Gastric varices without esophageal varices. An important preendoscopic diagnosis.
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Adult↗
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Results for “ESOPHAGEAL VARICES”
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Hemodynamic assessment of the left gastric vein in patients with esophageal varices with color Doppler EUS: factors affecting development of esophageal varices.
BACKGROUND: An understanding of the development of esophageal varices is important in the evaluation of risk of variceal hemorrhage. To clarify factors affecting the development of esophageal varices, the morphology and hemodynamics of the left gastric vein were analyzed with color Doppler EUS. METHODS: Sixty-seven patients with esophageal varices underwent color Doppler EUS. Seventeen had small varices (F1), 32 had medium varices (F2), and 18 had large varices (F3). RESULTS: Hepatofugal blood flow velocity in the left gastric vein trunk increased as the size of the varices increased (p < 0.0001), whereas the diameter did not increase. The left gastric vein bifurcates into anterior and posterior branches. As the size of the varices enlarged, the branch pattern was more likely to be anterior branch dominant (p = 0.041). There was no significant difference between the 3 size groups of esophageal varices with respect to the size of the paraesophageal collaterals. The detection rate and diameter of the perforating vein increased as the size of the varices increased (p = 0.032 and 0.012, respectively). CONCLUSION: Blood flow velocity in the left gastric vein trunk, branches, and perforating veins may regulate blood flow supplying the esophageal varices and contribute to their development. These findings are important to understanding the pathogenesis of esophageal varices.
Adult↗
Long-term follow-up of patients with liver cirrhosis after endoscopic ethanol injection sclerotherapy for esophageal varices.
BACKGROUND/AIMS: Esophageal variceal hemorrhage is a severe complication of liver cirrhosis, and therapy for acute bleeding and prevention of hemorrhage are important. In this study, we evaluated the long-term cumulative survival rate of patients with esophageal varices after treatment with endoscopic ethanol injection sclerotherapy (EIS group) or pharmacological therapy (non-EIS group). METHODOLOGY: All 110 patients were treated for their esophageal varices and their prognosis and complications were analyzed during the follow-up period. RESULTS: The cumulative survival rate in the primary preventive EIS group was superior to that in the non-EIS group. The preventive EIS group had greater long-term survival rate than those treated on an emergency group. With respect to emergency therapy, the EIS group had better survival rates than the non-EIS group during the two-year follow-up period after esophageal variceal therapy. CONCLUSIONS: We conclude that primary preventive EIS is an effective therapy for survival of patients with esophageal varices over a long-term period.
Endoscopy, Gastrointestinal↗
[Portal hypertension and bleeding esophageal varices in children. Esophageal transection with paraesophagogastric devascularization versus shunting procedures (author's transl)].
It is known that portasystemic shunts in the treatment of portal hypertension causes in the long term a high rate of complications in children. The most severe are encephalopathy, postoperative hepatic failure in intrahepatic hypertension and occlusion or poor functioning of the shunts. The incidence of the last mentioned complication is high in children, especially in those operated in their early years of life. The most severe danger of portal hypertension is the haemorrhage from bleeding esophageal varices. During the last few years the technique of esophagogastric devascularization with esophageal transection and ligation of varices (Sugiura's procedure) has given a very high percentage of success in the long term. The Authors report their experience with Sugiura's procedure in 9 children with portal hypertension (average age at operation of four and half years). In six cases there was a prehepatic and in the other three an intrahepatic hypertension. The follow-up varied from six months to seven and half years with an average of almost four years. In all the children the surgical treatment was successful with the complete disappearance of haemorrhage and esophageal varices. For their own experience and for Sugiura's long-term results, the Authors think that Sugiura's procedure offers the most effective alternative to portasystemic shunts in the surgical treatment of portal hypertension, especially in early childhood.
Child↗
Postoperative motor function and mucosal blood flow of lower esophagus: comparison between terminal esophagoproximal gastrectomy and esophageal transection for esophageal varices.
Reflux esophagitis and anastomotic ulcer are potential complications associated with surgery for esophagogastric lesions. This study compared 10 cases following terminal esophagoproximal gastrectomy (TEPG) for esophageal varices and 20 cases following esophageal transection (ET) for esophageal varices with respect to postoperative motor function and mucosal blood supply, to ascertain the reason for the development of anastomotic ulcer. Endoscopic findings showed that anastomotic ulcers were detected more often after TEPG than after TR. Maximum swallowing pressure, high pressure zone pressure, and length did not differ between the two groups. However, maximum swallowing pressure in the lower esophagus after both procedures was significantly lower than in the control group (20 cases; p < 0.01). The results, measured by reflectance spectrophotometry, showed that the index of esophageal mucosal blood volume following TEPG is significantly lower than that following ET and in non-operated esophageal varices (10 cases; p < 0.01). Yet the index of oxygen saturation of hemoglobin was similar in the three groups. This study has demonstrated that patients undergoing TEPG have mucosal ischemia of the lower esophagus, causing the development of anastomotic ulcers.
Anastomosis, Surgical↗
Esophageal transit of liquid in chronic alcoholism in patients with cirrhosis. Influence of esophageal varices.
Disturbances of esophageal motility are often encountered in chronic alcoholism, and numerous physiopathologic mechanisms responsible for this alteration have been documented. The exact role of esophageal varices, however, in inducing esophageal transit abnormalities remains unclear. In this study using scintigraphy, the authors studied esophageal transit in a large number of patients with cirrhosis to assess the direct effect of esophageal varices. Esophageal transit was found altered in 58 out of 141 patients with cirrhosis (41.1%). It was prolonged in 47.3% of patients with esophageal varices and in 29.2% of patients without varices (P < 0.05). The frequency of esophageal transit alteration was also related to the Child-Turcotte-Pugh (CTP) score, an index of the severity of liver disease (P < 0.01). The relationship between CTP class and transit alteration remained statistically significant in the group of patients with esophageal varices (P < 0.05). Conversely, when patients in each CTP class were analyzed separately, the frequency of esophageal transit abnormalities was not different in patients with and without esophageal varices. These results suggest that the severity of cirrhosis, rather than the presence of esophageal varices, constitutes the major factor in inducing esophageal transit alteration in patients with cirrhosis.
Adult↗
Improvement of collateral vessels in the vicinity of gastric cardia after endoscopic variceal ligation therapy for esophageal varices.
BACKGROUND & AIMS: Endoscopic variceal ligation (EVL) therapy has been performed widely to treat or prevent variceal bleeding. We sought to examine the influence of EVL for esophageal varices on collateral vessels in the vicinity of gastric cardia. METHODS: In 42 patients with esophagogastric varices, conventional endoscopy and endoscopic ultrasonography with a 20-MHz probe (CUP-EUS) were performed before and at every 3 months after EVL for esophageal varices. By using conventional endoscopy, cardial variceal sizes were divided into 3 grades: F0, F1, and F2. The sizes of submucosal, perforating, and paracardial vessels at the cardia also were classified into 3 grades according to CUP-EUS findings. RESULTS: Conventional endoscopy showed cardial varices in 33 (79%) patients before and 23 (55%) patients at 3 months after the treatment (P < 0.05). CUP EUS showed that 29 (69%) patients had severe grade cardial submucosal vessels before EVL, but only 13 (31%) patients did after the treatment (P < 0.01). Nineteen (45%) patients had severe grade cardial perforating vessels before EVL, but only 4 (10%) patients did after the treatment (P < 0.001). Furthermore, patients with severe grade residual submucosal or perforating vessels at the cardia had shorter recurrence-free times of esophageal varices (P < 0.01, 0.05, respectively). CONCLUSIONS: Collateral vessels in the vicinity of gastric cardia were improved significantly after EVL, indicating that esophageal varices can be treated by EVL even though they connect with cardial varices. Furthermore, eradication of such collateral vessels by EVL may lead to longer recurrence-free status of esophageal varices.
Adult↗
Risk of esophageal variceal bleeding based on endoscopic ultrasound evaluation of the sum of esophageal variceal cross-sectional surface area.
OBJECTIVE: The aim of this study was to evaluate the risk of future variceal bleeding, based on the endoscopic ultrasound measurement of the sum of the cross-sectional surface area (CSA) of all of the esophageal varices in the distal esophagus. METHODS: Twenty-eight patients with portal hypertension and esophageal varices, but no prior history of variceal bleeding, were evaluated using endoscopic ultrasound (20-MHz ultrasound probe, Microvasive, Boston, MA; Olympus, Tokyo, Japan). The entire esophagus was imaged, and an image was selected at a point where the varices appeared the largest. This image was digitized, and the sum of the CSA of all of the varices was measured (Image Pro Plus, Silver Springs, MD) by an investigator blinded to the patients' clinical status. The follow-up time for each patient was calculated (time to first bleed, time to liver transplantation, time to death, or time to the end of study). The Cox Proportional Hazards Model was used to determine if there was a significant difference between the sums of the CSA in the patients who bled compared with those who did not bleed. An OR was calculated to determine the risk of future variceal bleeding based on the sum of the CSA as measured in cm(2)/month. Positive and negative predictive values were calculated for future variceal bleeding. RESULTS: Six of 28 patients (21%) experienced esophageal variceal bleeding on follow-up. The mean CSA +/- SEM of the sum of the esophageal varices in these patients was 0.77 cm(2) +/- 0.31 cm(2) (range 0.07-2.09 cm(2)). The mean time to bleeding was 15.5 months +/- 4.95 months (range 1-29 months). Twenty-two of 28 patients (79%) did not experience variceal bleeding. The mean CSA +/- SEM of the sum of the varices in these patients was 0.36 cm(2) +/- 0.08 cm(2) (range 0.02-1.19 cm(2)). The mean time to follow-up was 35.7 months +/- 6.69 months (range 1.2-103.2 months). The sum of the CSA between the patients who bleed and those who did not bleed was significantly different at the p < 0.018 level. The OR for the risk of variceal bleeding for each one cm(2) difference in the sum of the CSA per month was 6.34. Using a cutoff of 0.45 cm(2), the sensitivity and specificity for future variceal bleeding was 83% and 75%, respectively. CONCLUSIONS: There is a significant difference (p < 0.018) in the sum of the esophageal variceal CSA between those patients who will experience future variceal bleeding and those who will not. There is a 76-fold increase per year in the risk of future variceal bleeding for each one cm(2) increase in variceal CSA. Using a cutoff value for the CSA of 0.45 cm(2), the sensitivity and specificity for future variceal bleeding above and below this point is 83% and 75%, respectively.
Adult↗
[Motility and mucosal hemodynamics of the lower esophagus after transabdominal esophageal transection for esophageal varices].
Lower esophageal motility and mucosal hemodynamics were investigated in 20 patients who underwent transabdominal esophageal transection for esophageal varices (ET), to evaluate their association with reflux esophagitis and variceal recurrence. In the manometric study with microtransducer catheter, maximum swallowing pressure in the lower esophagus of the patients was significantly lower than that of the healthy controls (20 cases) (26.1 +/- 20.5mmHg vs. 80.0 +/- 10.0mmHg: p < 0.01), while high pressure zone pressure did not differ between the two groups. In comparison between patients with and without esophagitis (E(+) and E(-)), maximum swallowing pressure of E(+) was statistically lower than that of E(-) (12.4 +/- 18.7mmHg vs. 31.0 +/- 19.1mmHg: p < 0.05). In the hemodynamic study by reflectance spectrophotometry, the index of esophageal mucosal blood volume (IHb) and the index of oxygen saturation of hemoglobin (ISo2) of E(+) and E(-) were no different from those in the patients with non-operated esophageal varices (10 cases). Although there was no correlation between the recurrence of RC-sign and mucosal microcirculation, the patients with larger varices tended to have a higher IHb and a patients with F1-varices had significantly lower ISo2 than the patients without varices. This study indicated that the poor clearance ability after ET may lead to reflux esophagitis and the patients with variceal recurrence had the congested mucosal microcirculation, compared to those without variceal recurrence.
Adult↗
Short- and long-term results of endoscopic variceal ligation for esophageal varices compared with injection sclerotherapy.
We assessed the efficacy and safety of endoscopic therapy for esophageal varices in Japanese patients comparing the results of ligation therapy performed in 101 patients with those of sclerotherapy with paravariceal injection of polidocanol in 40 patients. Both therapies were effective in controlling active hemorrhages. Hemostasis rates at the first endoscopic session were 100% in both groups and rebleeding rates were 40.0% in the sclerotherapy and 29.6% in the ligation group. Variceal eradication was achieved equally in both groups in approximately 90% of the patients. However, the ligation achieved eradication more quickly in fewer endoscopic sessions than did the sclerotherapy (mean; 2.1 vs. 3.7 sessions, P < 0.01). Complications such as rebleeding and intramural hematomas were less common in the ligation group. These results indicate some advantages of the ligation over the sclerotherapy. A disadvantage of the ligation therapy is that recurrence occurs more quickly than in the sclerotherapy, although the difference was not statistically significant.
Endoscopy↗
Control of bleeding esophageal varices by transabdominal esophageal transection, gastric devascularization, and splenectomy.
Between November 1980 and October 1982, 11 patients underwent modified Sugiura procedures (esophageal transection, gastric devascularization, and splenectomy) for bleeding esophageal varices, with an operative mortality of 36%. One patient rebled at 2 months and was successfully managed by sclerotherapy. Intraoperative portal pressure fell approximately 25% after splenectomy. We contend that esophageal transection and gastric devascularization provide good short-term control of bleeding varices, and that the decrease in portal pressure provided by splenectomy allows scars to form during a period of reduced portal pressure, providing long-term arrest of variceal hemorrhage.
Adult↗
Hyperbilirubinemia induced by endoscopic variceal ligation for esophageal varices in a patient with primary biliary cirrhosis: a case report.
We describe the case of a 51-year-old woman with primary biliary cirrhosis who developed hyperbilirubinemia with transient liver dysfunction after undergoing endoscopic variceral ligation to control hemorrhaging from esophageal varices. After undergoing a variceal ligation, the serum total bilirubin increased from 4.0 mg/dL to 9.5 mg/dL, and the degree of liver failure worsened. She finally had to undergo a liver transplant. We discuss the mechanism of hyperbilirubinemia after endoscopic variceal ligation.
Endoscopy↗
[Hydrostatic pressure in esophageal varices and the risk of an esophageal variceal hemorrhage].
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Esophageal and Gastric Varices↗
An evidence-based approach to the treatment of esophageal variceal bleeding.
Esophageal varices are a life threatening cause of gastrointestinal bleeding. Management includes both primary prevention of variceal bleeding and treatment of actively bleeding varices. Evidence from randomized controlled trials indicates that beta blockers and nitrates may prevent the initial episode of bleeding varices. Ample data from randomized controlled trials indicate that band ligation is more effective than scleropathy for the treatment of bleeding esophageal varices. Somatostatin may decrease rebleeding rates with or without endoscopic therapy. No effective treatment has been developed for the treatment of patients who fail endoscopic therapy.
Adult↗
Should children with esophageal varices receive beta-blockers for the primary prevention of variceal hemorrhage?
Esophageal variceal hemorrhage occurs in up to 10% of children with portal hypertension annually, and may be fatal. In contrast to the strong evidence in adults that nonselective beta-adrenergic antagonism reduces the risk of variceal bleeding by approximately 50%, few pediatric data are available. The use of beta-blockers for primary prophylaxis has been reported in children, but not tested in a randomized controlled trial. The risks and benefits in children remain unquantified and may differ from adults in light of the different cardiovascular response to hypovolemia in young children. The circumstances of the individual patient must, therefore, be carefully considered before beta-blockers are prescribed to children with esophageal varices.
Adrenergic beta-Antagonists↗
The adult with bleeding esophageal varices.
Bleeding esophageal varices are a life-threatening complication of portal hypertension. During the emergent phase, nurses have an important role in assessing the patient's response to volume replacement and in monitoring interventions to control hemorrhage. Complications contribute to the high mortality associated with variceal hemorrhage. Knowledge of the pharmacologic side effects of vasopressin and of the potential complications associated with endoscopic injection sclerotherapy and esophagogastric balloon tamponade is critical for successful nursing management of the adult with bleeding esophageal varices. The goal of long-term management is to prevent recurrent hemorrhage. This is accomplished by repeated injection sclerotherapy and strategies to reduce portal pressure. Patient education is focused on modification of behaviors that increase the risk for bleeding and on the early recognition of recurrent bleeding.
Adult↗
Endoscopic variceal ligation for intractable esophageal variceal bleeding in children with idiopathic extrahepatic portal vein occlusion: report of three cases.
Extrahepatic portal vein occlusion (EPVO) is an important cause of extrahepatic portal hypertension and variceal hemorrhage in children. We report 3 children with a diagnosis of EPVO and intractable esophageal variceal bleeding who underwent scheduled endoscopic variceal ligation (EVL) and prophylactic propranolol therapy for eradication of esophageal varices. Complete variceal obliteration was achieved in all 3 children following 3-4 treatment sessions. There were no significant complications or gastrointestinal hemorrhage during a follow-up period of 9 to 31 months after variceal eradication. In conclusion, EVL and long-term propranolol prophylaxis is safe and effective in eradicating bleeding esophageal varices in children with EPVO.
Child↗
Present status of sclerotherapy and surgical treatment for esophageal varices in Japan. Japanese Research Society for Portal Hypertension and Japanese Research Society for Sclerotherapy of Esophageal Varices.
A nationwide survey on the treatment for esophageal varices was performed in 1990 jointly by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to clarify the present status and strategy of this treatment in Japan. A total of 12,675 cases, including 4,159 cases of nonshunting procedures and 7,612 cases of sclerotherapy, were collected from 101 institutions. The number of patients had greatly increased in the first half of the 1980s. With regard to the therapeutic strategy, surgical procedures were not recommended in either emergency or prophylactic cases in terms of the timing of the operation, or in Child C cases in terms of the degree of hepatic insufficiency. Endoscopic injection sclerotherapy became the leading method of treatment and in 1988 only 16% of 1,528 cases were treated by surgical procedures. The strategy for the same group of patients differed between medical and surgical institutions. With regard to sclerotherapy, repeated intravariceal injection and combined intra- and paravariceal injection were the two main techniques and 10-year cumulative survival rates were 62.8% in Child A cases, 47.7% in Child B cases, and 13.2% in Child C cases. With regard to surgical procedures, 10-year survival rates were 50.6% in esophageal transection, 42.5% in gastric transection, 53.1% in cardiectomy, and 43.0% in selective shunt procedures. We are quite convinced that this report will prove useful in determining the future strategy for treating esophageal varices.
Esophageal and Gastric Varices↗