirrhosis treated with EBL in primary or secondary prophylaxis or urgent treatment for acute variceal bleeding and (b) identifying predictors of PBUB.

Methods

We conducted a systematic review of articles in English published in 2006–2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were made in eight databases including Embase, PubMed and Cochrane Library. Random-effects meta-analysis was used to determine the incidence, mean interval and predictors of PBUB.

Results

Eighteen studies (9034 patients) were included. The incidence of PBUB was 5.5% (95% CI 4.3–7.1). The mean time for it to occur was 11 days (95% CI 9.94–11.97). Model for End-stage Liver Disease (MELD) score (OR 1.162, 95% CI 1.047–1.291) and EBL done in emergency setting (OR 4.902, 95% CI 2.99–8.05) independently predicted post-ligation ulcer bleeding. Treatment included drugs, endoscopic procedures and transjugular intrahepatic portosystemic shunt. Refractory bleeding was treated with self-expandable metallic stents or balloon tamponade. Mortality was on average 22.3% (95% CI 14.1–33.6).

Conclusions

Patients with high MELD score and receiving EBL in an emergency setting are more prone to develop PBUB. Prognosis is still poor and the best therapeutic strategy to address remains to be ascertained.     

A randomized trial of terlipressin plus nitroglycerin vs. balloon tamponade in the control of acute variceal hemorrhage

A randomized trial was undertaken to determine the efficacy of nitroglycerin in addition to terlipressin infusion to improve the control of acute variceal hemorrhage compared with balloon tamponade. Forty-seven bleeding episodes in 34 cirrhotic patients were included, with terlipressin plus sublingual nitroglycerin in 23 episodes (group I) and balloon tamponade in 24 episodes (group II). At the end of the 12-hr period, hemorrhage had been equally controlled in both groups (18 of 23; 78% in group I and 19 of 24; 79% in group II). When attempted, balloon tamponade appeared more efficient in the failures of group I (4 of 4) than did terlipressin plus nitroglycerin in the failures of group II (0 of 3), although this difference was not significant. Major complications were rare (one in each group) and never required cessation of therapy. Thus terlipressin and nitroglycerin were as effective as balloon tamponade in controlling variceal hemorrhage and were associated with few minor complications.     

Endoscopic sclerotherapy in the management of gastric variceal haemorrhage.

The value of injection sclerotherapy in the management of active gastric variceal bleeding is unclear. A retrospective study was therefore performed of 46 episodes of acute variceal haemorrhage in 41 patients who were treated by endoscopic sclerotherapy. The site of gastric variceal haemorrhage was the lesser curve (Group 1) in 13, within a hiatus hernia (Group 2) in six, and fundal with or without associated oesophageal varices (Type 3) in 22 cases. Haemostasis was achieved by sclerotherapy in 54%, 71.4% and 26%, respectively. After additional measures including balloon tamponade or surgery 85% of the Group 1 cases had stopped bleeding significantly more frequently than was observed in Group 3 (44.4%). More patients in Group 3 died due to uncontrolled bleeding (41%) than in Group I (7.7%). Hospital mortality depended on the severity of the liver disease with 15% of Child's grade A and 56% of grade C cases dying. It is concluded that endoscopic sclerotherapy of gastric varices should be reserved only for lesser curve or hiatal varices and that early surgery (or sclerotherapy using tissue adhesive) be considered for variceal haemorrhage originating from fundal varices.