BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to era...BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to eradicate esophageal varices completely,and a control endoscopy after 2-4 weeks is required to assess eradication and/or the need for another band ligation.Liver stiffness measurement(LSM)is being increasingly used as a screening non-invasive tool to predict varices according to Baveno VII criteria.However,to date,there are no instruments able to non-invasively predict the outcome of EVBL.AIM To identify non-invasive predictors of varices eradication(VE)after EVBL through multiparametric ultrasound(US).Secondary aim was to develop a prediction model of successful variceal eradication based on non-invasive parameters.METHODS We prospectively enrolled consecutive cirrhotic patients intolerant or with contraindications to beta-blockers undergoing EVBL for bleeding prophylaxis.Patients underwent multiparametric US with LSM,spleen stiffness measurement(SSM)and dynamic contrastenhanced US(DCE-US)on liver parenchyma and portal vein,at baseline(T0)and one month(T1)after EVBL.Each US parameter and their variations from baseline were correlated with VE evaluated by control endoscopy performed at T1.RESULTS We enrolled 41 patients(median age 64 years,75.6%males).At T128 patients(68.3%)reached VE,whereas 13(31.7%)required a second EVBL.Patients who achieved VE showed a significant decrease in SSM(P=0.018),and a significant increase in peak enhancement,area under the curve and wash-in rate of both liver parenchyma and portal vein after treatment(P<0.001).Statistically significant differences between the two groups of patients were incorporated in a multivariate analysis and used to develop three prediction models.CONCLUSION A multimodal US approach based on DCE-US parameters,LSM and SSM might become a reliable predictor of VE and a useful non-invasive alternative to endoscopy.展开更多
Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective...Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective but limited by the risk of ectopic embolism,particularly in the presence of gastrorenal shunts.Clip-assisted ECI(clip-ECI)has emerged as a novel modification designed to reduce embolic risk while maintaining hemostatic efficacy.We appraised the recent study by Xiong et al,which compared clip-ECI with endoscopic ultrasoundguided coil and cyanoacrylate injection in 108 propensity-matched patients with cardiofundal varices and shunts.Both techniques demonstrated comparable efficacy,with obliteration rates exceeding 90%and similar one-year rebleeding rates.Importantly,no embolic events were reported.These findings are consistent with prior studies,including multicenter cohorts and a recent randomized controlled trial,which highlight clip-ECI as a safe,effective,and efficient technique,with advantages of shorter procedure times,fewer sessions,and lower costs.While endoscopic ultrasound(EUS)-guided therapy offers precision in expert hands,clip-ECI provides a practical,accessible alternative,particularly in resource-limited settings.Larger prospective studies with standardized definitions and cost-effectiveness analyses are needed to refine treatment algorithms.Clip-ECI represents a promising“flow-control assisted”strategy and a real-world alternative to EUS-based therapies for GV.展开更多
BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are assoc...BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are associated with an increased risk of bleeding.Existing risk models for variceal bleeding in cirrhotic patients have limited applicability to BCS due to differences in pathophysiology.Radiomics,as a noninvasive technique,holds promise as a tool for more accurate prediction of bleeding risk in BCS-related GEVs.AIM To develop and validate a personalized risk model for predicting variceal bleeding in BCS patients with GEVs.METHODS We retrospectively analyzed clinical data from 444 BCS patients with GEVs in two centers.Radiomic features were extracted from portal venous phase computed tomography(CT)scans.A training cohort of 334 patients was used to develop the model,with 110 patients serving as an external validation cohort.LASSO Cox regression was used to select radiomic features for constructing a radiomics score(Radscore).Univariate and multivariate Cox regression identified independent clinical predictors.A combined radiomics+clinical(R+C)model was developed using stepwise regression.Model performance was assessed using the area under the receiver operating characteristic curve(AUC),calibration plots,and decision curve analysis(DCA),with external validation to evaluate generalizability.RESULTS The Radscore comprised four hepatic and six splenic CT features,which predicted the risk of variceal bleeding.Multivariate analysis identified invasive treatment to relieve hepatic venous outflow obstruction,anticoagulant therapy,and hemoglobin levels as independent clinical predictors.The R+C model achieved C-indices of 0.906(training)and 0.859(validation),outperforming the radiomics and clinical models alone(AUC:training 0.936 vs 0.845 vs 0.823;validation 0.876 vs 0.712 vs 0.713).DCA showed higher clinical net benefit across the thresholds.The model stratified patients into low-,medium-and high-risk groups with significant differences in bleeding rates(P<0.001).An online tool is available at https://bcsvh.shinyapps.io/BCS_Variceal_Bleeding_Risk_Tool/.CONCLUSION We developed and validated a novel radiomics-based model that noninvasively and conveniently predicted risk of variceal bleeding in BCS patients with GEVs,aiding early identification and management of high-risk patients.展开更多
BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic ...BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic cyanoacrylate injection(Clip-CYA)and endoscopic ultrasound-guided coil and cyanoacrylate injection(EUS-CG)are two currently used modalities.There are limited data comparing the two techniques.AIM To compare the efficacy,safety,and procedural characteristics of Clip-CYA vs EUS-CG for treatment of gastric varices(GVs)with spontaneous portosystemic shunts.METHODS Between April 2019 and August 2023,162 patients with GVs and concomitant gastrorenal or splenorenal shunts who underwent either Clip-CYA or EUS-CG at our center were included.After 1:2 propensity score matching,108 patients were included in the final analysis.The evaluated outcomes included the amount of cyanoacrylate,eradication of GVs,cyanoacrylate embolization,all-cause rebleeding,operating time and endoscopic therapy costs.RESULTS Of the 108 patients,72(male,83.3%;mean age,56.2±10.8 years)received Clip-CYA,and 36(male,72.2%;mean age,59.1±10.7 years)received EUS-CG.The amount of cyanoacrylate used,rates of obliteration of GVs and all-cause rebleeding were similar between the two groups(2.0±1.1 mL vs 2.0±0.6 mL,P=0.913;91.7%vs 94.4%,P=0.603;and 23.6%vs 19.4%,P=0.623,respectively).No cyanoacrylate embolization occurred in either group.Compared with EUS-CG,Clip-CYA was associated with significantly shorter operating times(24.0±9.9 minutes vs 47.1±21.0 minutes,P<0.001)and lower endoscopic therapy costs(7523.4±5719.4 Chinese yuan vs 11153.7±7679.1 Chinese yuan,P=0.007).These advantages persisted in the subgroup analysis of patients whose GVs had a maximum diameter>3 cm or>4 cm.CONCLUSION Compared with EUS-CG,Clip-CYA of GVs appears to be a safe procedure with shorter operating times and lower endoscopic therapy costs.展开更多
BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is ...BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is invasive,costly and carries risks.Noninvasive predictive models using ultrasound and serological markers are essential for identifying high-risk patients and optimizing endoscopy utilization.Machine learning(ML)offers a powerful approach to analyze complex clinical data and improve predictive accuracy.This study hypothesized that ML models,utilizing noninvasive ultrasound and serological markers,can accurately predict the risk of EGVs in hepatitis B patients,thereby improving clinical decisionmaking.AIM To construct and validate a noninvasive predictive model using ML for EGVs in hepatitis B patients.METHODS We retrospectively collected ultrasound and serological data from 310 eligible cases,randomly dividing them into training(80%)and validation(20%)groups.Eleven ML algorithms were used to build predictive models.The performance of the models was evaluated using the area under the curve and decision curve analysis.The best-performing model was further analyzed using SHapley Additive exPlanation to interpret feature importance.RESULTS Among the 310 patients,124 were identified as high-risk for EGVs.The extreme gradient boosting model demonstrated the best performance,achieving an area under the curve of 0.96 in the validation set.The model also exhibited high sensitivity(78%),specificity(94%),positive predictive value(84%),negative predictive value(88%),F1 score(83%),and overall accuracy(86%).The top four predictive variables were albumin,prothrombin time,portal vein flow velocity and spleen stiffness.A web-based version of the model was developed for clinical use,providing real-time predictions for high-risk patients.CONCLUSION We identified an efficient noninvasive predictive model using extreme gradient boosting for EGVs among hepatitis B patients.The model,presented as a web application,has potential for screening high-risk EGV patients and can aid clinicians in optimizing the use of endoscopy.展开更多
In this letter we comment on the article by Zhang et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2024.We focus specifically on the management of gastric varices(GV),which is a s...In this letter we comment on the article by Zhang et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2024.We focus specifically on the management of gastric varices(GV),which is a significant consequence of portal hypertension,is currently advised to include beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt for secondary prophylaxis or active bleeding.Although it has been studied,direct endoscopic injection of cyanoacrylate glue has limitations,such as the inability to fully characterize GV endoscopically and the potential for distant glue embolism.In order to achieve this,endoscopic ultrasound has been used to support GV characterization,real-time therapy imaging,and Doppler obliteration verification.展开更多
BACKGROUND Bleeding ectopic varices located in the small bowel(BEV-SB)caused by portal hypertension(PH)are rare and life-threatening clinical scenarios.The current management of BEV-SB is unsatisfactory.This retrospec...BACKGROUND Bleeding ectopic varices located in the small bowel(BEV-SB)caused by portal hypertension(PH)are rare and life-threatening clinical scenarios.The current management of BEV-SB is unsatisfactory.This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy(EIS)and subsequent interventional radiology(IR).AIM To analyze the management of BEV-SB caused by PH and develop a treatment algorithm.METHODS This was a single tertiary care center before-after study,including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center.A retrospective review of the medical records was conducted.The management of these four patients involved the utilization of EIS followed by IR.The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches:Phase 1,from the initial occurrence of BEV-SB to the initial EIS;phase 2,from the initial EIS to the initial IR treatment;and phase 3,from the initial IR to December 2023.Descriptive statistics were performed to clarify the blood transfusions in each phase.RESULTS Four out of 519 patients diagnosed with PH were identified as having BEV-SB.The management duration of each phase was 20 person-months,42 personmonths,and 77 person-months,respectively.The four patients received a total of eight and five person-times of EIS and IR treatment,respectively.All patients exhibited recurrent gastrointestinal bleeding following the first EIS,while no further instances of gastrointestinal bleeding were observed after IR treatment.The transfusions administered during each phase were 34,31,and 3.5 units of red blood cells,and 13 units,14 units,and 1 unit of plasma,respectively.CONCLUSION EIS may be effective in achieving hemostasis for BEV-SB,but rebleeding is common,and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.展开更多
Cirrhosis of liver is a major problem in the western world.Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals.Gastro...Cirrhosis of liver is a major problem in the western world.Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals.Gastrointestinal varices are dilated submucosal veins,which often develop at sites near the formation of gastroesophageal collateral circulation.The incidence of varices is on the rise due to alcohol and obesity.The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices,which is associated with substantial morbidity and mortality.In addition,this can cause a significant burden on the health care facility.Gastrointestinal varices can happen in esophagus,stomach or ectopic varices.There has been considerable progress made in the understanding of the natural history,pathophysiology and etiology of portal hypertension.Despite the development of endoscopic and medical treatments,early mortality due to variceal bleeding remains high due to significant illness of the patient.Recurrent variceal bleed is common and in some cases,there is refractory variceal bleed.This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions,strategies to handle refractory variceal bleed and newer endoscopic treatment modalities.Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.展开更多
Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for...Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for portal hyper-tension and esophagogastric variceal bleeding,respectively.With advancements in artificial intelligence in medicine,non-invasive diagnostic methods are in-creasingly replacing traditional invasive procedures,permitting more rational and personalized patient care.This review summarizes the formation and diagnosis of portal hypertension,as well as the primary prophylaxis,secondary prophylaxis,and management of acute esophagogastric variceal bleeding.This study also highlights the latest progress in artificial intelligence in the diagnosis and treat-ment of portal hypertension and esophagogastric varices.展开更多
Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed ...Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.展开更多
Endoscopic ultrasound(EUS)guided vascular interventions have expanded the reach of therapeutic endoscopy to include vascular pathology previously inaccessible by endoscopists.Gastric variceal bleeding comprises 20%of ...Endoscopic ultrasound(EUS)guided vascular interventions have expanded the reach of therapeutic endoscopy to include vascular pathology previously inaccessible by endoscopists.Gastric variceal bleeding comprises 20%of all variceal bleeding and is associated with high morbidity and mortality.Historically,endoscopic injection of thrombosis-inducing agents such as glue has been used.However,glue injection carries potential risks including systemic embolization,damage to the endoscope,and recurrent bleeding.The introduction of hemostatic coils has revolutionized the endoscopic approach,with EUS-guided coil embolization emerging as an effective and safe modality for the management of gastric varices(GVs).When compared with conventional glue injection,EUSguided embolization is associated with improved visualization,higher efficacy,and better safety profile.Despite its expanding adoption,the standardization of EUS guided embolization remains a challenge.High-quality studies are needed to standardize this promising technique and define its role in clinical practice.In this review,we will discuss the indications,efficacy,techniques,and various approaches for EUS-guided embolization of GVs.展开更多
AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous p...AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous pressure gradient (HVPG) were done in 146 patients. Each transjugular HVPG was measured twice, first using an end whole catheter (EH-HVPG), and then using a balloon catheter (B-HVPG). The HVPG was compared with the endoscopic grade of esophageal varices (according to the general rules for recording endoscopic findings of esophagogastric varices), which was recorded within a month of the measurement of HVPG.RESULTS: The study included 110 men and 36 women, with a mean age of 56.1 years (range, 43-76 years). The technical success rate of the pressure measurements was 100% and there were no complication related to the procedures. Mean HVPG was 15.3 mmHg as measured using the end hole catheter method and 16.5 mmHg as measured using the balloon catheter method. Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). Portal hypertension (> 12 mmHg HVPG) occurred in 66% of patients according to EH-HVPG and 83% of patients according to B-HVGP, and significantly correlated with Child’s status (B-HVPG, P < 0.000; EH-HVGP, P < 0.000) and esophageal varies observed upon endoscopy (EH-HVGP, P = 0.003; B-HVGP, P = 0.006). One hundred and thirty-five endoscopies were performed, of which 15 showed normal findings, 27 showed grade 1 endoscopic esophageal varices, 49 showed grade 2 varices, and 44 showed grade 3 varices. When comparing endoscopic esophageal variceal grades and HVPG using univariate analysis, the P value was 0.004 for EH-HVPG and 0.002 for B-HVPG.CONCLUSION: Both EH-HVPG and B-HVPG showed a positive correlation with the endoscopic grade of esophageal varices, with B-HVPG showing a stronger correlation than EH-HVPG.展开更多
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 iden...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.展开更多
Variceal bleed represents an important complication of cirrhosis,with its presence reflecting the severity of liver disease.Gastric varices,though less frequently seen than esophageal varices,present a distinct clinic...Variceal bleed represents an important complication of cirrhosis,with its presence reflecting the severity of liver disease.Gastric varices,though less frequently seen than esophageal varices,present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality.Based upon the Sarin classification,GOV1 is the most common subtype of gastric varices seen in clinical practice.展开更多
The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varice...The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.展开更多
Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or largesized varices can be treated for primary prophylaxis of va...Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or largesized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers(NSBBs) or endoscopic variceal ligation(EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt(TIPS) with polytetrafluoroethylene(PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.展开更多
To assess“predictors”of esophageal varices(EV)and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis.METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients wi...To assess“predictors”of esophageal varices(EV)and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis.METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis.Model for end-stage liver disease(MELD),aspartate aminotransferase(AST)to alanine aminotransferase(ALT)ratio(AST/ALT),AST to platelet ratio index(APRI),platelet count to spleen diameter(PC/SD),fibrosis-4-index(FIB-4),fibrosis index(FI)and King’s Score were measured for all participants.All patients underwent endoscopic assessment within two days of hospitalization.The major end point was the first esophageal variceal bleeding(EVB)event.The diagnostic performance of“predictors”for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure.RESULTSFIB-4 was the only strong and significant“predictor”of esophageal varices(multivariable-adjusted OR=1.57 for one unit increment;95%CI:1.15-2.14).Furthermore,a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices,with a sensitivity of 72%,a specificity of 58%and a proportion of area under the curve(AUC)of 66%(P=0.01).During the follow-up(median:31.5 mo;interquartile range:11-59 mo),34 patients(24%)experienced a first EVB.FIB-4 was a poor predictor of EVB(the AUC was only 51%)for a cut-off value of 5.02.Furthermore,the AUC of AST/ALT,APRI,PC/SD,FI,MELD and King’s Score ranged from 45%to 55%.None of the non-invasive markers turned out to be a useful predictor of EVB.CONCLUSIONDespite the low diagnostic accuracy,FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.展开更多
Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatment...Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow- up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bimonthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.展开更多
Elastography-based liver stiffness measurement(LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver di...Elastography-based liver stiffness measurement(LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease(ACLD). The presence of varices and especially of varices needing treatment(VNT) indicates distinct prognostic stages in patients with compensated ACLD(cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa(by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These(and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography(pSWE) and two-dimensional shear wave elastography(2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for "any" varices and for VNT. Finally, the measurement of spleen stiffness(SSM) by elastography(mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of "any" varices and VNT. Finally,we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.展开更多
Abstract AIM:To evaluate the role of multi-detector row computed tomography(MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization(PTVE) for esophageal varices(EVs)....Abstract AIM:To evaluate the role of multi-detector row computed tomography(MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization(PTVE) for esophageal varices(EVs).METHODS:The subjects of this prospective study were 156 patients who underwent PTVE with cyanoacrylate for EVs.Patients were divided into three groups according to the filling range of cyanoacrylate in EVs and their feeding vessels:(1) group A,complete obliteration,with at least 3 cm of the lower EVs and peri-/EVs,as well as the adventitial plexus of the gastric cardia and fundus filled with cyanoacrylate;(2) group B,partial obliteration of varices surrounding the gastric cardia and fundus,with their feeding vessels being obliterated with cyanoacrylate,but without reaching lower EVs;and(3) group C,trunk obliteration,with the main branch of the left gastric vein being filled with cyanoacrylate,but without reaching varices surrounding the gastric cardia or fundus.We performed chart reviews and a prospective follow-up using MDCT images,angiography,and gastrointestinal endoscopy.RESULTS:The median follow-up period was 34 mo.The rate of eradication of varices for all patients was 56.4%(88/156) and the rate of relapse was 31.3%(41/131).The rates of variceal eradication at 1,3,and 5 years after PTVE were 90.2%,84.1% and 81.7%,respectively,for the complete group;61.2%,49% and 42.9%,respectively,for the partial group;with no varices disappearing in the trunk group.The relapsefree rates at 1,3 and 5 years after PTVE were 91.5%,86.6% and 81.7%,respectively,for the complete group;71.1%,55.6% and 51.1%,respectively,for the partial group;and all EVs recurred in the trunk group.Kaplan-Meier analysis showed P values of 0.000 and 0.000,and odds ratios of 3.824 and 3.603 for the rates of variceal eradication and relapse free rates,respectively.Cyanoacrylate in EVs disappeared with time,but those in the EVs and other feeding vessels remained permanently in the vessels without a decrease with time,which is important for the continued obliteration of the feeding vessels and prevention of EV relapse.CONCLUSION:MDCT provides excellent visualization of cyanoacrylate obliteration in EV and their feeding veins after PTVE.It confirms that PTVE is effective for treating EVs.展开更多
文摘BACKGROUND Endoscopic variceal band ligation(EVBL)represents a pivotal treatment in the prophylaxis of esophageal varices bleeding in patients with cirrhosis,but in some cases a single session of EVBL is unable to eradicate esophageal varices completely,and a control endoscopy after 2-4 weeks is required to assess eradication and/or the need for another band ligation.Liver stiffness measurement(LSM)is being increasingly used as a screening non-invasive tool to predict varices according to Baveno VII criteria.However,to date,there are no instruments able to non-invasively predict the outcome of EVBL.AIM To identify non-invasive predictors of varices eradication(VE)after EVBL through multiparametric ultrasound(US).Secondary aim was to develop a prediction model of successful variceal eradication based on non-invasive parameters.METHODS We prospectively enrolled consecutive cirrhotic patients intolerant or with contraindications to beta-blockers undergoing EVBL for bleeding prophylaxis.Patients underwent multiparametric US with LSM,spleen stiffness measurement(SSM)and dynamic contrastenhanced US(DCE-US)on liver parenchyma and portal vein,at baseline(T0)and one month(T1)after EVBL.Each US parameter and their variations from baseline were correlated with VE evaluated by control endoscopy performed at T1.RESULTS We enrolled 41 patients(median age 64 years,75.6%males).At T128 patients(68.3%)reached VE,whereas 13(31.7%)required a second EVBL.Patients who achieved VE showed a significant decrease in SSM(P=0.018),and a significant increase in peak enhancement,area under the curve and wash-in rate of both liver parenchyma and portal vein after treatment(P<0.001).Statistically significant differences between the two groups of patients were incorporated in a multivariate analysis and used to develop three prediction models.CONCLUSION A multimodal US approach based on DCE-US parameters,LSM and SSM might become a reliable predictor of VE and a useful non-invasive alternative to endoscopy.
文摘Gastric variceal(GV)bleeding remains a life-threatening complication of portal hypertension,with ongoing debate regarding the optimal endoscopic therapy.Conventional endoscopic cyanoacrylate injection(ECI)is effective but limited by the risk of ectopic embolism,particularly in the presence of gastrorenal shunts.Clip-assisted ECI(clip-ECI)has emerged as a novel modification designed to reduce embolic risk while maintaining hemostatic efficacy.We appraised the recent study by Xiong et al,which compared clip-ECI with endoscopic ultrasoundguided coil and cyanoacrylate injection in 108 propensity-matched patients with cardiofundal varices and shunts.Both techniques demonstrated comparable efficacy,with obliteration rates exceeding 90%and similar one-year rebleeding rates.Importantly,no embolic events were reported.These findings are consistent with prior studies,including multicenter cohorts and a recent randomized controlled trial,which highlight clip-ECI as a safe,effective,and efficient technique,with advantages of shorter procedure times,fewer sessions,and lower costs.While endoscopic ultrasound(EUS)-guided therapy offers precision in expert hands,clip-ECI provides a practical,accessible alternative,particularly in resource-limited settings.Larger prospective studies with standardized definitions and cost-effectiveness analyses are needed to refine treatment algorithms.Clip-ECI represents a promising“flow-control assisted”strategy and a real-world alternative to EUS-based therapies for GV.
基金Supported by Natural Science Foundation of Henan Province,China,No.232300420232Henan Provincial Key Research and Development Project,No.231111313500.
文摘BACKGROUND Budd-Chiari syndrome(BCS)is caused by obstruction of the hepatic veins or suprahepatic inferior vena cava,leading to portal hypertension and the development of gastroesophageal varices(GEVs),which are associated with an increased risk of bleeding.Existing risk models for variceal bleeding in cirrhotic patients have limited applicability to BCS due to differences in pathophysiology.Radiomics,as a noninvasive technique,holds promise as a tool for more accurate prediction of bleeding risk in BCS-related GEVs.AIM To develop and validate a personalized risk model for predicting variceal bleeding in BCS patients with GEVs.METHODS We retrospectively analyzed clinical data from 444 BCS patients with GEVs in two centers.Radiomic features were extracted from portal venous phase computed tomography(CT)scans.A training cohort of 334 patients was used to develop the model,with 110 patients serving as an external validation cohort.LASSO Cox regression was used to select radiomic features for constructing a radiomics score(Radscore).Univariate and multivariate Cox regression identified independent clinical predictors.A combined radiomics+clinical(R+C)model was developed using stepwise regression.Model performance was assessed using the area under the receiver operating characteristic curve(AUC),calibration plots,and decision curve analysis(DCA),with external validation to evaluate generalizability.RESULTS The Radscore comprised four hepatic and six splenic CT features,which predicted the risk of variceal bleeding.Multivariate analysis identified invasive treatment to relieve hepatic venous outflow obstruction,anticoagulant therapy,and hemoglobin levels as independent clinical predictors.The R+C model achieved C-indices of 0.906(training)and 0.859(validation),outperforming the radiomics and clinical models alone(AUC:training 0.936 vs 0.845 vs 0.823;validation 0.876 vs 0.712 vs 0.713).DCA showed higher clinical net benefit across the thresholds.The model stratified patients into low-,medium-and high-risk groups with significant differences in bleeding rates(P<0.001).An online tool is available at https://bcsvh.shinyapps.io/BCS_Variceal_Bleeding_Risk_Tool/.CONCLUSION We developed and validated a novel radiomics-based model that noninvasively and conveniently predicted risk of variceal bleeding in BCS patients with GEVs,aiding early identification and management of high-risk patients.
基金Supported by the National Natural Science Foundation of China,No.82200664the Clinical Research Program of The First Affiliated Hospital,Zhejiang University School of Medicine,No.BL2025023.
文摘BACKGROUND The high rebleeding rate and severe adverse events have raised concerns regarding the safety of endoscopic cyanoacrylate as a conventional treatment for gastric variceal hemorrhage.Clip-assisted endoscopic cyanoacrylate injection(Clip-CYA)and endoscopic ultrasound-guided coil and cyanoacrylate injection(EUS-CG)are two currently used modalities.There are limited data comparing the two techniques.AIM To compare the efficacy,safety,and procedural characteristics of Clip-CYA vs EUS-CG for treatment of gastric varices(GVs)with spontaneous portosystemic shunts.METHODS Between April 2019 and August 2023,162 patients with GVs and concomitant gastrorenal or splenorenal shunts who underwent either Clip-CYA or EUS-CG at our center were included.After 1:2 propensity score matching,108 patients were included in the final analysis.The evaluated outcomes included the amount of cyanoacrylate,eradication of GVs,cyanoacrylate embolization,all-cause rebleeding,operating time and endoscopic therapy costs.RESULTS Of the 108 patients,72(male,83.3%;mean age,56.2±10.8 years)received Clip-CYA,and 36(male,72.2%;mean age,59.1±10.7 years)received EUS-CG.The amount of cyanoacrylate used,rates of obliteration of GVs and all-cause rebleeding were similar between the two groups(2.0±1.1 mL vs 2.0±0.6 mL,P=0.913;91.7%vs 94.4%,P=0.603;and 23.6%vs 19.4%,P=0.623,respectively).No cyanoacrylate embolization occurred in either group.Compared with EUS-CG,Clip-CYA was associated with significantly shorter operating times(24.0±9.9 minutes vs 47.1±21.0 minutes,P<0.001)and lower endoscopic therapy costs(7523.4±5719.4 Chinese yuan vs 11153.7±7679.1 Chinese yuan,P=0.007).These advantages persisted in the subgroup analysis of patients whose GVs had a maximum diameter>3 cm or>4 cm.CONCLUSION Compared with EUS-CG,Clip-CYA of GVs appears to be a safe procedure with shorter operating times and lower endoscopic therapy costs.
基金Supported by the Agency Natural Science Foundation of Fujian Province,China,No.2022J011285 and No.2023J011480.
文摘BACKGROUND Severe esophagogastric varices(EGVs)significantly affect prognosis of patients with hepatitis B because of the risk of life-threatening hemorrhage.Endoscopy is the gold standard for EGV detection but it is invasive,costly and carries risks.Noninvasive predictive models using ultrasound and serological markers are essential for identifying high-risk patients and optimizing endoscopy utilization.Machine learning(ML)offers a powerful approach to analyze complex clinical data and improve predictive accuracy.This study hypothesized that ML models,utilizing noninvasive ultrasound and serological markers,can accurately predict the risk of EGVs in hepatitis B patients,thereby improving clinical decisionmaking.AIM To construct and validate a noninvasive predictive model using ML for EGVs in hepatitis B patients.METHODS We retrospectively collected ultrasound and serological data from 310 eligible cases,randomly dividing them into training(80%)and validation(20%)groups.Eleven ML algorithms were used to build predictive models.The performance of the models was evaluated using the area under the curve and decision curve analysis.The best-performing model was further analyzed using SHapley Additive exPlanation to interpret feature importance.RESULTS Among the 310 patients,124 were identified as high-risk for EGVs.The extreme gradient boosting model demonstrated the best performance,achieving an area under the curve of 0.96 in the validation set.The model also exhibited high sensitivity(78%),specificity(94%),positive predictive value(84%),negative predictive value(88%),F1 score(83%),and overall accuracy(86%).The top four predictive variables were albumin,prothrombin time,portal vein flow velocity and spleen stiffness.A web-based version of the model was developed for clinical use,providing real-time predictions for high-risk patients.CONCLUSION We identified an efficient noninvasive predictive model using extreme gradient boosting for EGVs among hepatitis B patients.The model,presented as a web application,has potential for screening high-risk EGV patients and can aid clinicians in optimizing the use of endoscopy.
文摘In this letter we comment on the article by Zhang et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2024.We focus specifically on the management of gastric varices(GV),which is a significant consequence of portal hypertension,is currently advised to include beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt for secondary prophylaxis or active bleeding.Although it has been studied,direct endoscopic injection of cyanoacrylate glue has limitations,such as the inability to fully characterize GV endoscopically and the potential for distant glue embolism.In order to achieve this,endoscopic ultrasound has been used to support GV characterization,real-time therapy imaging,and Doppler obliteration verification.
基金Supported by the Air Force Medical Center Outstanding Youth Program,No.2022YXQNNO36.
文摘BACKGROUND Bleeding ectopic varices located in the small bowel(BEV-SB)caused by portal hypertension(PH)are rare and life-threatening clinical scenarios.The current management of BEV-SB is unsatisfactory.This retrospective study analyzed four cases of BEV-SB caused by PH and detailed the management of these cases using enteroscopic injection sclerotherapy(EIS)and subsequent interventional radiology(IR).AIM To analyze the management of BEV-SB caused by PH and develop a treatment algorithm.METHODS This was a single tertiary care center before-after study,including four patients diagnosed with BEV-SB secondary to PH between January 2019 and December 2023 in the Air Force Medical Center.A retrospective review of the medical records was conducted.The management of these four patients involved the utilization of EIS followed by IR.The management duration of BEV-SB in each patient can be retrospectively divided into three phases based on these two approaches:Phase 1,from the initial occurrence of BEV-SB to the initial EIS;phase 2,from the initial EIS to the initial IR treatment;and phase 3,from the initial IR to December 2023.Descriptive statistics were performed to clarify the blood transfusions in each phase.RESULTS Four out of 519 patients diagnosed with PH were identified as having BEV-SB.The management duration of each phase was 20 person-months,42 personmonths,and 77 person-months,respectively.The four patients received a total of eight and five person-times of EIS and IR treatment,respectively.All patients exhibited recurrent gastrointestinal bleeding following the first EIS,while no further instances of gastrointestinal bleeding were observed after IR treatment.The transfusions administered during each phase were 34,31,and 3.5 units of red blood cells,and 13 units,14 units,and 1 unit of plasma,respectively.CONCLUSION EIS may be effective in achieving hemostasis for BEV-SB,but rebleeding is common,and IR aiming to reduce portal pressure gradient may lower the rebleeding rate.
文摘Cirrhosis of liver is a major problem in the western world.Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals.Gastrointestinal varices are dilated submucosal veins,which often develop at sites near the formation of gastroesophageal collateral circulation.The incidence of varices is on the rise due to alcohol and obesity.The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices,which is associated with substantial morbidity and mortality.In addition,this can cause a significant burden on the health care facility.Gastrointestinal varices can happen in esophagus,stomach or ectopic varices.There has been considerable progress made in the understanding of the natural history,pathophysiology and etiology of portal hypertension.Despite the development of endoscopic and medical treatments,early mortality due to variceal bleeding remains high due to significant illness of the patient.Recurrent variceal bleed is common and in some cases,there is refractory variceal bleed.This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions,strategies to handle refractory variceal bleed and newer endoscopic treatment modalities.Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.
基金Supported by the National Natural Science Foundation of China,No.81970533the Natural Science Foundation of Shandong Province,No.ZR2022ZD21.
文摘Esophagogastric variceal bleeding is a common and severe complication of cirr-hotic portal hypertension.Hepatic venous pressure gradient measurement and esophagogastroduodenoscopy are the diagnostic gold standards for portal hyper-tension and esophagogastric variceal bleeding,respectively.With advancements in artificial intelligence in medicine,non-invasive diagnostic methods are in-creasingly replacing traditional invasive procedures,permitting more rational and personalized patient care.This review summarizes the formation and diagnosis of portal hypertension,as well as the primary prophylaxis,secondary prophylaxis,and management of acute esophagogastric variceal bleeding.This study also highlights the latest progress in artificial intelligence in the diagnosis and treat-ment of portal hypertension and esophagogastric varices.
文摘Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.
文摘Endoscopic ultrasound(EUS)guided vascular interventions have expanded the reach of therapeutic endoscopy to include vascular pathology previously inaccessible by endoscopists.Gastric variceal bleeding comprises 20%of all variceal bleeding and is associated with high morbidity and mortality.Historically,endoscopic injection of thrombosis-inducing agents such as glue has been used.However,glue injection carries potential risks including systemic embolization,damage to the endoscope,and recurrent bleeding.The introduction of hemostatic coils has revolutionized the endoscopic approach,with EUS-guided coil embolization emerging as an effective and safe modality for the management of gastric varices(GVs).When compared with conventional glue injection,EUSguided embolization is associated with improved visualization,higher efficacy,and better safety profile.Despite its expanding adoption,the standardization of EUS guided embolization remains a challenge.High-quality studies are needed to standardize this promising technique and define its role in clinical practice.In this review,we will discuss the indications,efficacy,techniques,and various approaches for EUS-guided embolization of GVs.
基金Supported by the Research Program of the National Research Foundation of Koreafunded by the Ministry of Education and Science and Technology No.2010-0011678and the Soonchunhyang University Research Fund
文摘AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous pressure gradient (HVPG) were done in 146 patients. Each transjugular HVPG was measured twice, first using an end whole catheter (EH-HVPG), and then using a balloon catheter (B-HVPG). The HVPG was compared with the endoscopic grade of esophageal varices (according to the general rules for recording endoscopic findings of esophagogastric varices), which was recorded within a month of the measurement of HVPG.RESULTS: The study included 110 men and 36 women, with a mean age of 56.1 years (range, 43-76 years). The technical success rate of the pressure measurements was 100% and there were no complication related to the procedures. Mean HVPG was 15.3 mmHg as measured using the end hole catheter method and 16.5 mmHg as measured using the balloon catheter method. Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). Portal hypertension (> 12 mmHg HVPG) occurred in 66% of patients according to EH-HVPG and 83% of patients according to B-HVGP, and significantly correlated with Child’s status (B-HVPG, P < 0.000; EH-HVGP, P < 0.000) and esophageal varies observed upon endoscopy (EH-HVGP, P = 0.003; B-HVGP, P = 0.006). One hundred and thirty-five endoscopies were performed, of which 15 showed normal findings, 27 showed grade 1 endoscopic esophageal varices, 49 showed grade 2 varices, and 44 showed grade 3 varices. When comparing endoscopic esophageal variceal grades and HVPG using univariate analysis, the P value was 0.004 for EH-HVPG and 0.002 for B-HVPG.CONCLUSION: Both EH-HVPG and B-HVPG showed a positive correlation with the endoscopic grade of esophageal varices, with B-HVPG showing a stronger correlation than EH-HVPG.
文摘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.
文摘Variceal bleed represents an important complication of cirrhosis,with its presence reflecting the severity of liver disease.Gastric varices,though less frequently seen than esophageal varices,present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality.Based upon the Sarin classification,GOV1 is the most common subtype of gastric varices seen in clinical practice.
文摘The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.
文摘Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or largesized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers(NSBBs) or endoscopic variceal ligation(EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt(TIPS) with polytetrafluoroethylene(PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.
文摘To assess“predictors”of esophageal varices(EV)and variceal bleeding using non-invasive markers in Albanian patients diagnosed with liver cirrhosis.METHODSOne hundred thirty-nine newly diagnosed cirrhotic patients without variceal bleeding were included in this analysis.Model for end-stage liver disease(MELD),aspartate aminotransferase(AST)to alanine aminotransferase(ALT)ratio(AST/ALT),AST to platelet ratio index(APRI),platelet count to spleen diameter(PC/SD),fibrosis-4-index(FIB-4),fibrosis index(FI)and King’s Score were measured for all participants.All patients underwent endoscopic assessment within two days of hospitalization.The major end point was the first esophageal variceal bleeding(EVB)event.The diagnostic performance of“predictors”for the presence of EV and EVB were assessed by sensitivity and specificity values obtained from the receiver operating characteristics procedure.RESULTSFIB-4 was the only strong and significant“predictor”of esophageal varices(multivariable-adjusted OR=1.57 for one unit increment;95%CI:1.15-2.14).Furthermore,a cut-off value of 3.23 for FIB-4 was a significant predictor of esophageal varices,with a sensitivity of 72%,a specificity of 58%and a proportion of area under the curve(AUC)of 66%(P=0.01).During the follow-up(median:31.5 mo;interquartile range:11-59 mo),34 patients(24%)experienced a first EVB.FIB-4 was a poor predictor of EVB(the AUC was only 51%)for a cut-off value of 5.02.Furthermore,the AUC of AST/ALT,APRI,PC/SD,FI,MELD and King’s Score ranged from 45%to 55%.None of the non-invasive markers turned out to be a useful predictor of EVB.CONCLUSIONDespite the low diagnostic accuracy,FIB-4 appears the most efficient non-invasive liver fibrosis marker which can be used as an initial screening tool for cirrhotic patients.
文摘Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow- up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bimonthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.
文摘Elastography-based liver stiffness measurement(LSM) is a non-invasive tool for estimating liver fibrosis but also provides an estimate for the severity of portal hypertension in patients with advanced chronic liver disease(ACLD). The presence of varices and especially of varices needing treatment(VNT) indicates distinct prognostic stages in patients with compensated ACLD(cACLD). The Baveno VI guidelines suggested a simple algorithm based on LSM < 20 kPa(by transient elastography, TE) and platelet count > 150 G/L for ruling-out VNT in patients with cACLD. These(and other) TE-based LSM cut-offs have been evaluated for VNT screening in different liver disease etiologies. Novel point shear-wave elastography(pSWE) and two-dimensional shear wave elastography(2D-SWE) methodologies for LSM have also been evaluated for their ability to screen for "any" varices and for VNT. Finally, the measurement of spleen stiffness(SSM) by elastography(mainly by pSWE and 2D-SWE) may represent another valuable screening tool for varices. Here, we summarize the current literature on elastography-based prediction of "any" varices and VNT. Finally,we have summarized the published LSM and SSM cut-offs in clinically useful scale cards.
文摘Abstract AIM:To evaluate the role of multi-detector row computed tomography(MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization(PTVE) for esophageal varices(EVs).METHODS:The subjects of this prospective study were 156 patients who underwent PTVE with cyanoacrylate for EVs.Patients were divided into three groups according to the filling range of cyanoacrylate in EVs and their feeding vessels:(1) group A,complete obliteration,with at least 3 cm of the lower EVs and peri-/EVs,as well as the adventitial plexus of the gastric cardia and fundus filled with cyanoacrylate;(2) group B,partial obliteration of varices surrounding the gastric cardia and fundus,with their feeding vessels being obliterated with cyanoacrylate,but without reaching lower EVs;and(3) group C,trunk obliteration,with the main branch of the left gastric vein being filled with cyanoacrylate,but without reaching varices surrounding the gastric cardia or fundus.We performed chart reviews and a prospective follow-up using MDCT images,angiography,and gastrointestinal endoscopy.RESULTS:The median follow-up period was 34 mo.The rate of eradication of varices for all patients was 56.4%(88/156) and the rate of relapse was 31.3%(41/131).The rates of variceal eradication at 1,3,and 5 years after PTVE were 90.2%,84.1% and 81.7%,respectively,for the complete group;61.2%,49% and 42.9%,respectively,for the partial group;with no varices disappearing in the trunk group.The relapsefree rates at 1,3 and 5 years after PTVE were 91.5%,86.6% and 81.7%,respectively,for the complete group;71.1%,55.6% and 51.1%,respectively,for the partial group;and all EVs recurred in the trunk group.Kaplan-Meier analysis showed P values of 0.000 and 0.000,and odds ratios of 3.824 and 3.603 for the rates of variceal eradication and relapse free rates,respectively.Cyanoacrylate in EVs disappeared with time,but those in the EVs and other feeding vessels remained permanently in the vessels without a decrease with time,which is important for the continued obliteration of the feeding vessels and prevention of EV relapse.CONCLUSION:MDCT provides excellent visualization of cyanoacrylate obliteration in EV and their feeding veins after PTVE.It confirms that PTVE is effective for treating EVs.
