LC : Mass-like Esophageal Varices (F3) are Different from Tortuous Varices (F2) in Eus Findings and Clinical Outcome

( Jae Jun Shim ),( Jeong Min Chae ),( Sung Hoon Hong ),( Jung Wook Kim ),( Chang Kyun Lee ),( Jae Young Jang ),( Byung Ho Kim ) 대한간학회 2013 춘·추계 학술대회 (KASL) Vol.2013 No.1

Background: Esophageal varices are simply defined by small or large ones based on their size (5 mm) in many countries rather than 3-grade system (F1, F2, and F3). We investigated difference between F2 and F3 varices in terms of their clinical outcomes and endoscopic ultrasonographic (EUS) findings. Methods: Patients with large esophageal varices defined by AASLD and no history of previous endoscopic therapy were included. F2 was defined as tortuous or beaded varices. F3 was defined as asymmetrically large mass-like varices. Perforating veins, esophageal collateral veins, and cardiac submucosal venous plexus were evaluated using a 20 MHz-miniature ultrasound probe during conventional endoscopic examination. After endoscopic band ligation (EBL), clinical outcome including variceal bleeding and aggravation of varices was assessed. Results: In total, 47 patients were included. Twenty patients (43%) had F3 varices. Ten of them (50%) had decompensated cirrhosis, which was more common than F2 variceal group (22%) (P=0.047). On EUS examination, perforating veins that connect esophageal collateral veins with varices were more common in F3 than in F2 (75% vs. 44%, P=0.036). Size of esophageal collateral veins was similar between two groups. EBL was performed and 31 patients were followed up. During 1 year, acute variceal bleeding occurred in 4 patients (13%). Bleeding or enlarged varices that required therapeutic intervention was noted in 8 out of 13 patients (62%) with F3 and 4 out of 18 patients (22%) with F2 (P=0.032). Conclusions: It should be considered that large esophageal varices be classified as F2 (tortuous) and F3 (mass-like), because F3 are different from F2 in clinical outcomes and perforating veins. F3 seems to be a more aggravated stage and needs more aggressive treatment and follow-up than F2 varices.

Percutaneous Transportal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices: Technique and Clinical Efficacy

곽효성,한영민 대한영상의학회 2008 Korean Journal of Radiology Vol.9 No.6

Objective: This study was deigned to evaluate the technique and clinical efficacy of the use of percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) for patients with gastric varices. Materials and Methods: Seven patients were treated by transportal sclerotherapy with the use of NBCA. For transportal sclerotherapy, portal vein catheterization was performed with a 6-Fr sheath by the transhepatic approach. A 5-Fr catheter was introduced into the afferent gastric vein and a microcatheter was advanced through the 5-Fr catheter into the varices. NBCA was injected through the microcatheter in the varices by use of the continuous single-column injection technique. After the procedure, postcontrast computed tomography (CT) was performed on the next day and then every six months. Gastroendoscopy was performed at one week, three months, and then every six months after the procedure. Results: The technical success rate of the procedure was 88%. In six patients, gastric varices were successfully obliterated with 1-8 mL (mean, 5.4 mL) of a NBCA-Lipiodol mixture injected via a microcatheter. No complications related to the procedure were encountered. As seen on the follow-up endoscopy and CT imaging performed after six months, the presence of gastric varcies was not seen in any of the patients after treatment with the NBCA-Lipiodol mixture and the use of microcoils. Recurrence of gastric varices was not observed during the followup period. Worsening of esophageal varices occurred in four patients after transportal sclerotherapy. The serum albumin level increased, the ammonia level decreased and the prothrombin time increased at six months after the procedure (p < 0.05). Conclusion: Percutaneous transportal sclerotherapy with NBCA is useful to obliterate gastric varices if it is not possible to perform balloon-occluded retrograde transvenous obliteration. Objective: This study was deigned to evaluate the technique and clinical efficacy of the use of percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) for patients with gastric varices. Materials and Methods: Seven patients were treated by transportal sclerotherapy with the use of NBCA. For transportal sclerotherapy, portal vein catheterization was performed with a 6-Fr sheath by the transhepatic approach. A 5-Fr catheter was introduced into the afferent gastric vein and a microcatheter was advanced through the 5-Fr catheter into the varices. NBCA was injected through the microcatheter in the varices by use of the continuous single-column injection technique. After the procedure, postcontrast computed tomography (CT) was performed on the next day and then every six months. Gastroendoscopy was performed at one week, three months, and then every six months after the procedure. Results: The technical success rate of the procedure was 88%. In six patients, gastric varices were successfully obliterated with 1-8 mL (mean, 5.4 mL) of a NBCA-Lipiodol mixture injected via a microcatheter. No complications related to the procedure were encountered. As seen on the follow-up endoscopy and CT imaging performed after six months, the presence of gastric varcies was not seen in any of the patients after treatment with the NBCA-Lipiodol mixture and the use of microcoils. Recurrence of gastric varices was not observed during the followup period. Worsening of esophageal varices occurred in four patients after transportal sclerotherapy. The serum albumin level increased, the ammonia level decreased and the prothrombin time increased at six months after the procedure (p < 0.05). Conclusion: Percutaneous transportal sclerotherapy with NBCA is useful to obliterate gastric varices if it is not possible to perform balloon-occluded retrograde transvenous obliteration.

ORiginal Article : The Risk Factors for Bleeding of Fundal Varices in Patients with Liver Cirrhosis

( Eui Ju Park ),( Jae Young Jang ),( Ji Eun Lee ),( Soung Won Jeong ),( Sae Hwan Lee ),( Sang Gyune Kim ),( Sang Woo Cha ),( Young Seok Kim ),( Young Deok Cho ),( Joo Young Cho ),( Hong Soo Kim ),( Bo The Editorial Office of Gut and Liver 2013 Gut and Liver Vol.7 No.6

Background/Aims: The relationship between portal he-modynamics and fundal varices has not been well docu-mented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosys-temic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices. Methods: In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelation-ship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied. Results: There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastro-esophageal varices type 1 (GOV1) groups (n=73) (17.1±7.7 mm Hg vs 19.7±5.3 mm Hg). Additionally, there was no sig-nificant difference in the HVPG between varices with spon-taneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3±5.8 mm Hg vs 17.0±8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal vari-ces compared with esophageal varices and GOV1 (8/12 pa-tients [66.7%] vs 20/73 patients [27.4%]; p=0.016). Conclu-sions: Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1. (Gut Liver 2013;7:704-711)

간경변증 환자에서 거대 식도 정맥류에 대한 비내시경 예측인자

장명희 ( Myung Hee Chang ),손주현 ( Joo Hyun Sohn ),김태엽 ( Tae Yeob Kim ),손병관 ( Byoung Kwan Son ),김종표 ( Jong Pyo Kim ),전용철 ( Yong Cheol Jeon ),한동수 ( Dong Soo Han ) 대한소화기학회 2007 대한소화기학회지 Vol.49 No.6

목적: 간경변증 환자에서 식도 정맥류 출혈은 중요 사인중의 하나로 간경변 진단 시 정맥류 존재 여부와 출혈 위험도를 평가하기 위해서 상부위장관내시경 검사가 권장된다. 그러나 비용-효과에서 모든 간경변증 환자를 대상으로 내시경 검사를 시행해야 하는지에 대한 논란이 있다. 이번 연구는 간경변증 환자에서 정맥류 출혈의 고위험군인 거대 식도정맥류에 대한 비내시경 예측인자를 찾고자 시행하였다. 대상 및 방법: 의무 기록을 후향 조사하여 처음 간경변증으로 진단된 총 736명 환자 중 상부위장관 출혈로 내원하였거나 출혈의 과거력이 있는 경우, 상부위장관내시경 검사를 이전 시행했던 경우, 베타 차단제 복용력, 간문맥 혈전증, 간암이 있는 환자 등을 제외하고 진단 당시 상부위장관내시경 검사를 시행한 환자 245명(남자 171명, 여자 74명)을 대상으로 조사하여 15개의 변수를 통해 거대 식도 정맥류의 비내시경 예측인자를 분석하였다. 간경변증 진단은 임상 소견 및 검사실 소견에서 간경변증에 합당하며 동시에 방사선 검사에서 간경변증 소견을 보이는 경우 혹은 간 조직 검사에서 확진된 경우로 하였다. 결과: 간경변증 환자 245명 중 186명(75.9%)에서 식도 정맥류가 관찰되었고, 55명(22.4%)에서 거대 식도 정맥류가 존재하였다. 간경변증 원인은 바이러스101명(41.2%), 알코올 104명(42.4%), 바이러스/알코올 모두있는 경우 24명(9.8%), 기타 16명(6.6%)이었다. 전체 환자에서 51%, 35.1%, 13.9%가 Child-Pugh A, B, C 등급에 각각 속하였다. 단변량 분석에서 나타난 거대 식도 정맥류 예측인자는 알코올과의 연관성, Child-Pugh 점수, 복수, 비장 비대 및 크기, 혈소판 감소증, 알부민, 프로트롬빈 활성도 등이었고, 다변량 분석에서는 알코올과의 연관성(p=0.017), 12 cm 이상의 비장 비대(p=0.003) 및 복수의 존재(p<0.001)만이 거대 식도 정맥류에 대한 독립 예측인자였다. 독립 예측인자 중 2개 이상을 가진 경우 진단 민감도는 80%, 특이도는 64.2%, 음성 예측도는 91.7%였으며, 한 개의 예측인자도 없을 경우 거대 정맥류는 존재하지 않았다. 결론: 이번 연구에서 거대 식도 정맥류에 대한 비내시경 예측인자는 복수의 존재, 비장 비대, 알코올과의 연관성이었고, 이 중 2가지 이상을 가진 환자는 거대 식도 정맥류가 존재할 가능성이 높으므로 선별검사 목적으로 상부위장관내시경 검사를 반드시 시행해야 할 것으로 생각한다. Background/Aims: The aim of this study was to identify non-endoscopic predictors for the presence of large esophageal varices in Korean patients with liver cirrhosis. Methods: Among 736 patients with liver cirrhosis newly diagnosed between the year 2001 and 2005, 245 patients (171 men and 74 women, mean age of 51.9 years) fulfilled the inclusion criteria and underwent EGD as screening tests for esophageal varices. Fifteen variables were analysed to identify the presence of large esophageal varices. Results: Esophageal varices were noted in 186 patients (75.9%) and large varices in 55 patients (22.4%), while 59 patients (24.1%) had no varices at the time of initial diagnosis of cirrhosis. The causes of liver cirrhosis were viral hepatitis (41.2%), chronic alcoholism (42.4%), viral hepatitis/alcoholism (9.8%), and others (6.6%). Fifty-one percent, 35.1% and 13.9% of the patients belonged to Child-Pugh class A, B, and C, respectively. Variables associated with the presence of large esophageal varices on univariate analysis were the presence of ascites, splenomegaly (long-axis ≥12 cm by ultrasound measure), alcoholism, Child-Pugh class, platelet count, prothrombin time, and albumin. On multivariate analysis, alcohol, splenomegaly, and ascites were significantly associated with the presence of large esophageal varices. If the patients have two of them, sensitivity and negative predictive value were 80% and 91.7%, respectively. Patients without all three factors had no large esophageal varices. Conclusions: These results suggest that patients who have at least two among ascites, splenomegaly, and alcoholism would have an increased risk of having large esophageal varices. (Korean J Gastroenterol 2007;49:376-383)

식도 정맥류 출혈에 대한 내시경적 결찰요법의 치료효과

송진호,장윤식,이옥주,정준용,이연재,이상혁,설상영,정정명 인제대학교 1996 仁濟醫學 Vol.17 No.4

식도 정맥류 출혈은 사망율이 높은 치명적인 질환으로 현재까지 확실한 치료법은 없는 실정이다. 최근 식도 정맥류 출혈에 비교적 지혈률이 높고 부작용이 적은 방법으로 식도 정맥류 결찰술이 보고되었다. 1993년 2월부터 1995년 12월까지 급성 식도 정맥류 출혈로 인제대학 부속 부산백병원에 입원한 환자 중에 내시경적 결찰요법을 72예에서 시행하여 그 결과를 분석해 본 결과 부작용이 적고 지혈효과가 비교적 우수한 치료법이라고 판단되어 이를 보고하는 바이다. Endoscopic injection sclerotherapy(EIS) has been an effective method of treatment for bleeding esophageal varices. However, it is associated with some undesirable complications. Endoscopic variceal ligation(EVL) is a recently developed technique that eradicates esophageal varices and controls active bleeding with similar efficacy and less complication rates than EIS. We have performed EVL in 72 patients who bled from esophageal varices. Total 350 variceal lagations were performed during 104 separate sessions. Control rate of acute bleeding was 93.1% (67 of 72 patients) and five patients died after EVL due to failure of bleeding control. Rebleeding following initiation of EVL occurred in eight patients. Among them, bleeding was successfully controlled by EVL in five, and two patients died of uncontrollable bleeding. In one patient, bleeding was controlled but varices were not completely eradicated. Varices were eradicated or reduced to Grade I in 36 (53.7%) of 67patients by 1-9 ligations (mean 4.9) in 1-4 EVL sessions(mean 1.4). After EVL, there were several minor complications; mild substernal discomfort in seven patients, mild dysphagia in three and fever in two. These results suggest that EVL is a safe and effective method of treatment for bleeding esophageal varices, and eradication of esophageal varices can be obtained with less complications.

Colonoscopic Cyanoacrylate Injection of Bleeding Ileal Varices in a Patient with Hepatocellular Carcinoma

( Aeden Bernice G. Timbol ),( Eric B. Yasay ),( Mark Anthony A. De Lusong ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Ectopic varices are rare and can occur in approximately 1-3% of cirrhotics - with small intestinal varices occurring in 17-18% of these patients. Due to its rarity, there is still no current standard of care for the treatment of ileal varices. We present a case in which bleeding terminal ileal varices was successfully controlled by colonoscopic cyanoacrylate injection. Methods: A 34 year-old male diagnosed with chronic hepatitis B was admitted due to hematochezia. Physical examination revealed a non-tender right upper quadrant mass. Laboratories showed severe anemia, deranged liver biochemical tests, and a markedly elevated alpha feto protein. Triphasic abdominal CT scan showed an arterially- enhancing mass with rapid wash out occupying and enlarging the left liver lobe. Results: On admission, he was transfused with 3 units packed red blood cells until esophagogastroduodenoscopy (EGD) and colonoscopy were performed. On EGD, four columns of engorged vessels were noted and 3 bands were deployed. No gastric or duodenal varices were found. On colonoscopy, an engorged vessel with nipple sign was noted 8-12 cm from the ileocecal valve. Intraluminal injection of N-butyl-2-cyanoacrylate (Histoacryl) on the ileal varices was performed without complications. Second-look colonoscopy showed sclerosed ileal vessels without any signs of active bleeding. CT-angiogram revealed absence of any vascular abnormalities or contrast extravasation. The patient was then primed for TIPS and palliative chemotherapy, however on the 9th day post-histoacryl injection, the patient expired due to respiratory failure. Conclusions: Ectopic varices are uncommon and the optimal treatment remains to be a challenge. Colonoscopic injection sclerotherapy is a promising option for control of terminal ileal variceal bleeding even in poor risk patients presenting with massive hemorrhage.

급성 정맥류 출혈의 내시경 치료와 예방

김영대 대한상부위장관ㆍ헬리코박터학회 2024 Korean Journal of Helicobacter Upper Gastrointesti Vol.24 No.1

Gastroesophageal varices occur in more than half of patients with cirrhosis and the incidence increases as liver function worsens. Although the mortality rate for acute variceal bleeding has decreased with the development of variceal endoscopic hemostasis and administration of vasoactive drugs and prophylactic antibiotics, it still reaches 20%. Therefore, surveillance of variceal occurrence and the prevention of their bleeding is very important in patients with cirrhosis. In patients with liver cirrhosis accompanied by portal hypertension, esophagogastroduodenoscopy should be performed to diagnose varices and stratify their bleeding risk. The interval of endoscopic surveillance is adjusted according to variceal condition and cirrhosis severity. If varices are diagnosed, primary prophylaxis (e.g., non-selective beta-blockers or endoscopic prophylaxis) is required to prevent variceal bleeding. Appropriate treatment, including timely endoscopic hemostasis, should be performed in patients with acute variceal bleeding, and secondary prophylaxis is required to prevent rebleeding. Endoscopic variceal ligation is the recommended endoscopic treatment for acute esophageal variceal bleeding; endoscopic variceal obstruction is usually recommended in patients with gastric varices. To prevent bleeding, endoscopic surveillance should be performed at regular intervals until the varices have been eradicated, and endoscopic followup should be performed periodically even after their disappearance. In this review, we investigate the role of endoscopy in the treatment and management of gastroesophageal varices.

The Role of Divided Injections of a Sclerotic Agent over Two Days in Balloon-Occluded Retrograde Transvenous Obliteration for Large Gastric Varices

Takuji Yamagami,Rika Yoshimatsu,Hiroshi Miura,Tomohiro Matsumoto,Terumitsu Hasebe 대한영상의학회 2013 Korean Journal of Radiology Vol.14 No.3

Objective: To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension. Materials and Methods: 50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed. Results: In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen. Conclusion: When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.

문맥압항진증에서 자기공명 혈관조영술을 이용한 위정맥류의 측부 혈관 분석

박철희 ( Park Cheol Hui ),전훈재 ( Jeon Hun Jae ),정록선 ( Jeong Log Seon ),김경오 ( Kim Gyeong O ),김용식 ( Kim Yong Sig ),김영선 ( Kim Yeong Seon ),진윤태 ( Jin Yun Tae ),이홍식 ( Lee Hong Sig ),엄순호 ( Eom Sun Ho ),이상우 ( Le 대한소화기학회 2003 대한소화기학회지 Vol.42 No.4

Managing liver cirrhotic complications: Overview of esophageal and gastric varices

Cosmas Rinaldi Adithya Lesmana,Monica Raharjo,Rino A. Gani 대한간학회 2020 Clinical and Molecular Hepatology(대한간학회지) Vol.26 No.4

Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia.